Gender Differences in Patients with Anxiety after Coronary Artery Bypass Surgery.

OBJECTIVE: The present study was designed to evaluate the relationship between gender and coexisting anxiety in patients undergoing coronary artery surgery. Materials and Methods: A total of 137 patients (41 women and 96 men with a mean age 66.1 ± 6.0 years) patients underwent state and trait anxiety evaluation at baseline (preoperatively) and at six months after (postoperatively) coronary artery bypass graft (CABG). Anxiety symptoms were assessed at enrollment using the Spielberger State-Trait Anxiety Inventory (STAI). Psychological, social, clinical, and surgical data were assessed statistically. Results: There were statistically significant differences between female and male patient characteristics for the mean age, mean education year, and mean body mass index. The women were found to be statistically younger and less educated, and more likely to be overweight, diabetic, and hyperlipidemic. The mean hospitalization time, wound infection, and extreme postoperative pain complaints were found to be higher in the female group. 61 patients (33 female and 28 male) (44.5%) were classified as presenting clinically significant anxiety symptoms (STAI score of ≥ 40). The female patients' STAI scores were significantly higher than men in state and trait anxiety, both preoperatively and six months postoperatively. Postoperatively, there was not any significant decrease in the level of trait anxiety when comparing the level of state anxiety in female patients.  Conclusion: Even after adjusting for known risk factors for compromised STAI, women do not show the same long-term quality benefits of CABG surgery that men do. The results indicate that the STAI is a valuable instrument for identifying and supporting patients with higher levels of anxiety, which can aid in determining patients that may have poor adjustment after CABG surgery.

Does dexamethasone therapy affect intimal hyperplasia after injury in rat abdominal aorta models?

BACKGROUND: Intimal hyperplasia is a normal adaptive feature of arteries in response to injuries, which include invasive vascular interventions. Its development limits the long-term success of bypass grafts. Various pharmacological agents have been successfully employed in experimental models to reduce the degree of intimal hyperplasia. In our study, we investigated the efficacy of dexamethasone in reducing intimal hyperplasia in rat abdominal aortas after partial transection and primary repair. METHODS: In this study, 20 Wistar Albino rats were randomly selected and divided into four groups to compare the effects of low- and high-dose dexamethasone on intima and media thickness compared to the control. Group A (n=5) was the control group, where only skin incision and laparotomy were performed. For Group B (n=5), a median laparotomy was performed, the abdominal aorta was partially transected, and repaired with an 8.0 prolene suture. Doses of 0.1 mg/kg and 0.2 mg/kg dexamethasone were administered in Group C (n=5) and Group D (n=5), respectively. After two weeks, all rats were euthanized, and the repaired abdominal aortas were excised and examined histopathologically. Intima and media thicknesses were measured using the 'Olympus AnalySIS 5' program (Olympus Corporation, Japan) after digital photos were taken. RESULTS: Based on the measurements, we demonstrated that after transection and repair of the abdominal aorta, the intima/media ratio was not significantly different between the low-dose dexamethasone and non-dexamethasone groups. The intima/media ratio was significantly lower in the high-dose dexamethasone group than in the non-dexamethasone and low-dose dexamethasone groups. CONCLUSION: After vascular interventions, dexamethasone treatment may reduce intimal hyperplasia and increase patency by providing vascular remodeling.

Morphometric evaluation of the left atrioventricular valve complex and its clinical relations.

