Results of combined preoperative direct percutaneous embolization and surgical excision in treatment of carotid body tumors.

BACKGROUND: Carotid body tumors are infrequent neoplasms in daily practice. Diagnostic difficulties exist because of their slow growth and asymptomatic progress. The surgical treatment is complicated and difficult due to their proximity to vascular and neural structures. In this study we present the results of 12 patients operated for carotid body tumor that underwent preoperative percutaneous direct embolization. PATIENTS AND METHODS: The data of 12 patients, diagnosed with carotid body tumor and surgically treated at our department between 2000 and 2010, was retrospectively analyzed. Duplex ultrasound, computerized tomography and selective carotid angiography were the applied diagnostic tools. Two days before the planned surgery all patients underwent percutaneous direct embolization to achieve devascularization of the tumor. Afterwards, surgical excision of the mass under general anesthesia was performed in all cases. RESULTS: Five tumors were classified as Shamblin type I (41.7%), and the others were type II (58.3%). All masses were removed sub-adventitially and no vascular reconstruction was necessary. There was no mortality and no permanent neural damage. Malfunction of the tongue was observed in only one case, which recovered completely in one month. There was one recurrence detected by Duplex ultrasound and angiography during the follow up period. CONCLUSIONS: Surgical excision is mandatory to be performed as soon as diagnosed in carotid body tumors. Preoperative direct percutaneous embolization of the mass helps to devascurize the tumor, enabling an optimal surgical procedure. The outcomes of such a combined intervention are excellent and neurovascular structure preservation decreases complication and morbidity rates.

Coronary subclavian steal syndrome in a patient with Behçet's disease.

We present a case of a 44-year-old woman with Behçet's disease, who underwent coronary artery bypass surgery. The patient was readmitted with symptoms of dizziness and angina pectoris that became more severe with movement of her left arm. Angiography revealed a totally occlusive stenosis, caused by coronary subclavian steal syndrome, which was detected in the left subclavian artery. The aim of this report is to emphasize the relationship between Behçet's disease and vascular occlusive changes.

Importance of urinary measurement of glutathione S-transferase in renal dysfunction patients after on- and off-pump coronary artery bypass surgery.

BACKGROUND: Acute renal failure (ARF) occurring after on-pump and off-pump cardiac surgery was assessed by urinary alpha glutathione S-transferase measurement (alpha-GST) in patients who already had renal dysfunction. METHODS: Fifty-one patients with plasma creatinine levels ranging between 1.5 and 2.0 mg/dL were included in the study. On-pump coronary artery bypass was performed in 25 of them, and off-pump surgery in the other 25 patients. Urinary alpha-GST levels, plasma creatinine levels, creatinine clearance and fractional excretion of sodium were measured. RESULTS: Urinary alpha-GST levels were found to be significantly increased at 24 hours postoperatively. A weak correlation was detected between alpha-GST levels and plasma creatinine, creatinine clearance and fractional excretion of sodium. Preoperative and postoperative 24 hour levels showed a positive predictive value for the occurrence of acute renal failure. CONCLUSIONS: Tubular damage produced by cardiopulmonary bypass is not the only factor associated with postoperative ARF. Because factors independent of pump usage can adversely affect renal function, excluding pump usage alone is not sufficient to prevent postoperative ARF in patients who have preoperative renal dysfunction.

Leukodepletion improves renal function in patients with renal dysfunction undergoing on-pump coronary bypass surgery: a prospective randomized study.

