Impact of Preoperative Embolization on Carotid Body Tumor Surgery.

BACKGROUND: The aim of this study is to investigate the effect of preoperative carotid body tumor embolization (CBTE) on the amount of bleeding, and vascular and neurological complications in carotid body tumors. METHODS: Fifty patients treated for 51 carotid body tumors in 2 clinics, between 2005 and 2020, were evaluated. Polyvinyl alcohol embolization of the carotid body tumor was performed in 23 patients before the surgical excision. The results were compared with the remaining 28 patients, in whom CBTE was not performed, in terms of neurological complications, requirement of additional vascular interventions, bleeding amount, and length of hospital stay. RESULTS: Mean bleeding amount was significantly lower in the CBTE group (406-217 mL, P < 0.05). Median erythrocyte suspension transfusion was significantly lower in the CBTE group (0.3 units vs. 1.1 units, P < 0.05). Neurological deficits developed in a total of 13 patients: 6 in the CBTE group and 7 in the non-CBTE group, in the early postoperative period (P = 0.90). No significant difference was observed between the groups in terms of additional vascular interventions and length of hospital stay (P = 0.79 and P = 0.61). CONCLUSIONS: Carotid body tumors are rarely encountered tumors. However, their surgical excision is challenging for surgeons regarding intraoperative and postoperative bleeding. This study demonstrates that preoperative CBTE significantly reduces the amount of bleeding, especially in Shamblin type II/III tumors.

Which is first: left anterior descending artery anastomosis or right coronary artery anastomosis in off-pump coronary artery bypass grafting?

OBJECTIVES: The sequence of the distal anastomosis for revascularization in off-pump coronary artery bypass grafting (OPCABG) surgery is under debate. The hypothesis in this study was that an analysis of cardiac markers would reveal that anastomosing the left anterior descending coronary artery (LAD) before the right coronary artery (RCA) would decrease myocardial damage in OPCABG surgery for 2-vessel disease. METHODS: Forty patients with stable angina who underwent OPCABG surgery and who had LAD and RCA lesions were randomized into 2 groups of 20 patients each. The LAD was revascularized first in group 1, and the RCA was revascularized first in group 2. Cardiac troponin I, creatine kinase (CK), and CK myocardial band (CK-MB) were measured in the 2 groups before surgery and at 8, 24, and 48 hours after surgery. RESULTS: No mortality occurred in the 2 groups. The groups were similar with respect to sex, age, durations of anastomosis of the left internal thoracic artery to the LAD and of the saphenous vein graft to the RCA, and preoperative CK, CK-MB, and troponin I levels. Postoperative CK-MB levels were significantly higher in group 2 in the eighth and 24th postoperative hours than in group 1 (P = .009 and .041, respectively). Similarly, troponin I levels were significantly higher in group 2 in the eighth, 24th, and 48th hours than in group 1 (P = .003, .003, and .006, respectively). CONCLUSIONS: Anastomosis to the LAD first in OPCABG surgery led to a slight reduction in myocardial enzyme release against the occlusion of the target vessels during anastomoses in patients with RCA and LAD stenoses.

Primary cardiac angiosarcoma with right coronary-to-right atrium fistula.

Primary tumours of the heart are rare. About 25% of all cardiac tumours are malignant and the most common of these is the angiosarcoma. We present a 61-year-old male with a right atrial angiosarcoma that was detected on coronary angiography. The tumour showed marked vascularity and a right coronary-to-right atrium fistula, and the patient underwent surgical resection. Pathological examination of the tumour was consistent with a cardiac angiosacoma and the diagnosis was also confirmed by immuno-histochemistry. He consequently underwent chemotherapy, however the patient died 60 days after the surgery.

A simple and effective technique for left ventricular deairing.