BACKGROUND: In this study, it was aimed to evaluate morphometrically and morphologically the left fibrous ring, mitral leaflets, tendinous cords, and papillary muscles, which are the components of the left atrioventricular valve complex (LAVC), and to reveal their clinical relationships. MATERIALS AND METHODS: A total of 120 human hearts were examined at the Forensic Medicine Institute. Cases aged 30 years and older, less than 24 hours after their death, were included in the study. Heart length, width, height/width ratio, anteroposterior and mediolateral diameters of the annulus, annular area, length and width of leaflets, number and attachment sites of tendinous cords, number, shape, length, the width of papillary muscles, and distances to various points were recorded to determine their spatial configurations. As well as the measurement data of LAVC components in cases with and without cardiovascular disease (CVD), the relationships of these data with the demographic characteristics of the cases are also explained. RESULTS: In the diagnostic performance test (ROC analysis), it was determined that body mass index (> 26.7), heart weight (> 414 g), heart height/width ratio (≤ 1.24), mitral valve width (> 99.96 mm), left ventricular wall thickness (> 15.08 mm), annular area (> 619.37 mm²) and mediolateral diameter of the annulus (> 30.71 mm) are important diagnostic criteria in determining CVD if they are outside the specified reference values. CONCLUSIONS: This study provides anatomical information about LAVC, as well as recommendations for diagnosis and surgical treatment planning. We therefore believe that our findings will be useful to clinicians.

The Effect of Perioperative Fluid Management and Operative Modifications on Mortality and Morbidity in Patients Undergoing Pulmonary Endarterectomy.

INTRODUCTION: Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe disease treated with pulmonary endarterectomy. Our study aims to reveal the differences in liquid modalities and operation modifications, which can affect the patients' mortality and morbidity. METHODS: One hundred twenty-five patients who were diagnosed with CTEPH and underwent pulmonary thromboendarterectomy (PTE) at our center between February 2011 and September 2013 were included in this retrospective study with prospective observation. They were in New York Heart Association functional class II, III, or IV, and mean pulmonary artery pressure was > 40 mmHg. There were two groups, the crystalloid (Group 1) and colloid (Group 2) liquid groups, depending on the treatment fluids. P-value < 0.05 was considered statistically significant. RESULTS: Although the two different fluid types did not show a significant difference in mortality between groups, fluid balance sheets significantly affected the intragroup mortality rate. Negative fluid balance significantly decreased mortality in Group 1 (P<0.01). There was no difference in mortality in positive or negative fluid balance in Group 2 (P>0.05). Mean duration of stay in the intensive care unit (ICU) for Group 1 was 6.2 days and for Group 2 was 5.4 days (P>0.05). Readmission rate to the ICU for respiratory or non-respiratory reasons was 8.3% (n=4) in Group 1 and 11.7% (n=9) in Group 2 (P>0.05). CONCLUSION: Changes in fluid management have an etiological significance on possible complications in patient follow-up. We believe that as new approaches are reported, the number of comorbid events will decrease.

Comparative Analysis of Transcriptome Profiles in Patients with Thromboangiitis Obliterans.

BACKGROUND: Thromboangiitis obliterans (TAO) causes vascular insufficiency due to chronic inflammation and abrupt thrombosis of the medium and small arteries of the extremities. In our study, we aimed to determine biomarkers for the diagnosis of TAO by evaluating 15 male TAO patients with Shinoya diagnostic criteria and 5 healthy controls who did not have TAO-related symptoms in their family histories. METHODS: The Clariom D Affymetrix platform was used to conduct microarray analysis on total RNA extracted from whole blood. A total of 477 genes (FC ≤ 5 or >5) common to the fifteen patient and five control samples were selected using comparative microarray analysis; among them, 79 genes were upregulated and 398 genes were downregulated. RESULTS: According to FC ≤ 10 or >10, in the same TAO patient and control group, 13 genes out of 28 were upregulated, whereas 15 genes were downregulated. The 11 key genes identified according to their mean log2FC values were PLP2, RPL27A, CCL4, FMNL1, EGR1, EIF4A1, RPL9, LAMP2, RNF149, EIF4G2, and DGKZ. The genes were ranked according to their relative expression as follows: FMNL1 > RNF149 > RPL27A > EIF4G2 > EIF4A1 > LAMP2 > EGR1 > PLP2 > DGKZ > RPL9 > CCL4. Using protein-protein interaction network analysis, RPL9, RPL27A, and RPL32 were found to be closely related to EIF4G2 and EIF4A1. The Reactome pathway found pathways linked to 28 genes. These pathways included the immune system, cellular responses to stress, cytokine signaling in the immune system, and signaling by ROBO receptors. CONCLUSIONS: By figuring out the protein expression levels of the genes that have been found to explain how TAO disease works at the molecular level, it will be possible to figure out how well these chosen transcripts can diagnose and predict the disease.

