A New Artificial Chordae Implantation Method in Mitral Valve Surgery.

A novel method is described for artificial chordae replacement with expanded polytetrafluoroethylene suture in mitral valve repair procedures. The technique does not involve knots over or beneath the free edge of the mitral valve leaflets. Artificial chords suspend the exact free margin of leaflets as if it were a continuation of the free margin, such that the smooth zone of the coapting area can be preserved. This technique is simple, reproducible, and applicable to both anterior and posterior leaflets. Moreover, the length of the artificial chords can be adjusted rapidly and accurately at the first attempt.

Hiccup as a result of late lead perforation: report of two cases and review of the literature.

Pacemaker (PM) lead perforation is a rare complication with an incidence of <1%. Late lead perforation is defined as the perforation of a device lead through the myocardium more than 1 month after implantation. It is a subcategory of overall lead perforation and it has been described in several case reports. In the current paper, we present two cases with late partial lead perforation developing after the PM implantation.

Innovative, replaceable heart valve: concept, in vitro study, and acute in vivo study.

The purpose of this study was to evaluate the feasibility of our innovative, replaceable heart valves that can be easily detached from the sewing ring at the time of repeat replacement. The prototype devices consist of the base magnet ring assembly and the valve magnet ring assembly that utilize magnetic coupling force for the locking mechanism. Magnetic coupling strength was evaluated in vitro. Prototype bioprosthetic valves were implanted acutely in three sheep to confirm the feasibility of the replaceable mitral valve. The static separation force of prototype size #25 was 12.5 lb, meeting the design goal. In situ attachment and detachment of the valve magnet ring assembly from the base magnet ring assembly were very easily accomplished in all animals. The magnetic coupling did not decouple even under extremely high left ventricular pressures. We have demonstrated the feasibility of this innovative concept of a replaceable mitral valve.

Reinsertion predictors of intraaortic balloon pumps.

The reinsertion rate of intraaortic balloon pumps (IABP) has not been clearly reported. We evaluated the use of left-ventricular ejection fraction (LVEF), fractional shortening (FS), and cardiac index (CI) values to asses cardiac performance as weaning criteria for IABP in a prospective study performed in 100 patients who required IABP. Patients were randomly divided into 2 groups of 50 patients. In group 1, classical hemodynamic criteria were considered as weaning criteria of IABP. In this group, IABPs were removed when measurements of general hemodynamic criteria were established to be in normal ranges. In group 2, LVEF, FS, and CI values reflecting cardiac performance were used to monitor patients under IABP support, and IABPs were removed when LVEF, FS, and CI values reached >30%, >20%, and >2.4 L/min per m2, respectively. Reinsertion of IABP was necessary in 13 patients in group 1 and in 9 patients in group 2 (P = .48). Vascular complications were the main cause of reinsertion of IABP in 7 and 9 patients in group 1 and group 2, respectively (P = .59). Nine patients died in group 1 and 2 in group 2 (P = .025). In group 1, death due to myocardial dysfunction occurred in 8 of 13 patients (62%) who had required reinsertion of IABP; 6 of these patients required reinsertion of IABP because of hemodynamic deterioration, whereas no patients in group 2 required reinsertion of IABP because of hemodynamic deterioration (P = .027). LVEF, FS, and CI values higher than 30% (P = .008), 20% (P = .005), and 2.4 L/min per m2 (P = .013), respectively, showed good outcomes in regard to avoiding reinsertion of IABP, indicating that these measurements were significant predictors for reinsertion of IABP.

Surgical challenges for urgent approach in penetrating heart injuries.