OBJECTIVE: Despite careful deairing procedures, residual air has been found in the left ventricle. For this reason, we created a simple and effective left ventricular deairing technique. DESIGN: Forty patients with pure mitral valve disease were randomly divided into 2 groups. In group 1, deairing was done by filling the left atrium actively by a line coming from the aortic cannula line, and by venting from the antegrade cardioplegia line. In group 2, the air was removed by ventilating the lungs, and venting from the antegrade cardioplegia line, but not active filling of the left atrium. The patients were evaluated with transesophageal echocardiograpy during the procedure. RESULTS: According to the preoperative data, the groups were similar. After 3 minutes of deairing, 5 patients in group 2 had transesophageal echocardiographical air bubbles. In these patients, after 2 minutes, the air was removed by an active filling technique. None of the patients in group 1 had air bubbles. DISCUSSION: The technique described in this study seems to solve remaining air problems in the cardiac chambers. It can be applied easily, and it is safe and effective.

Protective effects of levosimendan and iloprost on lung injury induced by limb ischemia-reperfusion: a rabbit model.

BACKGROUND: The aim of this study was to clarify whether levosimendan could prevent lung tissue injury from limb ischemia/reperfusion. METHODS: The common femoral arteries of 50 New Zealand white rabbits, both male and female, each weighing about 3 kg, were clamped and 1 h of ischemia followed by 4 h of reperfusion. In an attempt to decrease reperfusion injury, the rabbits were given levosimendan in Group A. In Group B, iloprost was infused at the same period. A similar value of saline solution was given in the control group, Group C correspondingly. Levosimendan and iloprost were given together the Group E, and Group D was sham group without medication and ischemia. Blood pH, pO2, pCO2, HCO3, Na, K, creatine phosphokinase, lactate dehydrogenase values were determined at the end of the reperfusion period. Malondialdehyde (MDA) was measured in plasma and lung as an indicator of free radicals. Hemodynamics parameters were noted for each group. After the procedure, left lung tissues were taken for histopathologic study. RESULTS: Blood PO2 and HCO3 levels were significantly higher (P < 0.05) and creatine phosphokinase, lactate dehydrogenase, and MDA levels were significantly lower (P < 0.05) in Groups A, B, D, and E compared with Group C. Similarly, the MDA levels in the lung tissue and plasma levels were significantly lower in the treatment groups compared with the control group (P < 0.05). Lung damage was significantly higher in Group C. There was no significant difference between groups in other parameters. CONCLUSIONS: The results suggest that levosimendan and iloprost are useful for attenuating oxidative lung damage occurring after a period of limb ischemia/reperfusion.

The influence of levosimendan and iloprost on renal ischemia-reperfusion: an experimental study.

The effects of iloprost on ischemia-reperfusion injury have been studied on the skeletal, muscle, liver, myocardium, kidney, and spinal cord. However, no sufficient data exist about effects of levosimendan on renal ischemia-reperfusion injury. The purpose of this experimental study was to investigate and compare effectiveness of levosimendan and iloprost on renal injury induced by ischemia and reperfusion. Fifty rabbits were divided into five groups. Levosimendan was continuously infused starting half an hour before the cross-clamp. Cross-clamp time was one hour. After one hour ischemia, levosimendan was continued for 4 h in Group A whereas Group B took iloprost in the same protocol. Group C was the control group which did not receive any medication. Group D was sham group and Group E was medicated both iloprost and levosimendan. Renal tissues were histologically and biochemically evaluated. The histological scores were obtained according to presence of tubular necrosis and atrophy, regenerative atypia, hydropic degeneration (Group A vs. Group C<0.001, Group B vs. Group C<0.001, Group D vs. Group C<0.01, Group E vs. Group C<0.001). Mean malondialdehyde levels were 114+/-12 nmol/g tissue; in Group A 121+/-13 nmol/g tissue, in Group B 134+/-13 nmol/g tissue, in Group E 130+/-11 nmol/g tissue, in Group D 134+/-11 nmol/g tissue (Group A vs. Group B; P=0.003, Group B vs. Group D; P=0.132, Group A vs. Group E; P=0.132). Malondialdehyde levels and histologic scores of all of the groups were significantly different from the control group. Iloprost and pentoxyfillin reduced renal ischemia-reperfusion injury in rabbit model. There was no significant difference between these two medications.

Direct versus side-graft cannulation of the right axillary artery for antegrade cerebral perfusion.