Investigating the protective effect of glutamine against cerebral ischemia and bilateral carotid occlusion in rats.

Background: This study aims to investigate the protective effects of glutamine against cerebral injury resulting from cerebral ischemia-reperfusion by bilateral carotid occlusion in rats. Methods: Eighteen Wistar albino rats were randomly divided into three equal groups: 1) control group; 2) ischemia-reperfusion group which underwent clamping of the carotid artery for 20 min; and 3) ischemiareperfusion + glutamine group which was treated with two doses of glutamine (1 g/kg) prior to the same clamping procedure as the ischemia-reperfusion group. All rats were sacrificed 24 h after the experiment. Their brain tissue was removed, separated into right and left hemispheres, and sent for analysis. Biochemical analysis was used to determine the oxidant parameters, antioxidant parameters, and glutathione levels in brain tissue. In the histopathological analysis of the brain tissue, ischemic markers such as red neurons, spongiosis, and satellitosis were examined. Results: Biochemical examination revealed that the levels of malondialdehyde and ferric reducing antioxidant power in the ischemia-reperfusion group were significantly higher than those in the control and ischemia-reperfusion + glutamine groups (p<0.05). The histopathological findings revealed that the levels of red neurons, satellitosis, and spongiosis in the ischemia-reperfusion group were significantly higher than those in the control group (p<0.05). The red neuron and spongiosis levels in the ischemia-reperfusion + glutamine group were significantly higher than those in the control group (p<0.05). Conclusion: Our study findings indicate that glutamine treatment has a protective effect against ischemia-reperfusion-induced brain damage in rats.

Assessment of anxiety and health-related quality of life in patients with lower extremity peripheral arterial occlusive disease.

INTRODUCTION: The aim of this study was to investigate the effect of chronic occlusive vascular disease on anxiety with adverse outcome with health-related quality of life (HRQoL). MATERIAL AND METHODS: Three hundred and thirty-five patients who were treated for peripheral arterial occlusive disease were enrolled in this study. 187 patients who had undergone percutaneous transluminal angioplasty and 148 patients who had one or more surgical revascularizations enrolled in the study. Mean age of the patients was 62.6 ±10 years. Two hundred and eighty-nine patients were male, 46 patients were female. Physical and mental domains of quality of life were measured using the 36-item Medical Outcomes Short-Form Health Survey (SF-36) self-administered questionnaire and anxiety symptoms were assessed using the Spielberger State-Trait Anxiety Inventory (STAI). At baseline 335 patients filled out the SF-36 and STAI, and 304 patients (90.7 % of the series) filled them out at 6-month follow-up. RESULTS: There was no mortality and no significant morbidity after vascular interventions in the series. Significant improvement was found in two of eight health domains. The score of social functioning increased to 60.4 from 52.6 (p < 0.03) and general health perception increased to 75.1 from 60.5 (p < 0.04) at 6-month follow-up. The two STAI sub-scores, the State Anxiety Inventory (STAI-S) and the Trait Anxiety Inventory (STAI-T) were found high (≥ 40) both preoperatively and 6 months postoperatively. Postoperatively there was no significant decrease of the levels of anxiety. CONCLUSIONS: This study suggests that the assessment of psychosocial factors, particularly the ongoing assessment of anxiety, could help in risk stratification and prediction of functional status in patients suffering from lower extremity peripheral arterial occlusive disease.

Anxiety and health-related quality of life after cardiac surgery.

