Coronary bypass grafting via minithoracotomy on the beating heart.

BACKGROUND: Recently the availability and the superiority of less invasive coronary artery bypass grafting on some selected groups of patients in the meaning of patient comfort and short hospital stay has been shown by some authors. We present here the clinical results of 40 patients operated on by minithoracotomy incision on the beating heart without using cardiopulmonary bypass mostly harvesting the left internal thoracic artery by videothoracoscopic assistance. METHODS: Between March 1996 and September 1996, 40 patients were operated on by harvesting the left internal thoracic artery mostly by video-assisted thoracoscopy and performing bypass through a minitoracotomy incision. Two patients in whom the procedure was switched to conventional technique were not included in this series. Nine of the patients were female and the rest were male. The mean age was 43.2 +/- 7. RESULTS: Left internal thoracic arteries were harvested by video-assisted thoracoscopy completely in 11 patients, incompletely in 24 patients (the harvesting was completed by direct vision afterwards), and under direct vision in 5 through a mini-anterior thoracotomy incision. Thirty-six patients received a bypass graft to left anterior descending coronary artery only, whereas 4 received a diagonal branch graft also. Left internal thoracic arteries were used to bypass the left anterior descending coronary artery directly in 38 patients. The left internal thoracic artery was injured in the middle portion during harvesting in 1 of the remaining 2 patients. The length was not enough in the other. A short saphenous vein graft was interposed between the left internal thoracic artery and the left anterior descending coronary artery in these 2 patients. There was no mortality. One patient had perioperative myocardial infarction. We did not see serious morbidity except one lung injury due to the trochar. CONCLUSIONS: The results obtained from our experience suggest that coronary artery bypass grafting by minithoracotomy could be applied effectively and safely without overwhelming additional risk to the patient. Furthermore, it has some advantages in reducing operative trauma and cost and also improving patient comfort.

Cardioscopy and robotic assistance for the diagnosis of intraventricular endocarditis.

A 44-year-old male patient with an undefined mass in the left ventricular endocardium was scheduled for minimally invasive cardiac surgery. Ventricular investigation and tissue biopsies were completed with the help of a voice-controlled robotic arm. Pathologic examination revealed non-bacterial thrombotic endocarditis. In addition to videoscopy, robotic assistance allows an easier diagnostic and therapeutic approach of intraventricular pathologies.

A new technique for abdominal heart transplantation in rats.

Experimental studies in animals play a major role in the progress of medicine. Different surgical techniques have been described for heterotopic heart transplantation in rats. In this study we introduce a new technique for heart transplantation in the abdominal cavity of rats. Fifteen Sprague Dawley rats have been used as recipients and 15 others as donors. Following preparation of recipient abdominal aorta and left renal vein, the donor heart including proximal arcus aorta was harvested. Donor aorta was anastomosed to the recipient's aorta; donor pulmonary artery was anastomosed to the left renal vein of the recipient using continuous suture technique. Graft function was evaluated daily by palpation of the rat abdomen. The mean operating time was 38.46+/-2.66 min and the mean ischemia time was 23.93+/-2.11 min. One death was seen because of bleeding of the aorto-aortic anastomosis. In this study we evaluated advantages and disadvantages of our technique and compared it to other techniques. This modification provides a more anatomical position, reduces exploration time, has a low incidence of morbidity and mortality. We conclude that, this implantation technique is more suitable for heterotopic heart transplantation in rats.

A left pulmonary artery aneurysm secondary to pulmonary hypertension.

We report a case of pulmonary trunk aneurysm extending into the left pulmonary artery, due to pulmonary hypertension secondary to mitral valve disease. The mitral valve was replaced with a bileaflet mechanical prosthesis. A Dacron graft interposed between main trunk and left pulmonary artery branch, and right pulmonary branch attached to the graft in an end-to-side fashion. Early postoperative angiogram revealed a very successful treatment.

Extra-anatomic coronary artery bypass graftings in patients with porcelain aorta.

AIM: Severely atherosclerotic (porcelain) ascending aorta is associated with increased morbidity and mortality during coronary artery bypass grafting (CABG) due to the increased risk of perioperative atheroembolism. Three maneuvers during CABG can cause atheromatous embolism from the diseased ascending aorta: 1) cannulation of the ascending aorta; 2) cross- clamping; 3) partial clamping for the construction of the proximal anastomosis. METHODS: In our hospital, extra-anatomic CABG was performed in 8 patients with heavily calcified ascending aorta: 6 patients were men and 2 women. Operations were performed on the beating heart in 5 patients, 2 patients operated on beating heart and another patient on fibrillating heart with supportive cardiopulmonary bypass (CPB). Arterial cannulation was done through the right femoral artery on these patients. Apart from internal mammary artery (IMA) grafts, proximal anastomotic sites were the right axillary, right subclavian and innominate arteries. RESULTS: One patient who preoperatively had dialysis dependent chronic renal failure, died as a result of dialysis complication on the 5th day. The postoperative course was uneventful in the other patients and no patient experienced either any cerebrovascular or visceral organ injury as a result of atheroemboli. CONCLUSION: We think that extra-anatomic CABG procedures are safe and reliable in patients with severely atherosclerotic (porcelain) ascending aorta to minimize the prevalence of perioperative stroke and systemic embolization.