BACKGROUND: We aimed to show the impact of leukodepletion on renal function in patients undergoing on-pump coronary revascularization. PATIENTS AND METHODS: Fifty patients awaiting elective on-pump coronary revascularization with normal preoperative cardiac functions and with plasma creatinine levels ranging between 1.5 and 2.0 mg/dL were prospectively randomized into two groups: on-pump CABG with (group A: n = 25) and without leukodepletion (group B, n = 25). Renal glomerular and tubular injury were assessed by urinary alpha glutathione s-transferase (GST), plasma creatinine, and blood urea nitrogen (BUN) levels. RESULTS: The patients consisted of 14 females and 36 males with a mean age of 57.6 +/- 5.3 years. In the leukodepletion group, the mean levels of creatinine, BUN and urinary GST were found to be decreased on the first, third and fifth postoperative days compared with the control group. There was no mortality. Three patients in the control group needed postoperative dialysis. CONCLUSION: Patients with renal dysfunction undergoing on-pump CABG surgery seem to benefit from leukodepletion as a measure to prevent tubular damage and renal impairment compared with a control group.

Comparison of ultrasonically activated scalpel and traditional technique in radial artery harvesting: clinical research.

BACKGROUND: Use of the radial artery (RA) as a conduit in coronary artery bypass grafting (CABG) has become increasingly popular in recent years. The aim of this study was to compare the results of two different RA harvesting techniques. Use of the harmonic scalpel is suggested to be safe and additionally reduces spasm rates. MATERIAL AND METHODS: From January 2000, the first 200 consecutive patients who underwent RA harvesting for CABG were enrolled in this study. Patients were divided into two groups. RA was harvested by means of electrocautery + hemoclips in Group I and by harmonic scalpel + hemoclips in Group II. 30 patients (30 %) in Group I and 25 patients (25 %) in Group II were female. Mean age was 53.9 +/- 9.3 and 53.5 +/- 8.4 years in Group I and Group II, respectively. Hand circulation and ulnar collateral flow was assured with a modified Allen test in all patients preoperatively. During the operation perfusion of the hand was monitored by oximetric plethysmography. The distal end of RA was also explored and clamped with a soft vascular clamp to evaluate the saturation values in the groups. During the clamping period, oxygen saturation values did not decrease so we harvested RAs in all patients. RESULTS: There were no statistically significant differences between the groups with the exception of the RA harvesting times, the postoperative analgesia requirements, the rate of vasospasm and the need for hemostatic clips. CONCLUSION: Harmonic scalpel usage in RA harvesting causes less trauma to adjacent tissues; the analgesia requirements, the rate of vasospasm, the RA harvesting time and the need of hemostatic clips decreases. We conclude that the use of a harmonic scalpel for radial artery harvesting is safer and faster than the routine technique.

Pre-emptive stellate ganglion block increases the patency of radial artery grafts in coronary artery bypass surgery.

BACKGROUND: We evaluated the role of pre-emptive stellate ganglion block (SGB) in preventing radial artery spasm and increasing radial artery graft patency in patients undergoing off-pump coronary artery bypass surgery. METHODS: In this prospective randomized study, 100 patients were divided into two equal groups (n= 50). In group A, SGB was achieved using 10 ml of ropivacaine and, in group B, SGB was not performed. Radial artery blood flow was measured pre- and intra-operatively. Post-operative clinical determinants (S-T segment elevation, use of inotropic agents, incidence of atrial fibrillation) were recorded. Early coronary angiography was performed. RESULTS: According to blood flowmeter measurements, the radial artery blood flow was significantly increased in patients with SGB. The incidence of atrial fibrillation, the need for inotropic agents and S-T segment elevation were all decreased in the SGB group. Angiographic intervention revealed that the incidence of graft spasm was also lower in the SGB group. CONCLUSION: Pre-emptive SGB is an effective method for increasing radial artery blood flow and preventing radial artery spasm. Complications related to radial artery spasm may be decreased and patients may have a more comfortable post-operative period with this method.

Results of endocardial radiofrequency ablation of atrial fibrillation during mitral valve surgery.

