Selective cerebral perfusion with aortic cannulation and short-term hypothermic circulatory arrest in aortic arch reconstruction.

BACKGROUND: The deep hypothermic circulatory arrest (DHCA) technique has been used in aortic arch and isthmus hypoplasia for many years. However, with the demonstration of the deleterious effects of prolonged DHCA, selective cerebral perfusion (SCP) has started to be used in aortic arch repair. For SCP, perfusion via the innominate artery route is generally preferred (either direct innominate artery cannulation or re-routing of the cannula in the aorta is used). Herein, we describe our technique and the result of arch reconstruction in combination with selective cerebral and myocardial perfusion (SCMP) and short-term total circulatory arrest (TCA) (5-10 min) through ascending aortic cannulation. METHODS: Thirty-seven cases with aortic arch and isthmus hypoplasia accompanying cardiac defects were operated on with SCMP and short TCA in Baskent University Istanbul Research and Training Hospital between January 2007 and Sep 2012. There were 17 cases with ventricular septal defect (VSD)-coarctation with aortic arch hypoplasia (CoAAH), 4 cases of transposition of the great arteries-VSD-CoAAH, 4 cases of Taussing Bing Anomaly-CoAAH, 2 cases complete atrioventricular canal defect-CoAAH, 3 cases single ventricle-CoAAH, 3 cases of type A interruption-VSD, 2 subvalvular aortic stenosis-CoAAH and 2 cases of isolated CoAAH. The aorta was cannulated in the middle of the ascending aorta in all cases. The cross-clamp was applied to the aortic arch distal to either the innominate artery or the left carotid artery. In addition, a side-biting clamp was applied to the descending aorta. The aorta between these two clamps was reconstructed with gluteraldehyde-treated autogeneous pericardium, using SCMP. The proximal arch and distal ascending aorta reconstructions were carried out under short TCA. RESULTS: The mean age of the patients was 2.5 ± 2 months. The mean cardiopulmonary bypass and cross-clamp times were 144 ± 58 and 43 ± 27 minutes, respectively. The mean SCMP and descending aorta ischemia times were 22.6 ± 4.8 and 27 ± 6.3 minutes, respectively. Mean TCA time was 7.6 ± 2.1 minutes (min: 4, max 10 min). The mean in-hospital stay time was 8.6 ± 1.9 days. None of the cases operated with this technique had neurological defects. The mortality rate was 2.7% (1 patient). CONCLUSION: SCMP with aortic cannulation and short TCA (under 10 minutes) in aortic reconstruction is safe and practical in this high-risk patient group.

Total correction in tetralogy of Fallot with anomalous major coronary artery: an alternative method to conduit use.

INTRODUCTION: A coronary artery anomaly precludes the use of a trans-annular patch in right ventricular outflow tract (RVOT) reconstruction. Herein we present three patients with coronary artery anomalies who underwent total corrective operations without using a conduit. METHODS: Between 2007 and 2010, 84 patients with tetralogy of Fallot (TOF) were operated on. Nine (9.4%) of them had a coronary artery anomaly. Three (3.1%) of the patients were operated on using the double-outflow technique and two had a Blalock-Taussig shunt before the total corrective operation. In two patients, the left anterior descending artery (LAD) and in one, the right coronary artery (RCA) crossed the RVOT. RESULTS: Postoperatively, the right-to-left ventricular pressure ratios were 0.45, 0.59 and 0.60 after cardiopulmonary bypass. No gradient was detected in the RVOT in postoperative echocardiographical measurements (< 15 mmHg gradient). In all three patients, there were moderate pulmonary insufficiencies. All were discharged home on the sixth day postoperatively. Mean follow-up duration was 9.8 ± 8 months. In the follow up of all three patients, there were moderate pulmonary insufficienciencies but no right ventricular dysfunction. CONCLUSION: The 'double-outflow' technique is appropriate for TOF patients with a major coronary artery anomaly since it can easily be performed without the need of a conduit.

Giant right atrial myxoma leading to cardiac arrest in an infant.