UNLABELLED: The aim of this clinical study is to assess the characteristics of penetrating heart injury and its surgical challenges for urgent surgical approach. MATERIALS AND METHODS: Seventeen patients suffering from penetrating heart wounds were evaluated retrospectively in the department of cardiovascular surgery between 1996 and 2004. All patients were male, with ages ranging from 19 to 36 years, with a mean age of 23.6 +/- 5 years. RESULTS: Median sternotomy, left anterior thoracotomy, and right anterior thoracotomy were performed to control the bleeding or to reach the heart for internal cardiac massage in 5, 11 and, 1 control, respectively. The right ventricle was the most commonly injured chamber (64.7%, n = 12), followed by left ventricle (17.7%, n = 4), and right atrium (17.6%, n = 3); a left atrial injury was not seen. Mortality rate was 29% (5 cases), and 12 controls were discharged without any complications. CONCLUSION: Although the most important factor affecting mortality in penetrating heart injuries is rapid transport, an urgent approach applied by a specialist team can decrease potential mortality and morbidity rates.

The PediPump: development status of a new pediatric ventricular assist device: update II.

The PediPump is a new ventricular assist device with a hydraulic output range designed for children from newborn infants to adolescents. The design is based on a mixed-flow rotary pump; the rotating assembly consists of a front impeller, front and rear radial magnetic bearings, and a central motor magnet. Two different implantable pumps were designed initially: an intravascular pump measuring 7 x 75 mm and an extravascular pump measuring 14 x 85 mm. Current prototypes are substantially smaller: The current intravascular version measures 4.5 x 55 mm, whereas the current extravascular version measures 11 x 70 mm. Both devices provide pressure and flows capable of supporting adults, far exceeding the initially defined physiologic requirements for children weighing 2 to 25 kg. This basic pump design may be used in acute or chronic clinical settings to provide right ventricular, left ventricular, or biventricular support. There are three objectives for the PediPump development program: 1) determination of basic engineering requirements for hardware and control logic including design analysis for system sizing, evaluation of control concepts, and bench testing of prototypes; 2) performance of preclinical anatomic fitting studies using CT-based 3D modeling; and 3) animal studies to provide characterization and reliability testing of the device.

Does combination of antegrade and retrograde cardioplegia reduce coronary artery bypass grafting-related conduction defects?

BACKGROUND: Conduction disorders appearing after coronary artery bypass surgery (CABG) may have many different causes. In this study, we evaluated the postoperative conduction disorders after CABG with respect to the ante-grade blood cardioplegia and ante-grade plus continuous retrograde cardioplegia delivery methods. MATERIALS AND METHODS: This retrospective study included 1824 patients undergoing CABG between January 2001 and December 2005. There were 694 female patients (38%) and 1130 male patients (62%). Myocardial protection was done by isothermic hyperkalemic blood cardioplegia. Patents in Group 1 (n = 704) were operated on using only intermittent antegrade cardioplegia and those in group 2 (n = 1120) were operated on using the antegrade plus retrograde continuous cardioplegia. The postoperative occurrences of a new right bundle branch block, left anterior hemiblock, left posterior hemiblock, left bundle branch block, or third-degree atrioventricular block were evaluated and compared. RESULTS: Total mortality rate was 1.6% (29 patients) without significant difference between the groups. The preoperative and perioperative characteristics were statistically similar in the groups. The occurrence of conduction disorders was significantly higher in group 1 (P = .006, 55 versus 52 patients). The analysis of the patients with conduction disorders showed a significantly increased mortality rate (P < .001) in addition to a significantly increased period of intensive care unit follow-up and duration of postoperative hospitalization (P <.001). CONCLUSION: The present study demonstrated that the perioperative occurrence of conduction disorders after CABG was decreased by antegrade controlled and retrograde continuous combination cardioplegia.

A novel technique for functional mitral regurgitation therapy: mitral annular remodeling.

