Coronary flow reserve in patients with left anterior descending artery-left internal mammary artery long patch plasty anastomosis: a prospective study.

BACKGROUND: We aimed at assessing the efficacy of the patch plasty technique without endarterectomy in patients with diffuse coronary artery. Long anastomosis of the left internal mammary artery graft (LIMA) to the left anterior descending (LAD) artery was performed and examined using transthoracic Doppler echocardiography to detect coronary flow reserve (CFR) and epicardial stenosis. METHODS: Forty-one patients (6 women; mean age, 58 ± 9 years) who underwent coronary artery bypass surgery using the patch plasty technique without endarterectomy were included in the study. Presence of CFR was examined in each patient by transthoracic Doppler echocardiography. RESULTS: One of the patients (2.4%) died on the first postoperative day. The remaining patients were divided into 2 groups: those with normal CFR (CFR ≥ 2) (n = 35, 88%) and those with low CFR (CFR < 2) (n = 5, 12.0%). The length of patch plasty (3.6 ± 0.82 cm) in the low CFR group was significantly longer than that in the normal CFR group (2.69 ± 0.75 cm). Coronary angiography was performed for the 3 patients with CFR < 2: Two patients showed normal grafts and anastomoses, but the third patient's distal LAD-LIMA anastomosis was almost 90% occluded. CONCLUSION: We elucidated the reliability of the patch plasty without endarterectomy method and transthoracic Doppler echocardiography for detecting the severity of coronary artery disease.

Does pulmonary artery venting decrease the incidence of postoperative atrial fibrillation after conventional aortocoronary bypass surgery?

OBJECTIVES: In this study, we tested the hypothesis that pulmonary artery venting would decrease the incidence of atrial fibrillation after coronary artery bypass surgery. METHODS: This prospective study included 301 patients who underwent complete myocardial revascularization with cardiopulmonary bypass in our department during a 2-year period. The patients were randomly divided into 2 groups: group I included 151 patients who underwent aortic root venting and group II included 150 patients who underwent pulmonary arterial venting for decompression of the left heart. Pre-, peri-, and postoperative risk factors for atrial fibrillation were assessed in both groups. RESULTS: The mean age was similar in the 2 groups. The mean number of anastomoses was significantly higher in group I (2.8 ± 0.8) than in group II (2.4 ± 0.8) (P = 0.001). The mean cross-clamp time was 42.7 ± 17.4 minutes in group I and 54.1 ± 23.8 minutes in group II (P = 0.001). The mean cardiopulmonary bypass time was 66.4 ± 46.1 minutes in group I and 77.4 ± 28.6 minutes in group II (P = 0.08). The incidence of atrial fibrillation was 14.5% (n = 21) in group I and 6.5% (n = 10) in group II (P = 0.02). Multivariate regression analysis showed that pulmonary artery venting decreased the postoperative incidence of atrial fibrillation by 17.6%. CONCLUSIONS: Pulmonary arterial venting may be used as an alternative to aortic root venting during on-pump coronary bypass surgery, especially in patients at high risk of postoperative atrial fibrillation.

Combined transdiaphragmatic off-pump and minimally invasive coronary artery bypass with right gastroepiploic artery and abdominal aortic aneurysm repair.