We present the case of a three-month-old infant with a giant right atrial myxoma obstructing the tricuspid valve, who following haemodynamic deterioration and cardiac arrest, was operated upon as an emergency. On echocardiogram, there was a mass attached to the tricuspid annulus, in close proximity to the septal leaflet, with dimensions of 16.6 × 12.5 mm. The mass was prolapsing through the tricuspid valve into the right ventricle and obstructing the inflow. While preparing for surgery, cardiac arrest occurred, so the patient underwent an emergency operation under cardiopulmonary resuscitation. The mass was excised without damaging the tricuspid valve and the conduction system. Histologically, the mass consisted of a myxoid matrix with scatted globoid and star-shaped myxoma cells. The patient stayed 15 days in the intensive care unit and was discharged home on the 20th day postoperatively. Although accepted as a benign tumour, a myxoma can display an aggressive clinical course in infants. In centres where cardiac operations cannot be performed, these patients need to be transferred to cardiac centres as soon as possible. Whatever the clinical presentation, we advocate immediate surgical extirpation of the tumour in order to avoid any unpredictable consequences in its clinical course.

Redo sternotomy for extra-anatomical correction of aortic coarctation and mitral repair in an adult after failed endovascular treatment.

Recently, extra-anatomical bypass surgery has been widely used in complicated adult aortic coarctation cases with concomitant intracardiac repair. Stent implantation has been widely used for primary aortic coarctation as well. The procedure has been shown to be effective with long term follow ups. However, failed stent implantations like stent fracture and dislodgement may complicate the clinical status and subsequent surgical procedure. Extra-anatomic bypass can provide effective results and lower morbidity in cases with concomitant intracardiac problems and stent failure. Here we present an adult aortic coarctation patient who had undergone a Bentall operation and two unsuccessful stent implantations for recurrent aortic coarctation. The patient then got an extra-anatomic bypass for aortic coarctation and concomitant mitral valve commissurotomy through median sternotomy.

Extending the boundaries of no-touch aorta technique usage for coronary artery bypass grafting in patients with diseased ascending aorta.

AIM: Atherosclerosis of the ascending aorta is a leading cause of cerebrovascular accidents (CVA) in patients who undergo coronary artery bypass grafting (CABG). However, the ascending aorta is considered untouchable only in cases of severe calcification. The aim of this study is to evaluate the effect of the no-touch aorta technique (NAT) on morbidity and mortality with an extension of indication to any degree of atherosclerotic disease is detected on the ascending aorta. METHODS: From March 2001 to March 2006, data were prospectively collected from 101 patients with ascending aorta atherosclerosis who underwent either on- or off-pump CABG with NAT. Demographic data from these 101 patients were compared with those of 1 473 patients who underwent conventional CABG with aortic cross-clamping during the same time period. All preoperative variables were assessed with stepwise logistic regression to determine predictors of ascending aortic disease. RESULTS: Age, hypertension, hyperlipidemia, peripheral vascular disease, EuroSCORE and unstable and redo rates were significantly higher in the NAT group than in the control group (P<0.05). Logistic regression analysis of preoperative variables for all 1 574 cases identified age, peripheral vascular disease, history of smoking, EuroSCORE, and reoperation as independent predictors of atherosclerotic disease of the ascending aorta. No operative or hospital CVA occurred in the study group. Hospital mortality was observed in 2 (1.9%) patients. During the follow-up period of 27.9 +/- 13 months, no patient was re-admitted with angina recurrence or CVA. CONCLUSION: Any degree of atherosclerotic disease on the ascending aorta can potentially cause CVA upon manipulation during CABG. Use of CABG with NAT to eliminate the risk of CVA is associated with low rates of morbidity, stroke and mortality during hospital stay and at mid-term follow-up.

Combined off-pump coronary artery bypass grafting and aorto-bicarotid bypass.

A 63-year-old man with severe coronary artery disease and occlusion of aortic arch branches presented with dizziness, syncope and unstable angina. He underwent a combined surgical procedure of aorto-bicarotid bypass and off-pump myocardial revascularization. The operation was successful and he had no complications during 11 months of follow-up.

An unusual cause of hemoptysis: ventriculopulmonary fistula.

A 55-year-old man presented with massive hemoptysis following coronary artery bypass grafting and repair of a left ventricular aneurysm. Radiological and bronchoscopic examinations revealed no bronchial cause. The findings of computed tomography (CT) of the chest and echocardiography showed a pseudoaneurysm of the left ventricle. Surgical exploration confirmed that the pseudoaneurysm communicated with the lung parenchyma.

[Peripheral vascular injuries]. / Periferik damar yaralanmalari.