AIM: The aim of the study is to evaluate the efficacy of thermocontrolled endocardial radiofrequency (RF) ablation for the patients with mitral valve disorder and associated chronic atrial fibrillation during mitral valve replacement operation. METHODS: Between February 2002 and January 2004, 43 patients with mitral valve disease and associated chronic atrial fibrillation underwent mitral valve replacement and thermocontrolled endocardial RF ablation with Cobra RF system flexible probe at Gulhane Military Academy of Medicine, Department of Cardiovascular Surgery. Eighteen of the patients (41.8%) were males, while the remaining 25 (58.2%) were females. The average age of the patients was 44+/-14.21 (18-66) years. Functional capacity of the patients was class II in 15 (34. 9%), class III in 24 (55.8%), class IV in 4 (9.3%) according to the NYHA classification. At the preoperative period all of the patients were evaluated routinely by twelve-lead ECG, chest film and transthoracic echocardiography (TTE). For the patients over 40 years of age, we performed additional coronary angiography to delineate any coronary lesions. The patients were evaluated at months 1, 3, 6 and annually by twelve-lead ECG, TTE and holter monitoring after discharge. RESULTS: There were not any complications related to the performed technique. No operative and hospital mortality were recorded. At the follow-up period for 35 of 43 patients (81.4%) sinus rhythm was restored. The mean follow-up time was 24.3+/-11.2 (12-35) months. CONCLUSION: Endocardial RF ablation especially during mitral valve surgery is a simple technique to be performed. Early and midterm results of the cohort are satisfying.

Leptin, soluble interleukin-6 receptor, C-reactive protein and soluble vascular cell adhesion molecule-1 levels in human coronary atherosclerotic plaque.

The aim of the present study was to explore the relationship between tissue levels of leptin, soluble interleukin-6 receptor (sIL-6R), high-sensitive-C-reactive protein (hs-CRP) and soluble vascular cell adhesion molecule-1 (sVCAM-1) in atherosclerotic plaques, and traditional risk factors. Coronary artery specimens were obtained from 35 consecutive patients (26 men and nine women) who underwent coronary artery bypass grafting procedure. The mean tissue levels of leptin, hs-CRP and sIL-6R were significantly higher in patients with diabetes mellitus than without diabetes mellitus. When patients were classified according to the smoking status, the mean tissue levels of leptin, hs-CRP and sIL-6R were significantly higher in current smokers than both former smokers and non-smokers. In addition, the mean tissue levels of leptin and sIL-6R were significantly higher in former smokers than non-smokers. There was a positive association between leptin and hs-CRP, sIL-6R and plasma glucose in all patients. Plasma HDL levels were associated negatively with atherosclerotic tissue levels of leptin. Tissue levels of sIL-6R were associated significantly in a positive manner with leptin, hs-CRP and plasma glucose, while tissue levels of hs-CRP were associated with both leptin and sIL-6R. In conclusion, it is attractive to speculate that hs-CRP, sIL-6R and leptin could act synergistically in course of local inflammatory activity and those molecules may not be just markers of inflammation and cardiovascular risk but are also likely to play a pathogenic role in atheromatous plaque. In addition, atherosclerotic tissue levels of CRP, sIL-6R and leptin were significantly higher in current smokers and patients with diabetes.

Midterm experience with the Sorin Bicarbon heart valve prosthesis for rheumatic disease.