BACKGROUND: Functional mitral regurgitation (AIR) plays a pivotal role in the pathophysiology of congestive heart failure, a major cause of cardiac morbidity and mortality. We have developed a mitral annular remodeling procedure through injection of a nonabsorbable substance into the peri-annular tissue of the posterior mitral annulus to reduce the mitral annular dimension in the septal-lateral axis. The purpose of this study is to describe a novel procedure for treatment of functional AIR and report its effects on the geometry of the mitral annulus and degree of AIR. METHODS: Seven preliminary studies were performed using an epicardial approach in a healthy dog model to establish the feasibility of this injection procedure. Unexpectedly, 2 of 7 healthy dogs had a functional AIR of grade 1 to 2+. In these 2 cases, the hemodynamic, angiographic, and echocardiographic assessments were conducted. RESULTS: A nonabsorbable substance injection was successfully performed on a beating heart without instability of hemodynamics or any evidence of myocardial ischemia in all 7 dogs. In the 2 dogs with a functional AIR, it was confirmed that the septal-lateral dimension decreased from 3.2 +/- 0.2 to 2.6 +/- 0.5 cm and the observed MR was reduced (AIR area from 1.2 +/-0.1 to 0 cm2) without any adverse effects on hemodynamics or coronary circulation (circumflex artery flow, 36.5 +/- 0.4 to 40.5 +/- 0.1 mL/min). CONCLUSION: Off-pump mitral annular remodeling through substance injection may be one procedural option for treatment of functional AIR.

Purple, stiff lesions resembling varicose veins on lower limb: certainly consider Kaposi sarcoma.

Kaposi's sarcoma (KS) typically presents multiple cutaneous lesions of the lower extremities. Lesions can rarely mimic varicose veins without venous insufficiency, vascular or stasis ulcers. As the initial diagnosis of KS is generally determined clinically, a high index of suspicion and palpation of lesions are necessary for all patients with atypical presentations of varicose-like lesions of lower extremities. Tissue biopsy with histological analysis is essential for all uncertain lesions. This is a case of KS occurring in a 79-year-old man who presented with indurated vascular plaques resembling varicose veins on the right foot.

Left atrial appendage mass: is it always a thrombus?

Myxoma is the most common benign tumor of the heart, but it is very rare for it to originate from the left atrial appendage. Distinguishing between a mass, a thrombus, and a tumor in the body of the left atrium with preoperative transthoracic or transesophageal echocardiography is very difficult, even more so in patients with mitral valve disease and chronic atrial fibrillation. A 50-year-old male patient was admitted for surgery with the diagnosis of mitral stenosis and chronic atrial fibrillation. Transesophageal echocardiography demonstrated a mass attached to the wall of the left atrial appendage. Histopathological examination of the mass showed an image compatible with a myxoma. We hereby describe a case of a left atrial appendage myxoma mimicking a left atrial appendage thrombus.

Hypothyroidism complicates bradyarrhythmic episodes in a heart-transplanted patient: Can it be treated with low-dose dopamine?

Extracorporeal circulation decreases thyroid hormone levels in peripheral blood. This clinical entity may complicate the postoperative period after heart transplantation if the recipient has taken thyroid hormone replacement therapy. Cardiac transplantation was performed on a patient in whom thyroid hormone levels decreased after surgery. Sinus bradycardia was seen after surgery (30-40 bpm). Thyroid hormones were replaced in the patient. Due to the fact that temporary pacing decreased blood pressure, dopamine was safely given in very low doses. This case was discussed under the literature knowledge.

Epicardial dissection may solve the problem of saphenous vein graft length.

Saphenous vein graft length may be not enough in some cases in aortocoronary bypass surgery. If the graft length is not enough, cardiac surgeons can use epicardial and fatty dissection to release tightening saphenous vein graft, especially in the right coronary artery fashion.

Coronary artery spontaneous dissection in a young male heavy smoker during bed rest.

Spontaneous dissection of coronary artery (SDCA) is an extremely infrequent cause of acute cardiac ischaemic manifestations or sudden cardiac death with complex pathophysiology. This condition mostly affects young women in association with peripartum or postpartum status with no known risk factors for cardiovascular disease although some correlations have been noted with connective tissue disorders contraceptive use or intense physical activity. Herein, we report a case of spontaneous dissection of the left anterior descending artery during bed rest in a 24-year-old young man who had no risk factors except smoking or family history of coronary artery diseases.

Novel variant of dual left anterior descending artery arising from single right coronary artery anomaly presenting with angina inversa.

