Surgical treatment of caseous calcification of the mitral annulus causing mitral stenosis and mimicking the clinical picture of infective endocarditis: A case report.

Among masses involving the mitral valve and annulus, caseous calcification of the mitral annulus (CCMA) is a rare disease. CCMA accounts for .63% of all mitral annular calcification (MAC) cases. The pathophysiology is still unknown. The correct diagnosis and treatment of this disease is very important to prevent complications. We present a case of giant CCMA with advanced mitral stenosis and hypertrophic cardiomyopathy, presenting with symptoms of infection and therefore a preliminary diagnosis of infective endocarditis. Because of these features, we wanted to share our case as it is the 1st case in the literature.

Surgical treatment of recurrent subvalvular discrete membrane and left ventricular outflow tract stenosis in an adult patient with a history of congenital cardiac surgery.

Left ventricular outflow stenosis can develop at the supravalvular, valvular, and subvalvular levels. Resection of strictures at the diffuse subvalvular level is very difficult. In such pathologies, Konno-Rastan procedure provides very successful solutions as an anterior aortoventriculoplasty method. In this article, we performed anterior aortaventriculoplasty surgical treatment for tunnel type left ventricular outflow tract stenosis, recurrent subvalvular discrete membrane, and aortic regurgitation in an adult patient with a history of partial atrioventricular septal defect repair and subvalvular discrete membrane resection operation in early childhood. The Konno-Rastan procedure, which we applied to the redo case, which is rarely used in adult patients and rarely seen in the literature, is shared.

A rare complication of double prosthetic valve endocarditis; reconstructive surgical treatment of mitral-aortic intervalvular fibrosa pseudoaneurysm and left atrial fistula.

Mitral aortic intervalvular fibrosa or aorto-mitral curtain is a fibrous avascular skeletal structure located between the anterior leaflet of the mitral valve and the non-coronary and left coronary cusps of the aortic valve. Mitral and aortic valve endocarditis are rarely accompanied by mitral aortic intervalvular fibrosa pseudoaneurysm and left atrial fistula of the aorta. Pseudoaneurysm of mitral aortic intervalvular fibrosa is a fatal complication that can occur after valvular surgery, valvular endocarditis, or blunt trauma. In this article, reconstructive surgical management with the Commando technique of a case who developed mitral-aortic intervalvular fibrosa pseudoaneurysm to left atrial fistula after aortic and mitral prosthetic valve endocarditis is described. The important feature of this article is that it is a first in the literature as it is accompanied by persistent left superior vena cava.

Should we wait until severe pulmonary hypertension develops? Efficacy of percutaneous mitral balloon valvuloplasty in patients with severe pulmonary hypertension: A subgroup analysis of our experience.

BACKGROUND: The primary goal of this study is to evaluate the immediate and long-term ef-fects of percutaneous mitral balloon valvuloplasty (PBMV) on patients with rheumatic mitral stenosis (MS) complicated with severe pulmonary hypertension (PH). METHODS: The study population consisted of 85 patients with MS complicated with severe PH (systolic pulmonary pressure > 75 mm Hg). PBMV was performed with Inoue balloon technique. Clinical and echocardiographic follow-up was scheduled at 6 months and 1 year and yearly thereafter. RESULTS: Mitral valve area (MVA) was increased (pre-PBMV MVA was 1.03 ± 0.21 cm2, post-PBMV MVA 1.89 ± 0.34 cm2, p < 0.001) significantly. The mean and the maximum transmitral pressure gradient significantly decreased (pre-PBMV mean transmitral gradient was 18.47 ± 6.59 mm Hg, post-PBMV 6.84 ± 3.84 mm Hg, p < 0.001, pre-PBMV maximum transmitral pressure gradient was 27.6 ± 8.38 mm Hg, post-PBMV 12.68 ± 4.74 mm Hg, p < 0.001). Systolic pulmonary artery pressure (SPAP) significantly decreased (pre-PBMV 89.9 ± 23.38 mm Hg, post-PBMV 54.5 ± 14.6 mm Hg, p < 0.001). Two patients underwent surgery due to rupture of anterior mitral leaflet. There was no peri-procedural mortality. The procedure time was 29.12 ± 11.37 min. Follow-up duration was 108.2 ± 31.4 months. One patient died due to heart failure. One patient underwent re-PBMV and 7 patients mitral valve replacement. At the last follow-up, MVA still remained high (1.52 ± 0.34 cm2) and mean transmitral pressure gradient was low (9.2 ± 5.7 mm Hg). SPAP was 56.5 ± 20.8 mm Hg which was the same as after PBMV. CONCLUSIONS: PBMV in patients with MS with severe PH is an effective therapy with low procedure time. However, it is recommended to perform PBMV before developing severe PH.