PATIENT: Male, 74 FINAL DIAGNOSIS: Abdominal aortic aneurysm (AAA) Symptoms: Palpable abdominal mass Medication: - Clinical Procedure: Abdominal aortic aneurysm repair Specialty: Surgery. OBJECTIVE: Rare disease. BACKGROUND: Coronary artery disease is common in elderly patients with abdominal aortic aneurysms. Here we report a case of the combination of surgical repair for abdominal aortic aneurysm and off-pump and minimally invasive coronary artery bypass surgery. CASE REPORT: A 74-year-old man who presented at our clinic with chest pain was diagnosed with an abdominal aortic aneurysm. His medical history included right coronary artery stenting. Physical examination revealed a pulsatile abdominal mass on the left side and palpable peripheral pulses. Computed tomography scans showed an infrarenal abdominal aneurysm with a 61-mm enlargement. Coronary angiography revealed 80% stenosis in the stent within the right coronary artery and 20% stenosis in the left main coronary artery. The patient underwent elective coronary artery bypass grafting and abdominal aortic aneurysm repair. Abdominal aortic aneurysm repair and transdiaphragmatic off-pump and minimal invasive coronary artery bypass grafting with right gastroepiploic artery were performed simultaneously in a single surgery. CONCLUSIONS: We report this case to emphasize the safety and effectiveness of transdiaphragmatic off-pump and minimally invasive coronary artery bypass surgery with abdominal aortic aneurysm repair. This combined approach shortens hospital stay and decreases cost.

Symptomatic intercostal lung hernia secondary to sternal dehiscence surgery.

Patient: Male, 60 Final Diagnosis: Iatrogenic intercostal lung hernia Symptoms: - Medication: No medication Clinical Procedure: Surgically cerrected Specialty: Thoracic surgery. OBJECTIVE: Unusual clinical course. BACKGROUND: Iatrogenic intercostal lung hernia is a rare thoracic pathology. Injury of intercostal muscles and costocondral separation during median sternotomy and sternal dehiscence surgery are important factors in the development of hernia. We report for the first time a case of a 60-year-old man with acquired lung hernia after sternal dehiscence surgery, presenting as chest pain and exertional dyspnea. CASE REPORT: A 60-year-old man presented with a 6-week history of progressive exertional dyspnea, particularly following vigorous coughing. Past medical history included slight chronic obstructive pulmonary disease and coronary artery bypass grafting surgery 8 weeks previously, using the left internal mammary artery for the left anterior descending artery via median sternotomy and sternal dehiscence by the Robicsek method. A chest X-ray showed intact sternal and parasternal wires, but the bilateral lung parenchyma appeared normal. A spiral computed tomography scan of the chest found intercostal herniation of the anterior segment of the left upper lobe. The lung hernia was repaired surgically to relieve exertional dyspnea and incarceration, and to improve respiratory function. The postoperative course was uneventful and the patient recovered well. CONCLUSIONS: Intercostal lung hernia after median sternotomy and sternal dehiscence surgery is rare, and it has been previously reported on. Preventive techniques include gentle manipulation of the sternal retractor, avoidance of rib fractures, and using a protective method of intercostal arteries and nerves such as Sharma technique. Thoracic surgeons should be aware of this rare complication in sternal dehiscence surgery.

Sternal dehiscence accompanied by protrusion of the left lung through the chest wall.

We report an almost complete protrusion of the lung through the anterior chest wall occurring as a complication following sternal dehiscence. Emergency treatment is mandatory since it has a high potential for incarceration, hemopneumothorax, respiratory failure, and infection. Twenty-eight days after coronary by-pass surgery, the left lung of a 66-year-old male patient almost completely protruded through the sternotomy incision in the chest wall; the lung tissue was successfully reduced and the sternotomy was closed. Recurrence was not observed within the 6-month follow-up period, his general condition was good. The clinical course of the patient was retrospectively reviewed, and this case was reported with a unique complication.

Comparison of inhaled nitric oxide and aerosolized iloprost in pulmonary hypertension in children with congenital heart surgery.

BACKGROUND: Pulmonary arterial hypertension is of importance in congenital cardiac surgery as being a significant cause of morbidity and mortality. Although therapy options are limited, inhaled nitric oxide (NO) is used as a standard therapy. The present study aimed to compare inhaled NO and aerosolized iloprost in children with secondary pulmonary hypertension who underwent congenital cardiac surgery. METHODS: Sixteen children included in the study were randomized into either inhaled NO or aerosolized iloprost group. For both groups, the observation period terminated at 72 h after cardiopulmonary bypass. RESULTS: There was no significant difference between the groups in terms of mean age, weight, cross clamp time, pump time, and extubation time. No significant change was observed in the arterial tension and central venous pressure of both groups before the operation, 30 min after the pump, 45 min after the pump, and after extubation, whereas an increase was observed in the heart rate and cardiac output, and a decrease was observed in the pulmonary artery pressure. The mean values at the above-mentioned time points showed no difference between the groups. No serious adverse event and mortality was detected. CONCLUSIONS: Both inhaled NO and aerosolized iloprost were found to be effective and comparable in the management of pulmonary hypertension.