INTRODUCTION: The aim of this study was to investigate the effect of elective cardiac surgery on health-related quality of life (HRQoL). MATERIAL AND METHODS: One hundred and eight (35 women and 73 men, mean age 62.3 ±12.7 years) patients undergoing open heart surgery were enrolled in the study. Physical and mental domains of quality of life were measured using the 36-item Medical Outcomes Short-Form Health Survey (SF-36) self-administered questionnaire, and anxiety symptoms were assessed using the Spielberger State-Trait Anxiety Inventory (STAI). At baseline 108 patients filled out the SF-36 and STAI, and 102 patients at 6-month follow-up. RESULTS: It was found that there was significant improvement in three out of eight health domains: physical functioning (p < 0.02), role physical (p < 0.01), and social functioning (p < 0.04), at 6-month follow-up. The two STAI sub-scores: the State Anxiety Inventory and the Trait Anxiety Inventory were found to be high (≥ 40) both preoperatively and 6 months postoperatively. Postoperatively there was not any statistically significant decrease in the levels of anxiety. CONCLUSIONS: This study suggests that the assessment of psychosocial factors, particularly the ongoing assessment of anxiety, could help in risk stratification and prediction of functional status and HRQoL in patients after cardiovascular surgery. Furthermore, the assessment of preoperative well-being should be integrated in routine care in order to identify and support patients with higher levels of anxiety.

Effects of patient-prosthesis mismatch on postoperative early mortality in isolated aortic stenosis.

BACKGROUND AND AIM OF THE STUDY: Small valve size and patient-prosthesis mismatch (PPM) generate high postoperative transvalvular gradients and may decrease both early and long-term survival. The study aim was to evaluate whether mismatch affected early mortality after aortic valve replacement (AVR) for isolated aortic stenosis (AS). METHODS: A total of 701 patients (437 males, 264 females; mean age 53.3 +/- 15.1 years; range: 14-84 years) with pure AS underwent AVR at the authors' institution between 1985 and 2005. The majority of patients (92%) received a mechanical valve. PPM was considered severe if the indexed effective orifice area was < or =0.65 cm2/m2, and moderate if > 0.65 but < or = 0.85 cm2/m2. RESULTS: Moderate-severe PPM was present in 47% of patients, and severe PPM in 13%. The early mortality was 5.4% (n=38). Multivariate analysis revealed age > or = 70 years (p < 0.001), female gender (p = 0.04) and severe PPM (p = 0.003) as independent predictors of early mortality. Moderate mismatch was not a predictor of early mortality on both univariate and multivariate analysis. Left ventricular dysfunction (ejection fraction < or = 40%) was a risk factor for early mortality only in patients with severe PPM. CONCLUSION: Patient-prosthesis mismatch should be prevented in patients undergoing AVR for isolated AS, especially in those with left ventricular dysfunction.

Risk factors for retinal arteriolar emboli in coronary artery disease.

This study determined the prevalence of retinal arteriolar emboli risk factors in 148 patients (86 males) diagnosed with coronary artery disease who required coronary artery bypass graft surgery (mean +/- SD age 59.1 +/- 12.9 years). The prevalence of smoking was 50.7%, hypertension was 49.3%, diabetes mellitus was 27.0% and obesity was 31.1%. Retinal arteriolar emboli were detected using binocular indirect ophthalmoscopy of both eyes. They were found in 10 patients (6.8%) and identified as the cholesterol type. Patients were divided according to their baseline low-density lipoprotein cholesterol (LDL-C) serum level; retinal arteriolar emboli were significantly more frequent in patients with LDL-C levels > 100 mg/dl. These results demonstrate that the prevalence of hypercholesterolaemia and high LDL-C were increased in patients with retinal arteriolar emboli. Identification and treatment of modifiable risk factors, such as high LDL-C and hypercholesterolaemia, might be beneficial in these individuals.

The Geometrical Modeling of Aortic Root Complex.

