A rare case of non-traumatic acute intraabdominal hemorrhage: ruptured superior mesenteric artery aneurysm.

INTRODUCTION: Rupture of superior mesenteric artery aneurysm (SMAA) is a very rare and life-threatening condition, presenting with acute intraabdominal hemorrhage. CASE: The patient was hospitalized upon complaint of nonspecific severe abdominal pain. Diagnosis of SMAA was established by abdominal Doppler ultrasound that showed a pseudo-aneurysmal lesion with size of 76 × 47 mm at the superior mesenteric main branch. Endovascular stenting was not performed because of the wide neck in the segment of the jejunal branches from SMA and the risk of branch loss during treatment. On the second day of hospitalization, the patient developed an acute abdomen. At explorative laparotomy for intraabdominal bleeding, the root of superior mesenteric artery was immediately and temporarily clamped to provide bleeding control. Aneurysmal tissue was resected and affected part was repaired by Dacron prosthetic graft to maintain proximal and distal vascular continuum. Intestinal viability was preserved. The patient survived disease-free as verified by his 18-month postoperative physical examination. CONCLUSIONS: The patient presents a very rare case showing ability to perform emergent intestine-sparing vascular surgery in ruptured SMAA. Surgery or endovascular treatment options should not be delayed especially in pseudo-aneurysms. It is critical to include ruptured SMAA in differential diagnosis of intraabdominal bleeding.

Cardiac Echinococcosis: A Single-Centre Study with 25 Patients.

BACKGROUND: In this study, we aimed to analyse patients who underwent surgery for cardiac echinococcosis in our department. METHODS: Between June 2005 and June 2013, 25 patients (15 male, 10 female) underwent cardiac hydatid cyst operation. The mean patient age was 33.4±12.6 (15-75) years. RESULTS: The most common presenting symptom was dyspnoea. Cysts were located only in the heart in 16 patients, lung in 4 patients, liver in 4 patients, and brain with lung involvement in 1 patient. Concomitant cardiac and pulmonary surgery was performed in 2 patients. The cardiac hydatid cysts were intracavitary in 11 patients and extracavitary in 14 patients. We used cardiopulmonary bypass in all but 1 patient, who presented with an extracavitary cyst. In 3 patients, surgery was performed with cardiopulmonary bypass without cross-clamping of the aorta. There were no mortalities in the early follow-up period. CONCLUSION: Cardiac echinococcosis is a rare but fatal disease and should be surgically treated when diagnosed. There is some controversy about how echinococcosis spreads to the heart (via haematogenous spread or direct extension from adjacent structures). According to our study, we think that haematogenous spread is the main method of the distribution of cardiac echinococcosis, and the direct extension method from adjacent structures must be questioned.

Interventions Involving the Use of Covered Coronary Artery Stents for Pseudoaneurysms of Blalock-Taussig Shunts.

One of the most rare and dangerous complications of a modified Blalock-Taussig shunt involves the formation of a pseudoaneurysm. A pseudoaneurysm may rupture or may result in other adverse events including compression of mediastinal structures or collapse of the underlying lung parenchyma. Shunt-related pseudoaneurysm may be associated with shunt occlusion, bacteremia, or pulmonary hemorrhage. We describe two cases complicated by large pseudoaneurysm formation, following systemic-to-pulmonary artery shunt operations. The patients in question had recurrent pulmonary hemorrhage. Both underwent successful placement of covered coronary artery stents.

Transcatheter closure of patent ductus arteriosus in under 6 kg and premature infants.

BACKGROUND: Transcatheter closure of a patent ductus arteriosus (PDA) has always been considered risky for infants weighing <6 kg and preterms. We present our findings regarding transcatheter closures of PDA. METHODS: The inclusion criteria were a weight of <6 kg and the presence of PDA symptoms. The study subjects were divided into two groups: <6 kg and premature infants. RESULTS: A total of 69 infants were included. The mean ages and weights of the <6 kg and the preterms were 5.4 ± 2.7 months and 30.3 ± 19.9 days, and 4.6 ± 0.8 and 1.7 ± 0.3 kg, respectively. Type C PDAs were most frequently observed in the premature group, and type A was in <6 kg. Sixteen of the patients were premature infants, and 81.2% of them had an extremely low birth weight. All of the premature infants had comorbidities, and had been receiving respiratory support therapy. Transcatheter closure was successfully completed in 81.2% of the premature infants and 94.3% of the <6-kg infants. Major complications occurred in 4 patients (one death and three device embolizations). The patient's age was found to be the main risk factor. The most frequently used device was the Amplatzer duct occluder II in additional sizes (84.6%) in the preterms and the Amplatzer duct occluder I (34%) and II (34%) in the <6-kg group. CONCLUSION: The transcatheter closure of PDA is relatively safe and effective in preterms and in infants <6 kg. The selection of a suitable device based on the type of PDA is critical to the success of the procedure.

Interesting case of a sewing needle inside the heart: report of a case.

Despite being rarely seen, penetrating cardiac injuries are clinically significant, as they are highly lethal. We herein present the case of a 3-year-old male who unintentionally injured himself by pricking his own chest with a sewing needle and introducing it through the left-lower margin of his sternum into his right ventricle. The needle was located anterior-posteriorly over the right ventricle. An anterior thoracotomy was performed, and the needle was safely removed. No hemorrhage or arrhythmia was seen, so the operation was ended. An early diagnosis and intervention proved to be life-saving for this penetrating cardiac injury.

Recurrent Prosthetic Mitral Valve Dehiscence due to Infective Endocarditis: Discussion of Possible Causes.