Effect of body mass index on early morbidity and mortality after isolated coronary artery bypass graft surgery.

OBJECTIVES: Obesity is a risk factor for morbidity after isolated coronary artery bypass grafting. This study aimed to analyze the sole effect of body mass index (BMI) on early morbidity and mortality in patients after isolated coronary artery bypass grafting. DESIGN: This study was retrospective and used an electronic database of anesthesia information management. SETTING: A single community hospital. PARTICIPANTS: The data of 803 consecutive patients after isolated on-pump coronary artery bypass grafting were analyzed retrospectively; off-pump cases were excluded. INTERVENTION: According to measured BMI, patients were divided into 5 groups: underweight (BMI <20 kg/m(2)), normal weight (BMI 20.0-24.9 kg/m(2)), overweight (BMI 25.0-29.9 kg/m(2)), obese (BMI 30.0-34.9 kg/m(2)), and morbidly obese (BMI >34.9 kg/m(2)). Early postoperative morbidity and mortality were evaluated using logistic regression analysis. MEASUREMENTS AND MAIN RESULTS: Early cumulative postoperative mortality was 3.9% (32 of 803 patients). Mortality was recorded in 3 underweight (n = 15, 20%, odds ratio [OR] 6.54, p = 0.001), 9 normal-weight (n = 159, 5.7%, OR 1.62, p = 0.228), 12 overweight (n = 371, 3.2%, OR 0.68, p = 0.314), 6 obese (n = 199, 3.0%, OR 0.69, p = 0.421), and 2 morbidly obese (n = 59, 3.4%, OR 0.83, p = 0.808) patients. Prolonged intensive care unit stay (p < 0.001), prolonged hospital stay (p < 0.001), and mortality (p = 0.01) were significantly more common in patients in the underweight group than in the other groups. Univariate and multivariate logistic regression analyses showed that underweight, hypertension, and chronic renal failure were independent risk factors for mortality. CONCLUSIONS: Underweight patients with a BMI <20 kg/m(2) are at increased risk of postoperative complications and mortality compared with normal-weight or overweight subjects.

Cardiac tamponade from a giant thymoma: case report.

Thymoma, the most common neoplasm of the anterior mediastinum especially in adults, accounts for 20-25% of all mediastinal tumors and 50% of anterior mediastinal masses. These tumors are routinely asymptomatic for prolonged periods of time. Pericardial tamponade is a very rare initial manifestation of a thymoma. This report presents a patient who had hemorrhagic pericardial tamponade that likely resulted from the largest symptomatic mixed type (type AB) thymoma described in the literature.

Comparison between local and general anesthesia for carotid endarterectomy: early and late results.

BACKGROUND: The aim of this retrospective study was to compare the results between general and local anesthesia (LA) for carotid endarterectomy (CEA). METHODS: Three hundred and twenty-nine patients in whom 365 CEA procedures were performed between January 1990 and September 2001, were included in this study. RESULTS: Operation time, shunt usage rates, hospitalization time (P < .0001), and permanent stroke rates (P < .05) were significantly lower in group with LA. For long-term period (121.3 ± 37.45 vs 98.6 ± 28.98 months), no significant difference was observed in these 2 group with respect to restenosis rates, neurological events, and deaths. CONCLUSIONS: Despite the lack of significant difference between LA and general anesthesia in terms of restenosis, neurological events, and death in the long-term period; LA is more preferable due its associated advantages including availability of testing the consciousness of the patients by direct contact, reduced use of shunts, shorter hospitalization periods, and less prevalence of permanent stroke in the short-term period.