BACKGROUND: In this study, we present a single center experience with Bicarbon bileaflet valve in 307 patients with rheumatic heart disease. METHODS: Between August 1998 and September 2000, 307 patients underwent heart valve replacement using the Bicarbon bileaflet valve (Sorin Biomedica, Saluggia, Italy) with an average age of 47.19+/-13.21 years (range 14 to 80 years), consisting of 147 males and 160 females at Alkan Hospital, Cardiovascular Surgery Department. Aortic valve replacement (AVR) was performed in 77 patients, mitral valve replacement (MVR) in 156 patients and double valve replacement (DVR) in 74 patients. RESULTS: The early mortality rate was 3.3% (10/307) and there was no late mortality. The actuarial survival rate, including hospital mortality, was 96.74+/-1.01% for the whole group, 96.5+/-1.5% for the MVR group, 97.4+/-1.8% for the AVR group and 97.3+/-1.9% for the DVR group at 35 months. One patient had obstructive valve thrombosis with MVR. The 35 months actuarial freedom from valve thrombosis was 99.58+/-0.4% for the whole group. Four patients were reoperated and the 35 months actuarial freedom from reoperation was 98.53+/-0.7% for the whole group, 98.65+/-0.9% for the MVR group, 96.73+/-02% for the DVR group and 100% for the AVR group. No instances of perivalvular leak, hemolysis, endocarditis or embolism were observed during the entire follow-up period. Mean follow-up duration was 16.5+/-7.9 months (ranged 4 to 35 months). CONCLUSION: We have presented our mid-term results with the Sorin Bicarbon bileaflet valve in patients with rheumatic heart disease, which provided good clinical performance combined with meticulous patient care and advanced surgical techniques.

Clinical experience with Sorin Bicarbon valve in patients with tight mitral valve stenosis and elevated pulmonary hypertension (early and mid-term results).

BACKGROUND: The results of mitral valve replacement (MVR) with Sorin mechanical valves in patients who had tight mitral stenosis with high pulmonary artery pressure were reviewed. METHODS: During a period of two years, from August 1998 to May 2000, a mitral valve replacement with a Sorin Bicarbon mechanical valve was performed in 51 patients with a diagnosis of tight mitral stenosis associated with severe pulmonary hypertension (preoperative mean systolic pulmonary artery pressure was 72+/-12 mmHg, range from 60 to 105 mmHg). There were 37 women and 14 men; mean age was 47.2+/-12 years. Forty-eight patients (94.12%) were in NYHA functional class III or IV. All the patients discharged from the hospital were submitted to a clinical follow-up program. A 100% follow-up was obtained with a mean of 12.6+/-6.4 months (range 2 to25 months). RESULTS: Operative mortality was 3.9%, 2 patients who had concomitant CABG died due to low cardiac output. Twelve patients (23.5%) needed an inotropic pharmacological support during the postoperative time. In one patient a re-exploration for bleeding was necessary, and in another one a cerebrovascular accident occurred 3 days after the operation. After 6 months, one patient was reoperated on because of mechanical valve dysfunction due to pannus formation. All survivors underwent a postoperative echocardiographic assessment. The systolic PAP decreased from a mean preoperative value of 72+/-12 mmHg to 39.9+/-12 mmHg. NYHA functional status significantly improved and 86% of the patients were in NYHA functional class I or II. CONCLUSIONS: The mitral valve replacement with Bicarbon mechanical valve prosthesis shows excellent results in patients with mitral valve stenosis associated with a severe pulmonary hypertension.

Primary pulmonary hypertension and coronary artery bypass surgery.

Coronary artery bypass surgery in patients with primary pulmonary hypertension is extremely rare. Right ventricular failure due to persistent elevation of pulmonary pressure is the most important complication in the postoperative period. Creation of an interatrial septal defect and reducing postoperative supraventricular arrhythmia by amiadarone infusion and continuous nasal oxygen therapy can reduce postoperative mortality and morbidity.

[Therapeutic approach in vascular injuries of the lower extremity: Amputation or limb salvage]. / Vasküler tutulumlu alt ekstremite yaralanmalarinda tedavi yaklasimi: amputasyon veya ekstremitenin kurtarilmasi.