BACKGROUND: This study was designed to investigate the anatomical relationship of the different levels of aortic root. MATERIALS AND METHODS: The morphological features of the aortic root were examined using of 12 adult hearts from fixed male cadavers who had expired due to noncardiac causes by magnetic resonance imaging and applied mathematical analyses to the results. The measurements of the aortic root were done at four levels: at the ventriculoarterial junction (annulus), at the largest level of the Valsalva sinuses (sinus), at the level of commissures (sinotubular junction [STJ]), and at 1 cm above the STJ (aorta ascendens). We derived an equation that allows calculation of the appropriate diameter of the aortic root from four levels. Statistical analysis among the variation of the diameters at the four levels of aortic root was achieved using test one-way analysis of variance. RESULTS: The data showed a geometric pattern of the aortic root. The comparison of the values from four levels showed that the narrowest at the sinotubular junctional level and the widest at the sinus level. CONCLUSION: The analysis of our data shows that the aortic root has a consistent shape with varying size and that is a definable mathematical relationship between root diameter.

Surgical treatment of post-infarction left ventricular pseudoaneurysm: a two-decade experience.

Herein, we present a retrospective analysis of our experience with acquired pseudoaneurysms of the left ventricle over a 20-year period.From February 1985 through September 2004, 14 patients underwent operation for left ventricular pseudoaneurysm in our clinic. All pseudoaneurysms (12 chronic, 2 acute) were caused by myocardial infarction. The mean interval between myocardial infarction and diagnosis of pseudoaneurysm was 7 months (range, 1-11 mo). The pseudoaneurysm was located in the inferior or posterolateral wall in 11 of 14 patients (78.6%). In all patients, the pseudoaneurysm was resected and the ventricular wall defect was closed with direct suture (6 patients) or a patch (8 patients). Most patients had 3-vessel coronary artery disease. Coronary artery bypass grafting was performed in all patients. Five patients died (postoperative mortality rate, 35.7%) after repair of a pseudoaneurysm (post-infarction, 2 patients; chronic, 3 patients). Two patients died during follow-up (median, 42 mo), due to cancer in 1 patient and sudden death in the other. Although repair of left ventricular pseudoaneurysm is still a surgical challenge, it can be performed with acceptable results in most patients. Surgical repair is warranted particularly in cases of large or expanding pseudoaneurysms because of the propensity for fatal rupture.

Midterm results of aortic valve repair with the pericardial cusp extension technique in rheumatic valve disease.

BACKGROUND: The encouraging results of valve repair in the atrioventricular valves have influenced a decision about aortic valve (AV) reconstruction. We report our experience with pericardial cusp extension to repair rheumatic AV disease. METHODS: From 1993 to 1998, 46 patients (25 women, 21 men) with a mean age of 31.5 +/- 12.2 years (range, 15 to 58 years) underwent AV repair. Twenty-two (47.8%) patients had moderate and 24 (52.2%) had severe aortic insufficiency (AI). Severe cusp retraction was repaired with glutaraldehyde-treated autologous pericardium. Twenty-one patients had more than one maneuver (mean, 1.8) to attain competence besides augmentation, which consisted of the release of stenotic commissures (in 11 cases), thinning of the AV cusps (in 10 cases), and resuspension of the cusps (in 17 cases). Simultaneous mitral valve repair was performed on 17 patients. Eight patients received triple valve reconstruction. RESULTS: There was no early mortality. Thirty patients no longer had AI with any significant transvalvular gradients. Five patients were followed with mild residual AI, and 2 patients with moderate AI not requiring reoperation. Nine patients developing severe AI required AV replacement with a reoperation rate 19.6% (4.26%/patient-year). The mean interval between repair and reoperation was 28.2 +/- 18.3 months (range, 3 to 58 months). The mean observation time was 4.6 +/- 3 years (211.6 patient-years). Late mortality rate was 2.2% with 1 patient. The significant negative predictors of aortic reoperation determined by univariate analysis were preoperative New York Heart Association class (p = 0.002) and postoperative severe AI (p < 0.001). Cox hazard studies identified that all risk factors were insignificant for aortic reoperation. The actuarial rate of freedom from aortic reoperation was 76.1% +/- 7% at 7.5 years. CONCLUSIONS: Although AV repair by extension with pericardium is worth considering with an acceptable solution to achieve a good geometry from unequal cusps, especially in young rheumatic patients for preservation of the native AV, the patients should be followed periodically for reoperation risk.