Intermediate-term results after surgery for anomalous origin of the left coronary artery from the pulmonary artery.

PURPOSE: Anomalous origin of the left coronary artery from the pulmonary artery is optimally treated by creating a dual coronary system. Our aim was to review the results of operations performed in these patients and determine the intermediate-term outcomes for left ventricular function and mitral regurgitation. METHODS: Between July 2004 and January 2009 seven patients (5 boys, 2 girls) aged between 4 months and 12 years (median, 4.5 years) were operated for anomalous origin of the left coronary artery from the pulmonary artery. The surgical correction was either performed by direct implantation (58%) or restoration of a composite tunnel (42%). Simultaneous mitral annuloplasty was performed in one patient with severe mitral regurgitation and simultaneous total correction of tetralogy of Fallot was performed in another. RESULTS: There was no hospital or late deaths. Postoperative echocardiograms demonstrated a significant improvement in the left ventricular ejection fraction (52% ± 6% versus 39% ± 8%, P = 0.02) and mitral regurgitation (11% mild versus 48% moderate, P = 0.02) compared to those obtained preoperatively. CONCLUSION: Direct re implantation of the left coronary artery to the aorta and restoration of a composite tunnel from aortic and pulmonary artery walls are equally effective techniques with an acceptable operative mortality, excellent cardiac recovery, and intermediate survival.

Repair of left main coronary ostial stenosis using autologous aortic tissue.

BACKGROUND: Patch angioplasty is one of the several surgical options for patients with left main coronary ostial stenosis. It restores native antegrade blood flow in the left main coronary artery (LMCA) and does not leave the patient with graft-dependent retrograde perfusion. Various direct techniques have been described for left coronary ostioplasty. Herein, we described the use of autologous aortic tissue in the surgical treatment of left main coronary ostioplasty, and reported the short- and long-term outcomes of the patients. METHODS: Between January 2003 and December 2010, 11 patients (nine males and two females) underwent surgical patch angioplasty for LMCA ostial stenosis using autologous aortic tissue as the patch material. RESULTS: All patients survived the operation, and there were no significant postoperative complications. The follow-up period was 44.09 ± 30.26 months (range, 1-94 months), and no deaths or restenoses were observed during follow-up. CONCLUSIONS: The use of autologous aortic tissue as an onlay patch for reconstruction of left main coronary ostial stenosis is safe and free of major complications. This tissue is a reasonable material for treating selected types of LCMA patients.

Left anterior descending artery revascularization in low-risk patients: early outcomes after off-pump versus on-pump surgery.

BACKGROUND AND AIM OF THE STUDY: This study aimed to compare the early outcomes of off-pump and on-pump myocardial revascularization in patients with stenosis in the left anterior descending artery (alone or with diagonal artery disease). METHODS: We retrospectively reviewed the medical records of 300 patients: 150 who underwent on-pump coronary artery bypass and 150 who underwent off-pump coronary artery bypass grafting. There were no significant differences between the 2 groups with respect to medical data and operative findings. On-pump and off-pump groups were compared in terms of mortality and morbidity within 30 days of the operation. RESULTS: Hospital mortality was 3.3% (5 patients) in the on-pump group and 2.6% (4 patients) in the off-pump group. Five patients (3.3%) in the on-pump group experienced myocardial infarction; 3 died of cardiogenic shock. Four patients (2.6%) in the off-pump group experienced myocardial infarction, and 2 of these patients died. Two patients (1.3%) in the on-pump group and 2 patients (1.3%) in the off-pump group experienced stroke; 1 patient in each group died. One patient (0.6%) in the on-pump group had mediastinitis and died of sepsis. CONCLUSIONS: Among low-risk patients (defined according to EuroSCORE criteria) who underwent left anterior descending coronary artery bypass, the results obtained with the on-pump and off-pump methods showed no significant differences with respect to morbidity or mortality.