Clinical features and patency rates of Remedy® biodegradable peripheral stents.

OBJECTIVE: The aim of this study was to investigate the midterm results of Remedy® biodegradable stents, which have recently come into use for lower-extremity arterial occlusive disease. METHODS: Sixty-five patients, who underwent surgical intervention in various cardiovascular surgery clinics throughout Turkey, were included in the study. The total number of stents used was 92. The mean age of the patients was 64.11 ± 24.13 years (20-82), and 16 (24.6%) were female. The mean number of stents per patient was 1.42, and 70.7% of the lesions were TASC type A. Patients were followed for a mean of 32 months. Sixty-five patients underwent a control examination using either digital subtraction angiography or colour Doppler ultrasonography. In-stent restenosis was defined as ≥ 50% stenosis in the stent area in asymptomatic patients. The procedure was repeated if the degree of stenosis was ≥ 70%. RESULTS: During the follow-up period, restenosis (≥50% stenosis) was observed in seven patients (10.7%). The patency rate after secondary intervention was 100%, and there was no loss of limbs in any patient. Restenosis was observed in six patients with superficial femoral artery stents, and in one patient with a popliteal arterial stent. CONCLUSION: Our experience shows that Remedy® biodegradable peripheral stents were safe and effective in our cohort of patients, with acceptable patency rates.

The place of carotico-subclavian bypass surgery in angina treatment.

Coronary-subclavian steal syndrome results from atherosclerotic disease of the proximal subclavian artery, causing reversal of flow in an internal mammary artery used as conduit for coronary artery bypass. In the present case, we discussed the diagnosis and the treatment of coronary steal syndrome in a patient hospitalized due to decompensated cardiac insufficiency.

Should an Inoue balloon larger than suggested by guidelines be used for percutaneous balloon mitral valvuloplasty?

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the immediate and long-term results of single inflation using a larger balloon size in patients with symptomatic rheumatic mitral stenosis (MS) METHODS: Among a study population of 231 patients with MS, percutaneous balloon mitral valvuloplasty (PBMV) was performed using the Inoue balloon technique. The ideal balloon size was measured according to the patients' height. Patients were allocated at random to two groups: a stepwise method was used in 115 patients (group 1), and a single-inflation method (with +2 mm larger balloon size) in 116 patients (group 2). Follow up was scheduled at six-month intervals for the first year, and annually thereafter. Patients were followed up until 2009. RESULTS: The mitral valve area (MVA) was increased from pre-PBMV values of 1.2 +/- 0.3 cm2 and 1.1 +/- 0.21 cm2 in groups 1 and 2, respectively, to post-PBMV values of 1.9 +/- 0.34 cm2 and 2.0 +/- 0.28 cm2 in groups 1 and 2, respectively; the increase in MVA for each group was statistically significant (p < 0.01) The mean transmitral pressure gradient (MMG) was decreased from pre-PBMV values of 14.1 +/- 5.5 mmHg and 13.2 +/- 5.9 mmHg in groups 1 and 2, respectively, to post-PBMV values of 5.9 +/- 2.3 mmHg and 5 +/- 2.5 mmHg in groups 1 and 2, respectively. One patient in group 2 underwent surgery due to severe mitral regurgitation. The procedure time was significantly shorter in group 2 (32 +/- 11.5 min versus 25 +/- 11 min; p < 0.001). The mean follow up duration was 49.5 +/- 19.2 months (range: 24-84 months). At the last follow up examination, the MVA was shown to be significantly larger in group 2 than in group 1 (1.65 +/- 0.3 versus 1.42 +/- 0.34 cm2; p = 0.02), while the MMG was lower (9 +/- 3.6 versus 6.7 +/- 3 mmHg; p = 0.017). CONCLUSION: The study results suggested that using a +2 mm larger balloon size with single overinflation may represent an alternative and effective therapy, with a shorter procedure time.