Antegrade selective cerebral perfusion through the right axillary artery has proved to be a safe and effective method for cerebral protection in aortic surgery. In this study, we prospectively evaluated the techniques of direct right axillary artery cannulation (Group 1) and right axillary artery side-graft cannulation (Group 2), investigated cannulation-related complications, and determined the hemodynamic advantages and disadvantages of both cannulation techniques. Sixty-eight patients underwent surgery from April 2001 through August 2004 with the diagnoses of ascending and aortic arch aneurysms (10 patients), type A aortic dissection (56 patients), and aortic pseudoaneurysm (2 patients). There were 22 patients in Group 1 (33.4%) and 46 patients in Group 2 (67.6%). The antegrade selective cerebral perfusion flow was 500 to 700 mL/min in Group 1, whereas in Group 2 the flow was adjusted in accordance with the mean right radial arterial pressure, which was 50 mmHg. There was no significant difference between the groups in antegrade selective cerebral perfusion times, but the transient neurologic dysfunction rate (4 of 22 patients in Group 1 vs 1 of 42 in Group 2) was significantly lower in Group 2 (P =0.035). In Group 1, axillary artery dissection occurred in 2 patients (9%), and postoperative arm ischemia occurred in 1 patient (4.5%). These complications were not seen in Group 2 (P =0.031). The side-graft cannulation technique may be more acceptable because of its lower local-complication rate and because it provides pressure-controlled cerebral perfusion.

Repair of post-infarct ventricular septal rupture with an infarct-exclusion technique: early results.

BACKGROUND: Ventricular septal rupture is a rare but life-threatening complication of acute myocardial infarction. The mortality rate with medical treatment is more than 90%, whereas the mortality rate after surgical repair varies between 19% and 60% in different studies. This study reviews our experience based on early closure of the septal rupture with an infarct-exclusion technique. METHODS: Eighteen consecutive patients who underwent post-infarct ventricular septal rupture operation between June 1, 2000, and November 1, 2005, were included in the study. There were 12 male and 6 female patients. Mean age was 65.72 +/- 5.21 years. All patients had echocardiography and coronary angiography before the operation. Rupture was closed with an infarct-exclusion technique in all patients. Preoperative, operative, and postoperative information were collected from patient cohorts. RESULTS: The median time from myocardial infarction to diagnosis of the ventricular septal rupture was 4.22 +/- 1.61 days. Fourteen of the patients had intra-aortic balloon pump support, and 5 had mechanic ventilator support preoperatively. Surgical repair was done 1 to 4 days after the diagnosis. Ten anterior and 8 posterior ventricular septal ruptures were found. Additional coronary artery bypass surgery was performed with a median of 1.27 +/- 0.8 grafts in 15 (83.3%) patients. The mean postoperative mechanic ventilator support time was 34.13 +/- 45.11 hours. Overall 30-day mortality was 16.7% with 3 patients. The mean intensive care unit stay was 3.3 +/- 1.6 days. Postoperative transthoracic echocardiography showed minimal residual shunts in 4 patients. CONCLUSION: Patch closure of the ventricular septal rupture with an infarct-exclusion technique provided acceptable results. Concomitant coronary artery bypass grafting might be beneficial to control additional risk of an associated coronary artery lesion. Prompt diagnosis followed by early surgical intervention is essential for patients with ventricular septal rupture.

Passive infusion: a simple delivery method for retrograde cardioplegia.