Sternal wrapping for the prevention of sternal morbidity in elderly osteoporotic patients undergoing median sternotomy.

Osteoporosis, a major risk factor for sternum-related morbidity after median sternotomy, is quite prevalent among the elderly. In this prospective study, we investigated the potential of sternal protection by use of the "sternal wrapping method" in elderly osteoporotic patients who were undergoing median sternotomy.For this study, we chose 100 elderly osteoporotic patients who were scheduled to undergo median sternotomy. During surgery, we wrapped the sternal edges with polyvinyl chloride tubing in 50 patients (group 1) and omitted the sternal wrapping in the remaining 50 patients (group 2). We then compared the groups with regard to postoperative pain, bleeding, early and late sternum-related morbidity, sternal fractures, and duration of hospitalization.Sternal wrapping was associated with fewer sternal fractures, less chest pain, and shorter hospital stays. Overall sternal morbidity was significantly less common among patients with sternal wrapping (4% vs. 20%, P = 0.03); however, the difference in individual rates for early and late dehiscence or deep sternal infection did not reach statistical significance.Sternal wrapping using polyvinyl chloride tubes provides mechanical protection and, apparently, less postoperative chest pain and shorter hospitalizations. Probably, it reduces sternum-related complications, particularly in high-risk patients. Its benefits, however, should be confirmed in larger studies.

Sternal dehiscence in patients with moderate and severe chronic obstructive pulmonary disease undergoing cardiac surgery: the value of supportive thorax vests.

OBJECTIVE: Sternal dehiscence after open surgery is a major cause of morbidity and mortality, and chronic obstructive pulmonary disease is a significant risk factor. Therefore, we aimed to determine whether moderate and severe chronic obstructive pulmonary disease had an effect on the development of sternal dehiscence and whether the use of the Robicsek technique for sternal closure along with sternal support vest postoperatively would reduce the incidence of sternal dehiscence in patients with moderate/severe chronic obstructive pulmonary disease undergoing cardiac surgery. METHODS: Two studies were performed. In study 1, 842 patients undergoing cardiac surgery and figure-of-8 wire closure were retrospectively evaluated in 2 groups: group 1a (328 patients with chronic obstructive pulmonary disease) and group 1b (514 patients without chronic obstructive pulmonary disease). In study 2, 221 patients with moderate and severe COPD who were scheduled for open surgery were prospectively enrolled. The Robicsek technique was used for sternal closure. The postoperative thorax support vest was used in 100 patients (group 2a), and no additional procedure was applied in 121 patients (group 2b). RESULTS: In study 1, the dehiscence rate was significantly higher in group 1a (7.9%) than in group 1b (1.2%; P < .001), and mortality rates in patients with dehiscence were 53.8% and 33.3%, respectively. In study 2, the dehiscence rate was significantly lower in group 2a (1%) than in group 2b (11.5%; P = .002). None of the patients with dehiscence in group 2a died, and 35.7% of patients died in group 2b. CONCLUSIONS: The Robicsek technique for sternal closure and the use of a thorax support vest postoperatively are highly effective in preventing sternal dehiscence after cardiac surgery in patients with moderate and severe chronic obstructive pulmonary disease.

Cardiac reoperation in a patient who previously underwent omentoplasty for postoperative mediastinitis: a case report.

Sternal infection has become a rare but challenging problem with significant mortality and morbidity rates since the introduction of sternotomy. Reported rates of mediastinal and sternal infection range from 0.4% to 5%. The ideal reconstruction after sternal debridement is still controversial. Different methods, such as debridement and open packing with continuous antibiotic irrigation, or sternectomy with omental or muscle transposition have been proposed. In this study, we present the cardiac reoperation of a 52 year old man with corrected transposition of great arteries (c-TGA) who had undergone a previous omentoplasty for postoperative mediastinitis.

Anaesthetic and post-operative management of a modified Norwood operation for hypoplastic left heart syndrome: a retrospective series of 11 cases.