The management of lower extremity trauma with vasculary involvement should be directed toward to the salvage of the extremity or to the primary amputation according to the additional pathologies, parameters of the patient and the extremity. We investigated the efficiency of Mangled Extremity Severity Score (MESS) system which is proposed as an grading system to evaluate the change to extremity salvage or the risk for onset of systemic complications. 81 patients with lower extremity trauma were analyzed according to MESS criteria. 79 of the patients were men and mean age was 23 +/- 4. Fourteen patients had higher MESS score. (MESS > 7). Seven of them were older than 50 years. Primary amputation was performed in four of these 7 patients. Vascular repair was performed in three of patients. Multiorgan failure was developed in two of them and both patients died. Secondary amputation was performed to another patients underwent vasculary repair who had MESS > 7 score. Primary amputation was not performed directly in young patients who had MESS > 7. Secondary amputation was required in two of these patients. MESS scoring system can easily predict amputation in older patients but may cause unnecessary amputation in young patients.

Extended use of radial artery with Y-graft technique for complete arterial revascularization.

One of the biggest problems encountered during complete arterial revascularization is difficulty obtaining sufficient graft length to perform multiple distal anastomoses. We describe a technique of dividing the radial artery during harvest and forming one or more composite Y-grafts to allow end-to-side rather than sequential anastomoses without substantially decreasing usable conduit length. This approach has merit and may be helpful in some patients who require complex arterial grafting.

Double coronary endarterectomy on the beating heart in two patients with porcelain aorta.

Patients with porcelain aorta carry a high risk of systemic embolism during coronary artery bypass grafting. Avoiding manipulation of the aorta during operation using the beating heart approach can prevent atheroemboli. In patients with diffuse atherosclerotic coronary artery disease who require endarterectomy, coronary bypass operations can be done safely on the beating heart.

Removal of the thrombosed prosthetic axillofemoral graft.

Late thrombosis of prosthetic graft material is rarely managed successfully by simple thrombectomy or thrombolytic therapy. Replacement with a new graft may be necessary. Although several techniques have been described, mobilizing and removing an old thrombosed prosthetic graft is usually extremely difficult because of a firm attachment to its tunnel. This attempt is more difficult especially for ringed grafts. We describe a simple technique of using an internal varicose vein stripper for the removal of such a late thrombosed axillofemoral spiral polytetrafluoroethylene graft and positioning a new graft into the old tunnel.

Simple de-airing technique for aortic valve replacement with upper ministernotomy.

Upper ministernotomy for aortic valve replacement is intimidating for many surgeons, not only for limited surgical exposure but also for the inability to complete de-airing the apex of the heart. Conversion to full sternotomy had been reported for this inability to de-air the apex of the heart in a limited number of cases. We describe a simple de-airing method by introducing a 16 GA catheter into the apex of the left ventricle through the aorta and prosthetic valve.

Left atrioventricular valve repair technique in partial atrioventricular septal defects.

BACKGROUND: The aim of our study was to evaluate the effect of chordal transfer around the cleft on left atrioventricular valve competence in the late postoperative period. METHODS: Forty-four adult patients underwent surgical correction of partial atrioventricular septal defect between 1983 and 1997. Fenestration was found in 8 patients (18.2%) and cleft, in 35 (79.5%). There was no chordal support of the free edges of the left superior and left inferior leaflets around the cleft in 18 patients. Two chordae were mobilized from the left lateral leaflet and reimplanted into the tip of the left superior and left inferior leaflets around the cleft. RESULTS: At 5 years postoperatively, left atrioventricular valve insufficiency was severe in 5 patients and moderate in 11 patients who had had cleft closure alone. In contrast, severe valvular insufficiency was present in only 1 patient in the group with chordal transfer (p < 0.05). Reoperation was done in 5 patients with isolated cleft closure. Left AV valve replacement was performed in 1 patient. CONCLUSIONS: Chordal transfer plus cleft closure with interrupted sutures significantly reduces early and late left atrioventricular valve incompetence and also decreases the rate of reoperation.

Effect of posterior pericardiotomy on postoperative supraventricular arrhythmias and late pericardial effusion (posterior pericardiotomy).