A 55-year-old female without a history of coronary artery disease, hypertensive for the past 17 years, was admitted with resting chest pain. Electrocardiography revealed a negative T-wave in anterior chest leads. Coronary angiography visualised anomalous coronary anatomy, with a common origin of the right coronary artery and the left main coronary artery in the right sinus of Valsalva serving as a common coronary trunk. It should be emphasised that T-wave abnormalities and chest angina may be related to this congenital coronary anomaly.

Does tranexamic acid reduce desmopressin-induced hyperfibrinolysis?

OBJECTIVE: Desmopressin releases tissue-type plasminogen activator, which augments cardiopulmonary bypass--associated hyperfibrinolysis, causing excessive bleeding. Combined use of desmopressin with prior administration of the antifibrinolytic drug tranexamic acid may decrease fibrinolytic activity and might improve postoperative hemostasis. METHODS: This prospective randomized study was carried out with 100 patients undergoing coronary artery bypass operations between April 1999 and November 2000 in Gülhane Military Medical Academy. Patients were divided into 2 groups. Desmopressin (0.3 microg/kg) was administrated just after cardiopulmonary bypass and after protamine infusion in group 1 (n = 50). Both desmopressin and tranexamic acid (before the skin incision at a loading dose of 10 mg/kg over 30 minutes and followed by 12 hours of 1 mg.kg(-1).h(-1)) were administrated in group 2 (n = 50). RESULTS: Significantly less drainage was noted in group 2 (1010 +/- 49.9 mL vs 623 +/- 41.3 mL, P =.0001). Packed red blood cells were transfused at 2.1 +/- 0.5 units per patient in group 1 versus 0.9 +/- 0.3 units in group 2 (P =.0001). Fresh frozen plasma was transfused at 1.84 +/- 0.17 units per patient in group 1 versus 0.76 +/- 0.14 units in group 2 (P =.0001). Only 24% of patients in group 2 required donor blood or blood products compared with 74% of those in the isolated desmopressin group (group 1, P =.00001). Group 1 and group 2 findings were as follows: postoperative fibrinogen, 113 +/- 56.3 mg/dL versus 167 +/- 45.8 mg/dL (P =.0001); fibrin split product, 21.2 +/- 2.3 ng/mL versus 13.5 +/- 3.4 ng/mL (P =.0001); and postoperative hemoglobin level, 7.6 plus minus 1.2 g/dL versus 9.1 plus minus 1.2 g/dL (P =.0001). CONCLUSION: Tranexamic acid administration significantly reduces desmopressin and bypass-induced hyperfibrinolysis. Combined use of tranexamic acid and desmopressin decreases both postoperative blood loss and transfusion requirement.

Supraclavicular control of patent internal thoracic artery graft flow during aortic valve replacement.

BACKGROUND: The mortality and morbidity of aortic valve replacement (AVR) after prior coronary artery bypass surgery (CABG) with patent left internal thoracic artery (LITA) is significant. The risk of LITA injury and inadequate myocardial preservation during the cross-clamp period may cause myocardial pump failure. METHODS: A total of 43 patients with a patent LITA graft underwent AVR. The patients were divided into the two groups. Group 1 included 19 patients who underwent AVR with deep hypothermia (20 degrees C) without LITA clamping. Group 2 included 24 patients in whom LITA flow was controlled through supraclavicular occlusion and AVR performed with moderate hypothermia (28 degrees C). RESULTS: Average cardiopulmonary bypass time (CPB) time was 118.79 +/- 20.36 minutes in group 1 and 102.67 +/- 9.66 minutes in group 2 (p = 0.006). Average cross-clamp time was 53.79 +/- 7.26 minutes in group 1 and 49.63 +/- 6.7 minutes in group 2 (p = 0.022). Inotropic support was required in 12 patients in group 1 and 4 patients in group 2 (p = 0.002). Average intensive care unit stay was 4.68 +/- 2.24 days in group 1 and 2.29 +/- 0.46 days in group 2 (p < 0.001). Average hospital stay was 11.84 +/- 2.91 days in group 1 and 8.04 +/- 2.38 days in group 2 (p < 0.001). Mortality due to myocardial failure developed in 4 patients in group 1 but in none of the patients in group 2 (p = 0.02). CONCLUSIONS: Proximal control of LITA flow by extrathoracic supraclavicular occlusion reduces the incidence of myocardial failure due to nonhomogenous cardioplegia delivery to the anterior wall of the heart, resulting in improved myocardial protection and the elimination of the need for deep hypothermia.