OBJECTIVE: This study aimed to describe the pre-operative and operative findings, as well as the post-operative haemodynamics of patients operated on for hypoplastic left heart. The findings of patients who survived or did not survive were also compared to anticipate the risk factors for mortality. METHODS: We retrospectively reviewed the anaesthetic and intensive care records of 11 (seven male and four female) patients who underwent a modified Norwood operation as neonates. There were eight patients who survived, while three did not survive after the operation. Haemodynamics, oxygenation, and medications of patients were recorded for the pre-operative and post-operative conditions for 2 days, and compared between groups of patients who survived and those who did not. RESULTS: The normalised modified Blalock-Taussig shunt area was 3.28, 0.57 square millimetres per kilogram (mean, standard deviation) for the group of patients who survived and 3.55, 1.4 square millimetres per kilogram for the group of patients who did not survive (p = 0.51). The group of patients who survived had a significantly larger normalised aortic annulus area (3.3, 0.89 square millimetres per kilogram versus 1.68, 0.21 square millimetres per kilogram, p = 0.01), lower median age (5.57 (3-8) days versus 46.67 (4-90) days, p = 0.02), and lower weight (2.95, 0.46 kilograms versus 3.85, 0.56 kilograms, p = 0.03) than the group of patients who did not survive. Furthermore, the group of patients who did not survive had a significantly worse pre-operative condition, lower systemic venous and arterial oxygen saturation, and need for a high dose of drugs in the pre-operative and post-operative periods (p was less than 0.05 for each variable). CONCLUSION: The pre-operative, operative, and post-operative findings may be related to mortality early after the modified Norwood operation for hypoplastic left heart syndrome.

Mitral regurgitation secondary to anterior leaflet rupture during percutaneous balloon valvuloplasty: case report.

Rheumatoid heart disease and the mitral stenosis secondary to it in the long term are still important cardiovascular problems in developing countries. Percutaneous balloon mitral valvuloplasty is a valid treatment option with low complication rates for relieving the signs and symptoms of selected patients with mitral valve stenosis. In this report, we describe subacute mitral regurgitation secondary to anterior leaflet rupture following percutaneous balloon mitral valvuloplasty and the management strategy in a 54-year-old female patient. Such a complication is rare in experienced hands in the current era.

Mitral valve repair in a patient with thrombocytopenia-absent radius syndrome: case report.

Thrombocyte level and functions are vital factors during cardiac surgery. Thrombocytopenia-absent radius syndrome (TAR) is a rare genetic disorder consisting of skeletal abnormalities and thrombocytopenia. In this report, we present the management strategy for a 23-year-old female patient with TAR syndrome who underwent mitral valve repair.

Myocardial injury during off-pump surgery. The effect of intraoperative risk factors.

OBJECTIVE: To achieve better outcomes, the degree of myocardial injury due to off-pump coronary artery bypass surgery (OPCAB) must be reduced. We studied the factors that render patients scheduled for OPCAB vulnerable to myocardial injury, using troponin T (cTnT) as a marker of myocardial injury. METHODS: We prospectively investigated 123 patients being operated by a group of surgeons with off-pump technique between January 2001 and June 2006 in Siyami Ersek Thoracic and Cardiovascular Surgery Center. Myocardial injury occurring during surgery was assessed by post-operative cTnT measurement. Then, the relation between intraoperative factors and postoperative cTnT release were statistically evaluated. RESULTS: Blood samples for cTnT measurement were taken from all patients before operation, immediately after arrival at the intensive care unit, then at 6, 12, and 24 hours after distal revascularization. When regarding the intraoperative risk factors, we found that the heart rate, blood pressure and anastomosis time are the main determinant of myocardial cell injury occurring during OPCAB surgery. CONCLUSION: Although aortic cross-clamp and cardioplegic arrest were not used in off-pump myocardial revascularization, the ischemic myocardial cell destruction was also inevitable in off-pump technique. Therefore, management of heart rate and myocardial contractility was desirable not only for precise anastomosis but also for myocardial protection during OPCAB surgery.