Surgical management of mitral regurgitation in patients with Marfan syndrome.

BACKGROUND AND AIM OF THE STUDY: Although, in patients with Marfan syndrome, the most common cardiovascular abnormalities are aortic root dilatation and aortic valve regurgitation, mitral valve dysfunction is the most frequently accompanying cardiac lesion. METHODS: The clinical course and management is reported of nine patients (seven men, two women; mean age 29.2 +/- 2.3 years) with Marfan syndrome who required different mitral valve procedures and aortic valve replacement. Mitral regurgitation was caused by annulus dilatation in all patients, by leaflet prolapse in five patients, and by chordal rupture due to endocarditis in two. Six patients underwent mitral valve replacement; three of these were operated on using preservation of the mitral valve apparatus. Three patients underwent mitral annuloplasty and chordal shortening. RESULTS: There was no hospital mortality, nor any valve-related complications in the series. The postoperative course was uneventful after each operation. At a mean follow up of 4.5 years, all patients were in NYHA class I or II, with improved functional capacity. CONCLUSION: This experience in mitral valve procedures indicated that the connective tissue defect might compromise the results of such surgery, but that mitral valve operations could be performed satisfactorily in young Marfan syndrome patients, despite complications of left ventricular dilatation.

Endovascular treatment of intracerebral mycotic aneurysm before surgical treatment of infective endocarditis.

Mycotic aneurysms are rarely seen in patients who have infective endocarditis, and the management of these patients remains controversial. We present the case of a patient who had infective endocarditis complicated by a mycotic aneurysm of the left middle cerebral artery. There was substantial mitral regurgitation, and Streptococcus viridans was isolated from the blood samples. Dysarthria appeared during the 4th week of the antibiotic therapy, but resolved completely 8 hours after onset. The left middle cerebral artery was embolized with platinum detachable coils. On the 7th day after the radiologic intervention, the native mitral valve was replaced with a 33-mm St. Jude Medical bi-leaflet mechanical mitral prosthesis. Most mycotic aneurysms show notable regression of symptoms with effective antibiotic treatment, and a very few may diminish in size. However it is impossible to predict the response of these aneurysms to therapy. To prevent the perioperative rupture of mycotic aneurysms and intracranial hemorrhage, priority should be given to endovascular interventions to treat cerebrovascular aneurysms in patients such as ours.

Surgical treatment of aortic abscess and fistula.

The formation of annular abscess and fistulous communication, the most devastating complication of destructive aortic valve endocarditis, requires extensive surgical débridement. Five men experienced destructive native aortic valve endocarditis in association with congestive heart failure (New York Heart Association functional class IV) and hemodynamic deterioration that developed from severe aortic regurgitation. To eradicate the aortic valve endocarditis, we performed (from July 1998 through November 2002) aortic annular skeletonization by dissecting all infectious and necrotic tissue within the abscess cavity and the fistula between the ventriculoarterial junction and the sinotubular junction. The completely resected annular area was covered with a glutaraldehyde-treated autologous pericardial patch that was sutured firmly to fibrous tissue, for a secure proximal anastomosis. Reconstruction of the aortic root was followed by implantation of a Freestyle stentless bioprosthesis, using the aortic root replacement technique. There were no deaths after surgery, nor is there record of a permanent complication due to a loss of conduction tissue. All 5 patients were in New York Heart Association functional class I or II during follow-up (range, 8-56 months). Echocardiography showed no signs of valve dysfunction, recurrent endocarditis, or fistulation. Annular skeletonization and reconstruction of the aortic annulus with glutaraldehyde-treated autologous pericardium permits radical removal of infected tissue and effective treatment of aortic annular abscess, with less risk of valve dehiscence from the fragile aortic annulus.