OBJECTIVE: The aim of this prospective study was to evaluate the effectiveness of posterior pericardiotomy from the point of pericardial effusion related with supraventricular tachycardia and development of delayed posterior cardiac effusions. MATERIALS AND METHODS: This prospective randomized study was carried out in 200 patients undergoing coronary artery bypass surgery in Gülhane Medical Academy Department of Cardiovascular Surgery between June 1996 and June 1997. Patients were divided into 2 groups; each group included 100 patients. Longitudinal incision was made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm in group I patients. Posterior pericardiotomy was not done in group II. RESULTS: Atrial fibrillation was developed in 6 patients (6%) in group I and in 34 patients (34%) in group II (P =.0000007). Atrial flutter and other supraventricular arrhythmia prevalence was not statistically significant. Early and late pericardial effusion were developed 54% and 21%, respectively, in group II, but neither early nor late pericardial effusion were developed in group I (P =.00001). Delayed pericardial tamponade was also significantly lower in group I (0% vs 10%; P =.001). CONCLUSION: Posterior pericardiotomy is technically easy to perform and a safe and effective technique that reduces not only the prevalence of early pericardial effusion and related atrial fibrillation but also delayed posterior pericardial effusion and tamponade.

Discrete subaortic stenosis: assessing adequacy of myectomy by transesophageal echocardiography.

BACKGROUND: Membranectomy and myectomy are standard therapy for discrete subaortic stenosis (DS) and are associated with low rates of endocarditis, recurrence, and aortic insufficiency. Extensive myectomy increases risk of complications such as conduction tissue damage and iatrogenic ventricular septal defect (VSD). MATERIALS AND METHODS: Forty-five adult patients with DS underwent operations in Gulhane Military Medical Academy. Exertional dyspnea was the principal symptom in 29 (64.4%) patients. Transesophageal echocardiography (TEE) was performed routinely in all patients to assess the length and depth of needed myectomy during the perioperative period. Aortic insufficiency (AI) was also noted preoperatively in 31 (68.9%) and a history of aortic valve endocarditis was present in 4 (8.9%) patients. RESULTS: Myectomy was performed according to TEE measurements. An average of 10 mm in width, 10 mm in depth, and 2.3 mm in length of septal tissue was resected. The mean left ventricle-aorta peak systolic gradient decreased from 70.2+/-9.7 to 17.2+/-2.7 mmHg (p < 0.001). Aortic valve repair was performed in 8 (7.8%) patients and aortic valve replacement in 11 (24.4%) patients at the initial operation. Iatrogenic VSD did not occur in any of the patients. Average postoperative left ventricular outflow tract diameter was 21+/-1.5 mm. Temporary complete heart block occurred in three patients. There was an early residual gradient (36+/-8 mmHg) resulting from temporary hypercontraction that decreased (18+/-5 mmHg) in the first postoperative day. CONCLUSIONS: Myectomy under perioperative TEE measurement is safe and effective in the treatment of DS. TEE-guided myectomy reduces complications such as complete heart block and iatrogenic VSD.

Surgical approach to military vascular injuries.

PURPOSE OF THIS STUDY: Vascular injuries caused by high-velocity military missiles are associated with bone fracture, soft-tissue, nerve and tendon injuries. In this study we will discuss the surgical strategy and results of vascular injuries, which require a different approach from primary and elective surgical procedure. BASIC METHODS: Surgical interventions were performed in 116 patients. Vascular lesions were localized on the lower extremity in 53, upper extremity in 55, and nine were in other regions. Vascular injuries were concomitant with bone fracture in 46 and nerve injuries in 36 patients. Vascular repair was performed after orthopedic stabilization in vessels with an ischemic period of less than 4 hours. PRINCIPAL FINDINGS: Fasciotomy was performed after vascular repair in the 22 cases that had arrived after 8 hours. Amputation was required in two cases. There was one mortality. CONCLUSIONS: The best results are obtained when a multidisciplinary and emergency approach are used by the team of vascular, orthopedic, plastic and neurosurgeons who are experienced in military injuries.