Between 1994-2000, 60 peripheral vascular injuries were admitted to the Turgut Ozal Medical Center Thoracic and Cardiovascular Surgery Clinic. Forty eight (80%) of patients were male, twelve (20%) were female and their age ranged from 5 to 70 years (mean 28.9 years). The causes of injuries were related to penetrating device in 34 (56.6%), gun shots in 14 (23.3%), blunt trauma in seven (11.6%) and iatrogenic causes in five(8.3%). Total laceration, partial laceration and pseudoaneurysm were observed in 45 (75%), 14 (23.3%) and one (1.6%) respectively. The localization of injuries were the upper limbs in 34(56.6%) and the lower limbs in 26 (43.4%). The vascular injury localizations in order of frequency were femoral artery in 12 cases (20.75%), radial artery in ten cases (17%), popliteal artery in ten cases (15%), brachial artery in nine cases (15%), axillary artery in nine cases (13.2%), ulnar artery in six cases (11.3%) and tibial artery in four cases(7.4%). There were nearby venous injuries in nine patients (15%) and neural injuries in ten patients (16.6%). The patients' mean admission time to the hospital was 3 hours and 30 minutes and mean operation time for revascularization was within 95 minutes. The operative techniques were autogenous saphenous vein graft interposition in 27 cases (45%), resection and end-to-end anastomosis in 19 cases (31.6%), lateral repair in ten cases (16.6%), synthetic graft insertion in three cases (4.8%) and ligation in one case (1.6%). Our success rate was 98.2% in salvaging the limbs. Mean length of hospital stay was 14.4 days. Mortality was not observed during the hospital stay.

The effects of aprotinin and steroids on generation of cytokines during coronary artery surgery.

OBJECTIVE: To compare the efficacy of aprotinin and methylprednisolone in reducing cardiopulmonary bypass (CPB)-induced cytokine release, to evaluate the effect of myocardial cytokine release on systemic cytokine levels, and to determine the influence of cytokine release on perioperative and postoperative hemodynamics. DESIGN: Prospective, randomized clinical trial. SETTING: University teaching hospital and clinics. PARTICIPANTS: Thirty patients undergoing elective coronary artery bypass graft surgery. INTERVENTION: Patients were randomly allocated into groups treated with aprotinin (n = 10) or methylprednisolone (n = 10) or into an untreated control group (n = 10). Aprotinin-treated patients received aprotinin as a high-dose regimen (6 x 10(6) KIU), and methylprednisolone-treated patients received methylprednisolone (30 mg/kg intravenously) before CPB. MEASUREMENTS AND MAIN RESULTS: Patients were analyzed for hemodynamic changes and alveolar-arterial PO2 difference (AaDO2) until the first postoperative day. Plasma levels of proinflammatory cytokines (tumor necrosis factor [TNF]-alpha, interleukin [IL]-1beta, IL-6, and IL-8) were measured in peripheral arterial blood immediately before the induction of anesthesia, 5 minutes before CPB, 3 minutes after the start of CPB, 2 minutes after the release of the aortic cross-clamp, 1 hour after CPB, 6 hours after CPB, and 24 hours after CPB; and in coronary sinus blood immediately before CPB and 2 minutes after the release of the aortic cross-clamp. The hemodynamic parameters did not differ among the groups throughout the study. After CPB, AaDO2 significantly increased (p < 0.05) in all groups. A significant decrease in AaDO2 was observed in aprotinin-treated patients at 24 hours after CPB compared with the other groups (p < 0.05). TNF-alpha level from peripheral arterial blood significantly increased in control patients 1 hour after CPB (p < 0.01) and did not significantly increase in methylprednisolone-treated patients throughout the study. In all groups, IL-6 levels increased after the release of the aortic cross-clamp and reached peak values 6 hours after CPB. At 6 hours after CPB, the increase in IL-6 levels in methylprednisolone-treated patients was significantly less compared with levels measured in control patients and aprotinin-treated patients (p < 0.001). In control patients, IL-8 levels significantly increased 2 minutes after the release of the aortic cross-clamp (p < 0.05), and peak values were observed 1 hour after CPB (p < 0.01). IL-8 levels in control patients were significantly higher compared with patients treated with aprotinin and patients treated with methylprednisolone 1 hour after CPB (p < 0.05). CONCLUSION: This study showed that methylprednisolone suppresses TNF-alpha, IL-6, and IL-8 release; however, aprotinin attenuates IL-8 release alone. Methylprednisolone does not produce any additional positive hemodynamic and pulmonary effects. An improved postoperative AaDO2 was observed with the use of aprotinin.