Pericardiectomy for chronic constrictive tuberculous pericarditis: risks and predictors of survival.

We performed this study to determine the predictors of early and long-term survival in the surgical treatment of tuberculous pericarditis and to examine the risks of pericardiectomy and the functional outcome in patients after surgery. A retrospective analysis was undertaken in 36 consecutive patients, 26 female and 10 male, with a mean age 32.2 +/- 16.3, who underwent pericardiectomy for chronic constrictive pericarditis from February 1985 to February 2002. All patients received antitubercular therapy in the postoperative period. The operative mortality rate was 6% (2 patients); the cause of death in both cases was severe low-cardiac-output syndrome. Nonfatal intraoperative complications affected 3 patients (8%). The median stay in the intensive care unit was 3.7 +/- 3.1 days. The median hospital stay was 14 +/- 2.6 days. The median ventilation time was 11.9 +/- 1.8 hours. The median volume of blood transfused was 2.1 +/- 1.6 units. Advanced age, atrial fibrillation, concomitant tricuspid insufficiency, inotropic support and low cardiac output were significant negative predictors of survival, according to univariate analysis. There were 4 late deaths. Actuarial survival at 5 years was 75.9% +/- 9.14%. At the 1-year follow-up examination, improved functional status was noted in 88% of patients. We suggest that pericardiectomy be performed early and as radically as possible, in an effort to prevent chronic illness. A combination of chemotherapy and surgery yields gratifying results in the treatment of tuberculous pericarditis.

Complete off-pump coronary revascularization in patients with dialysis-dependent renal disease.

Patients who have dialysis-dependent renal disease frequently present with coronary artery disease but are considered at high risk for coronary artery bypass grafting. From 1 September 2000 through 31 August 2003, we performed complete off-pump coronary revascularization in 6 patients who had end-stage dialysis-dependent renal failure, and we prospectively studied the perioperative and early postoperative results. The effect of off-pump coronary artery bypass grafting on mortality, morbidity, postoperative complications, and transfusion requirements in this group of patients was investigated. No perioperative deaths or ischemic cardiac events were observed after off-pump coronary artery bypass grafting. In all patients, anginal symptoms were relieved during the postoperative period. The mean duration of follow-up was 172 +/- 12.4 months. Patients with dialysis-dependent chronic renal failure who present with coronary artery disease should be thoroughly evaluated preoperatively for risk factors and coexistent severe diseases. We believe that in patients with end-stage dialysis-dependent chronic renal failure, off-pump coronary revascularization is a good alternative.

Atresia of coronary sinus ostium with coronary venous flow to left atrium.

The rare cardiac anomaly of atresia of the coronary sinus ostium with a large communication between the coronary sinus and the left atrium was discovered during a mitral valve replacement operation in a 44-year-old woman.

Surgical outcome of subtypes of aortic arch dissection.

This study was conducted to investigate if the site of primary intimal tear involving the aortic arch and the surgical approach affect the early and late results of total aortic arch replacement. Between 1993 and November 2001, 42 patients underwent graft replacement of the total aortic arch for aortic dissection. Their mean age was 51.9 +/- 9.8 years, and 38 of them were male. All operations were performed under hypothermic circulatory arrest with retrograde cerebral perfusion. Hospital mortality was 28.6% (12 patients). There were 2 late deaths. Multivariate analysis showed that chronic obstructive pulmonary disease and ascending aortic replacement with or without valve replacement were significant independent determinants of early death. Patients with the intimal tear originating in the ascending aorta showed a tendency towards lower 7-year survival rates than those with a tear at other aortic sites or with multiple tears, while the presence of chronic obstructive pulmonary disease adversely affected early and late outcomes. We conclude that the primary site of an intimal tear that involves the aortic arch affects early and late survival, but concomitant non-cardiac diseases play an even more important role in the early outcome as they increase the complexity of the operation.