Cardiac reoperation by Carpentier bicaval femoral venous cannula: GATA experience.

BACKGROUND: Division of the sternum is primarily a blind procedure in reoperation and carries an increased risk of injury for major cardiac structures in the presence of adhesions between the posterior table and the heart. METHODS: Two hundred patients were randomly divided into two groups. Cardiopulmonary bypass was established through the femoral artery and vein in group 1 (n = 100) patients before sternal reentry. Carpentier dual-stage femoral venous return cannula was used in all group 1 patients. Cardiopulmonary bypass was performed after sternal reentry in group 2 (n = 100) patients. RESULTS: Six severe cardiac injuries developed in group 2. Cardiopulmonary bypass time was 93 +/- 9 minutes in group 1 and 71 +/- 11 minutes in group 2 (p = 0.011), and the operation time was 155 +/- 23 minutes in group 1 and 185 +/- 32 minutes in group 2 (p = 0.024). Inotropic therapy was required in 52 patients in group 1 and 76 patients in group 2 (p = 0.032). Average chest drainage was 450 +/- 135 mL in group 1 and 850 +/- 250 mL in group 2 (p < 0.001). Average fresh whole blood transfusion was 3.3 +/- 1.2 U in group 1 and 5.8 +/- 0.9 U in group 2 (p = 0.033). Average intensive care unit stay was 2.2 +/- 1.3 days in group 1 and 4.5 +/- 2.3 days in group 2 (p = 0.025). Average hospital stay was 7.3 +/- 2.4 days in group 1 and 9.1 +/- 3.1 days for group 2 (p = 0.011). CONCLUSIONS: Cardiopulmonary bypass by bicaval Carpentier femoral venous cannula before resternotomy not only allows adequate cardiopulmonary bypass flow but also significantly reduces the risk of cardiac injury and catastrophic hemorrhage and allows safe reopening. Although this procedure increases cardiopulmonary bypass time, the operation time, bleeding, and blood transfusion requirement are significantly reduced.

Vascular complications related to lumbar disc surgery.

OBJECT: Vascular complications related to lumbar disc operations are rare but extremely fatal conditions. The authors analyzed data retrospectively obtained in 13 patients with vascular complications that occurred during lumbar disc operations performed between January 1990 and January 2002. METHODS: One patient underwent an L5-S1 procedure and the remaining underwent L4-5 surgery. Missed injuries, which were found during the late postoperative period, included pseudoaneurysm in four cases and an arteriovenous fistula in one. In all cases except one in which complication occurred early in the postoperative period, the retroperitoneal area was reached via a transperitoneal approach. In eight patients with complications occurring early in the postoperative period. Dacron graft was placed in four with arterial injuries and saphenous vein graft in one. In three cases of arterial injury and five of venous injury, the lesion was repaired using the primer suture technique. The most commonly affected vessels were left common iliac arteries (76.9%) and left common iliac vein (30.8%). In eight early cases, shock or preshock due to hemorrhage developed during the early phase. During the late postoperative period, graft-related infection occurred in two cases in which Dacron graft was placed, and axillofemoral extraanatomical bypass surgery was later performed. There was no surgery-related death. During a mean follow-up period of 5.6 years, none of the patients suffered any problems related to vascular injury. CONCLUSIONS: Despite its low incidence, iatrogenic vascular injury related to lumbar disc surgery is a possible complication. During lumbar disc operations early diagnosis of vascular injuries and urgent transperitoneal surgery can save patients' lives.