Evaluation of pentoxifylline in experimental spinal cord ischemia.

OBJECTIVE: Despite the advance of anesthesia and surgery, postoperative neurological dysfunction has remained a challenging problem after descending and thoracoabdominal aortic surgery. The pathophysiology of early and especially late paraplegia is not clearly understood. The effect of pentoxifylline (PTX), an agent known to inhibit in vitro neutrophil activation and improve recovery after cerebral ischemia in animals, was investigated on spinal cord protection. METHODS: Twenty four New Zealand white rabbits were used for spinal cord ischemia models. Infrarenal aortic occlusion devices were placed. After 48 h, the rabbits were randomly taken for study. The PTX groups (n = 12) were given PTX 40 mg/kg i.v. bolus followed by 0.2 mg/kg/min infusion. The control (CT) group (n = 12) received normal saline. Two groups underwent temporary (20-24 min) spinal cord ischemia in a conscious state. After the operation, the spinal cord function was assessed at 6, 12, 24, 48 and 72 h by the scale (score of 5 = normal hop, score of 0 = no movement). Histological analysis of the spinal cords was carried out immediately after acute paraplegia or within 24 h after development of delayed paraplegia. RESULTS: During the aortic occlusion, the distal aortic pressures were the same in both groups (PTX group: 14.92 +/- 3.78 mmHg; CT group: 17.42 +/- 3.2 mmHg). At the 72nd h, the scores were not different in the PTX group (1.58 +/- 2.11) and in the CT group (0.83 +/- 1.95) (P = 0.817). Acute paraplegia developed in 3 rabbits (25%) of each group. Delayed paraplegia was observed in 6 rabbits (50%) in the PTX group and 7 rabbits (58%) in the CT group. On morphological examination on the spinal cords, ischemic changes were observed in both groups. Although neutrophil leukocytes were noted in the control group with acute paraplegia and macrophage infiltration was noted in the control group with delayed paraplegia, there was not any leukocyte or macrophage sequestration in the PTX group. CONCLUSIONS: Neurological deficits after spinal cord ischemic/reperfusion injury were not directly responsible for blood-originated phagocytic cells and the inhibition of this type of cell function did not change the outcome.

The effect of pentoxifylline on the lung during cardiopulmonary bypass.

Cardiopulmonary bypass (CPB) produces an inflammatory response due to the interaction of blood with a foreign body surface. The lungs are most affected by this inflammatory response. Pentoxifylline (PTX), a phosphodiesterase inhibitor and an inhibitor of leukocyte activation, is used to minimize damage in lungs where leukocytes play an important role. Twenty patients with mitral valve stenosis with planned mitral valve surgery were included in the study. The ten patients receiving pentoxifylline (PTX group) were administered 400 mg PTX orally TID for 3 days preoperatively and, following anesthetic induction, a 300 mg PTX infusion was given. The ten patients receiving no PTX were the control group (CT). Platelet and leukocyte counts, mean pulmonary arterial pressure (mPAP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI), pulmonary vascular resistance (PVR), alveolar-arterial PO2 gradient (AaDO2) were measured just before and after CPB, and 2 h postoperatively. The number of the leukocytes increased in the blood samples drawn 15 min after CPB in both groups and 2 h postoperatively showed no statistical change. The number of platelets had decreased significantly at the end of the CPB in both groups and, 2 h postoperatively, there was a further decrease in the blood count in the control group (P < 0.05). There was no significant difference in either the preoperative or postoperative PAP, PAWP, and CI. Pulmonary vascular resistance increased in both groups following the CPB (CT, before: 136 +/- 44, after: 177 +/- 94 dyne. sec.cm-5; PTX, before: 151 +/- 82, after 182 +/- 43 dynes.sec.cm-5). Two hours postoperatively, a considerable increase continued in the control group (CT 219 +/- 170 dynes.sec. cm-5), while there was an insignificant increase in the PTX group (PTX 193 +/- 51 dynes.sec.cm-5) (P < 0.05). The alveolar-arterial PO2 gradient increased after the CPB in both groups but a moderate decrease was observed 2 h postoperatively. In lung biopsy specimens taken before and after the CPB, there was marked leukocyte sequestration in the control group, whereas the number of leukocytes was seen to be insignificant in the PTX group (P < 0.005). This dosage regimen of PTX inhibits the postoperative increase in PVR and greatly minimized leukocyte sequestration in the lung due to CPB.