The role of posterior pericardiotomy on the incidence of atrial fibrillation after coronary revascularization.

AIM: Pericardial effusion and atrial fibrillation (AF) are two common complications in coronary revascularization surgery. The aim of this study was to evaluate the efficiency of posterior pericardiotomy in pericardial effusion and AF. METHODS: This randomized prospective study includes 113 patients who underwent isolated CABG procedure between May 2000 and December 2000 in our hospital. Posterior pericardiotomy incision was done in Group I (n=54). Group II constituted the control group (n=59). Postoperative pericardial effusion was assessed by echocardiography and rhythm follow-up was done by the same cardiologist. RESULTS: There was no significant difference between study group and the control group considering the chest drainage (940.18+/-367.96 vs 894.92+/-360.65; p=0.507). The number of patients with remarkable intrapericardial effusion (>50 ml) was significantly lower in the posterior pericardiotomy group (25.93% vs 47.45%, p=0.020). The incidence of postoperative AF was no different between the posterior pericardiotomy group and the control group (12.96% vs 20.34%; p=0.32). In both groups, the incidence of AF was significantly higher in patients with mild or moderate pericardial effusion (29%), compared to patients with no or minimal pericardial effusion (10%), (p=0.017). CONCLUSION: Posterior pericardiotomy significantly reduces the pericardial effusion in coronary bypass procedure postoperatively. Patients with pericardial effusion were subjected to AF more frequently.

Atrial septal defect repair with minithoracotomy using two stage single venous cannula.

AIM: Repair of atrial septal defect (ASD) via minimal access has been the preferred method to improve cosmesis and fast rehabilitation. A 2-stage single venous cannula introduced via the femoral route allows better vision of the surgical field and improves surgical acts through a limited incision. METHODS: From February 1999 to December 2001 a minithoracotomy approach was used for closure of secundum type ASD by using single bicaval venous cannula in 17 adult patients. A 6 to 7 cm anterior minithoracotomy (submammary) approach with femoral arterial and 2-stage single venous cannula were utilized. Defects were closed primarily by running suture in 14 and with a patch in 3 patients. RESULTS: Calculated flow levels were maintained with a single venous cannula without assisted venous drainage in all patients. The postoperative course was uneventful in all patients except 1 who required revision for bleeding which was done through the same incision. Extension of the thoracotomy or shifting to the classic sternotomy was never required. CONCLUSION: Single venous bicaval cannula allows efficient drainage of both vena cavae and improves the surgical vision and manipulation through the right minithoracotomy. With this technique, repair of ASD can be done safely with good cosmesis.

Acute aortic valve regurgitation secondary to blunt chest trauma.

Blunt injury to the cardiac valves leads to progressive acute ventricular failure, which often requires urgent surgical management. In this case report, we describe an acute aortic valve rupture caused by air-bag inflation during an automobile accident. Laceration of an aortic valve cusp was treated successfully with urgent aortic valve replacement. A concomitant orthopedic injury was treated electively 15 days after cardiac surgery Acute aortic valve rupture is a very rare complication of blunt chest trauma. We discuss how to diagnose and manage this potentially catastrophic event.

[Coronary bypass surgery in octogenarians]. / Dokuzuncu dekatta koroner bypass cerrahisi.

OBJECTIVE: The age of the patients referred for coronary bypass surgery is getting older progressively. Early and late postoperative outcome of octogenarians were evaluated and compared with younger age group in this study. METHODS: Records of 55 patients aged 80 years or older (mean age 82.7 +/- 2.8) among 3834 patients, who had coronary bypass graft procedure, operated between 1995 and 2001 were reviewed retrospectively. RESULTS: There were 39 men (70.9%) and 16 women (29.1%). Three patients had aortic valve replacement, 1 had left ventricular aneurysm repair, 1 had carotid endarterectomy additionally. Atrial fibrillation (21.8%), renal dysfunction (16.4%), and prolonged ventilation (10.9%) were the prominent complications. The hospital mortality rate was 7.27% (4 patients). Kaplan Meier Survival Analysis estimated that at the end of 5 years 83.1 + 5.2% of patients were still alive. CONCLUSION: Coronary bypass operations can be performed in octogenarians with slightly increased but acceptable hospital mortality and longer hospital stay. Early intervention and individual modifications in cardiopulmonary bypass techniques may improve the results in this patient population.

Deep venous thromboembolism and pulmonary embolization as a rare complication of diagnostic femoral catheterization and prevention of recurrence with inferior vena cava filter prior to cardiac surgery.

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are rare complications after diagnostic femoral catheterization. A few clinical cases have been reported, especially in the setting of venous compression with an enlarging haematoma, mechanical groin compression or prolonged procedures. Similarly, clinically evident PE after cardiac surgery is also very rare, but may be catastrophic. In this article, we present a case of PE after silent (symptomless) DVT due to femoral catheterization. The patient had critical coronary artery disease and was a candidate of coronary artery bypass grafting. A inferior vena cava filter was implanted prior to cardiac surgery for prevention of a potential pulmonary embolus.