Some damage to the capillaries and increase in myocardial edema have been shown when retrograde cardioplegia perfusion pressure exceeds 40-50 mmHg, or possibly when it falls within this pressure interval. To avoid these complications, we designed a very simple delivery method for retrograde cardioplegia: passive continuous infusion by gravitational force alone. From August 2002 through April 2003, 147 patients undergoing elective coronary artery bypass surgery were randomly allocated into 2 groups. In both groups, isothermic blood cardioplegic solution was infused continuously in a retrograde fashion, after antegrade cardioplegic arrest. Group 1 (n=76) received retrograde infusion passively by gravitational force, while Group 2 (n=71) received retrograde infusion from a manually controlled pressure bag, with the pressure maintained at about 40 mmHg. Myocardial biopsy specimens were taken just before the aorta was declamped, and myocardial edema was scored upon histopathologic examination. Postoperative myocardial damage was evaluated with periodic measurements of CK-MB isoenzyme and cardiac troponin T levels. We recorded cardioplegic infusion pressures and rates, and the total amount of potassium administered. The mean cardioplegic infusion pressures and rates, total potassium levels, and cardioplegic solution amounts were significantly lower in Group 1 than Group 2. Histologic observations revealed significantly less myocardial edema in Group 1. There were no differences between groups in CK-MB isoenzyme or cardiac troponin T levels, mortality, or morbidity. Retrograde continuous infusion of isothermic blood cardioplegic solution by gravitational force alone appears to provide satisfactory myocardial protection and to eliminate the harmful effects of higher pressures upon the myocardium.

Large atherosclerotic left main coronary aneurysm: a case report and review of literature.

Left main coronary aneurysm is a very rare disorder. Aneurysm may be single or multiple, saccular or fusiform. Atherosclerosis, mucocutaneous lymph node syndrome, trauma, angioplasty, atheroctomy, laser procedures, systemic lupus erythematosus, periarteritis nodosa or types of arteritis, dissection, syphilis, mycotic emboli may lead to coronary aneurysms. The main complications of coronary aneurysms are: thrombosis, distal embolisation, rupture and calcification. Operative therapy should be necessary for large left main coronary aneurysms because of their predisposition to thrombosis and embolism. The coexisting significant obstructive CAD may be important in making a decision for the operative treatment in patients with the left main coronary aneurysm. The proper type of operation is not clear.

Early- and long-term comparison of the on- and off-pump bypass surgery in patients with left ventricular dysfunction.

OBJECTIVE: The adverse effects of extracorporeal circulation increase the morbidity and mortality risk of coronary bypass surgery, especially in patients with left ventricular dysfunction. The purpose of this study was to provide a comparison of the early and long-term outcome between patient groups with left ventricular dysfunction (LVEF<40% or LVPS>or=15) operated with or without using cardiopulmonary bypass. METHODS: Fifty-one patients with left ventricular dysfunction, who were operated on between October 1992 and March 1994, were investigated retrospectively. They were divided into two groups: BH-group included 26 patients and cardiopulmonary bypass group had 25 patients. Mean age and risk factors were identical. All patients received one vessel bypass left internal mammary artery to left descending artery. RESULTS: There was no early mortality and perioperative myocardial infarction in either group. In the early postoperative period the need of cardiac support therapy was significantly higher in the cardiopulmonary-bypass group than in the beating heart-group: 32% versus 7.7% (p<0.05). The need for blood products (for fresh frozen plasma 3.63 +/- 2.15u versus 2.5 +/- 1.34u; p = 0.023; for packed red blood cells 1.8 +/- 0.75u versus 1.25 +/- 0.46u; p = 0.048), the extubation time (18.2 +/- 5.5 hours versus 15.3 +/- 3.8 hours; p = 0.03) and the hospital stay (10.64 +/- 3.2 days versus 7.92 +/- 2.25 days; p = 0.001) were higher in the cardiopulmonary bypass -group than in the beating heart-group. Actuarial survival for the beating heart-group was 92.3 +/- 5.2% at 6 years, and for the cardiopulmonary bypass group was 92 +/- 5.4% at 6 years (p = 0.67). CONCLUSIONS: In spite of more than four times as many patients in the cardiopulmonary bypass group requiring inotropic support after surgery, survival and cardiac death rates were similar for both groups. Off-pump bypass surgery conserves the blood constituents. The benefits of both techniques to improve the left ventricular performance score and ejection fraction were similar, but postoperative extubation time, length of intensive care unit and hospital stay were reduced significantly in the beating heart group. With these good results of the beating heart coronary bypass surgery and considering its cost effectiveness, we concluded that coronary bypass on a beating heart can be an alternative to cardiopulmonary bypass technique in selective patient groups.