Unilayer Closure of Saphenous Vein Incision Lines is Better than Bilayer Closure.

OBJECTIVE: To examine early results in patients with incision lines closed only along the skin and subcutaneous tissue after removal of the great saphenous vein during coronary artery bypass surgery. MATERIALS AND METHODS: We enrolled 82 patients who underwent elective operations in our clinic between December 2008 and April 2009. The patients had similar demographic characteristics, and the method of incision closure was chosen randomly. Three patients were excluded due to in-hospital mortality. The saphenous incision lines were closed using continuous skin sutures in 41 patients (Group 1) or using continuous subcutaneous sutures followed by continuous skin sutures in 38 patients (Group 2). Patients were followed every day that they were in the hospital, in the first week after being discharged, and at the end of the second month after discharge. The incision lines were evaluated for hematomas, infection, edema, pain and numbness. RESULTS: During the follow-up performed in-hospital and in the first week after discharge, infection, edema and numbness were observed significantly more often in Group 2 than in Group 1. Hematoma was observed more often in Group 1, and pain was observed more often in Group 2, but neither of these findings reached statistical significance. During the follow-up at the end of the second month after discharge, infection, edema, and numbness were observed significantly more frequently in Group 2. CONCLUSION: In patients undergoing saphenous removal using standard procedures, it is sufficient to close the incision line using only skin sutures.

Aortic dissection due to sildenafil abuse.

This report deals with a 28-year-old male patient, admitted with a type A aortic dissection, potentially related to the use of sildenafil. In the literature, we found only two other potentially sildenafil-related cases of aortic dissections, one type A and one type B. In our patient, a bicuspid aortic valve and an ascending aortic aneurysm were other underlying anomalies that could have led to the aortic dissection.

Magnesium sulphate and amiodarone prophylaxis for prevention of postoperative arrhythmia in coronary by-pass operations.

BACKGROUND: The aim of this study was to investigate the use of prophylactic magnesium sulphate and amiodarone in treating arrhythmias that may occur following coronary bypass grafting operations. METHODS: The study population consisted of 192 consecutive patients who were undergoing coronary artery bypass grafting (CABG). Sixty-four patients were given 3 g of magnesium sulphate (MgSO4) [20 ml = 24.32 mEq/L Mg(+2)] in 100 cc of isotonic 0.9% solution over 2 hours intravenously at the following times: 12 hours prior to the operation, immediately following the operation, and on postoperative days 1, 2, and 3 (Group 1). Another group of 64 patients was given a preoperative infusion of amiodarone (1200 mg) on first post-operative day (Group 2). After the operation amiodarone was administered orally at a dose of 600 mg/day. Sixty-four patients in group 3 (control group) had 100 cc. isotonic 0.9% as placebo, during the same time periods. RESULTS: In the postoperative period, the magnesium values were significantly higher in Group 1 than in Group 2 for all measurements. The use of amiodarone for total arrhythmia was significantly more effective than prophylactic treatment with magnesium sulphate (p = 0.015). There was no difference between the two drugs in preventing supraventricular arrhythmia, although amiodarone significantly delayed the revealing time of atrial fibrillation (p = 0.026). Ventricular arrhythmia, in the form of ventricular extra systole, was more common in the magnesium prophylaxis group. The two groups showed no significant differences in other operative or postoperative measurements. No side effects of the drugs were observed. CONCLUSION: Prophylactic use of magnesium sulphate and amiodarone are both effective at preventing arrhythmia that may occur following coronary by-pass operations. Magnesium sulphate should be used in prophylactic treatment since it may decrease arrhythmia at low doses. If arrhythmia should occur despite this treatment, intervention with amiodarone may be preferable.