Prosthetic valves are being widely used in the treatment of heart valve disease. Prosthetic valve endocarditis (PVE) is one of the most catastrophic complications seen in these patients. In particular, prosthetic valve dehiscence can lead to acute decompensation, pulmonary edema, and cardiogenic shock. Here, we discuss the medical management of late PVE in a patient with a prior history of late and redo early PVE and recurrent dehiscence. According to the present case, we can summarize the learning points as follows. A prior history of infective endocarditis increases the risk of relapse or recurrence, and these patients should be evaluated very cautiously to prevent late complications. Adequate debridement of infected material is of paramount importance to prevent relapse. A history of dehiscence is associated with increased risk of relapse and recurrent dehiscence.

Short-term and mid-term results with the Sorin Freedom Solo aortic valve.

BACKGROUND AND AIM OF THE STUDY: The study aim was to present the short- and mid-term results for patients who underwent aortic valve replacement (AVR) with the Sorin Freedom Solo third-generation stentless prosthetic valve. METHODS: AVR with a Sorin Freedom Solo valve was performed in 14 patients between March 2006 and March 2011. Patients aged > or = 60 years (male:female ratio 6:8; mean age 73.28 +/- 5.42 years) who required AVR with the Sorin Freedom Solo valve according to the surgeon's choice were included in the study. The valvular prosthesis was implanted in the supra-annular position, using a single suture line. RESULTS: Eight patients underwent an isolated AVR; combined interventions were carried out in the other patients due to concomitant cardiac disease. One patient died during the immediate perioperative period, and two more during the follow up, from non-cardiac causes. The mean maximum transvalvular gradient of patients with aortic stenosis was 88.1 +/- 20.2 mmHg, and this fell to 26.4 +/- 7.6 mmHg during the early postoperative period. The mean gradient at one year of follow up was further decreased to 19.4 +/- 5.3 mmHg. The left ventricular end-diastolic and end-systolic diameters were also significantly reduced, from 4.8 +/- 0.9 to 4.3 +/- 0.6 cm and from 3.2 +/- 0.6 to 2.8 +/- 5.3 cm, respectively. The average left ventricular ejection fraction was 60.2 +/- 4.9% preoperatively, and 63.2 +/- 2.1% at one year after surgery (p = NS). No paravalvular leakage, endocarditis, prosthesis failure or neurologic events were reported among patients. CONCLUSION: The Sorin Freedom Solo stentless valve has provided good early and intermediate-term results. Implantation of the prosthesis is straightforward, with low rates of morbidity and mortality. However, these data require further support from larger patient series and long-term follow up.

Lateral cavoatriotomy for partial anomalous pulmonary venous connection to the superior vena cava.

PURPOSE: Surgical correction of the partial anomalous pulmonary venous connection (PAPVC) draining into the superior vena cava (SVC) has been associated with sinus node dysfunction and venous return obstruction, postoperatively. We present the results of our lateral cavoatriotomy approach with little modifications to avoid injury to the sinus node and its artery. METHODS: 32 patients who underwent surgical repair of PAPVC to SVC with modified lateral cavoatriotomy in our clinic between January 2003 and January 2009 were evaluated retrospectively. RESULTS: Median age was 6 years (2-32 years). The mean follow-up time was 65.8 ± 23.7 months (36-111 months). There were no early or late deaths. No patients required reoperation. New onset of arrhythmia had developed in two patients and resolved before hospital discharge. Stenosis of the SVC in one patient had developed 11 months after the operation and was treated with balloon angioplasty, successfully. No sinus node dysfunction or venous return obstruction was detected in their last follow-up. CONCLUSION: Cavoatrial incision for repair of PAPVC to SVC may become a safer surgical technique with some modifications.

Isolated ruptured inter-atrial septal cystic echinococcosis during pregnancy.

Herein, we present a case of asymptomatic isolated cardiac cystic echinococcosis localized entirely to the inter-atrial septum in a pregnant woman. The patient underwent successful surgery. Cardiac cystic echinococcosis is rarely seen in pregnancy. A high index of suspicion is necessary for the diagnosis of a cardiac cyst hydatid. The treatment of cardiac cyst hydatid is surgical and should not be delayed during pregnancy. Early surgery might prevent septic embolization and cardiac life-threatening complications and save the lives of both mother and baby as in the present case.

"V-PLASTY": a novel technique to reconstruct pulmonary valvular and annular stenosis in patients with right ventricular outflow tract obstruction.

BACKGROUND: The goal of repair of right ventricular outflow tract obstruction with or without Tetralogy of Fallot (TOF) is to eliminate valvular and/or subvalvular obstruction. However, this operation has a high risk of late complication of pulmonary insufficiency. In this study, we aimed to present early period results of our new technique that we call "V-Plasty" developed to prevent pulmonary insufficiency after pulmonary valve reconstruction in selected patients. METHODS: Between January 2006 and January 2010, we performed V-plasty for pulmonary valve reconstruction in 10 patients. Eight patients (5 males, 3 females) had TOF and 2 patients (1 male, 1 female) had atrial septal defect concomitant with pulmonary valve stenosis. Patient selection for V-plasty reconstruction was made due to the pulmonary valve anatomy and degree of stenosis. The mean follow-up time was 55.7 ± 16.2 months (ranging from 32 to 80 months). RESULTS: Functional capacity of the patients improved immediately after the surgery. There were no mortality and re-operation in follow-up period. Patients were followed up with echocardiography one week after the operation, at 1st, 6th, 12th months and annually. There was no pulmonary insufficiency. CONCLUSIONS: Operative correction of the pulmonary outflow tract obstruction with or without TOF, frequently requires transannular enlargement because of the infundibular and/or annular-valvular obstruction. This conventional technique is usually a reason for late pulmonary insufficiency. In our study, we have not seen pulmonary insufficiency in early term follow-up period. Our early term results are encouraging, but long term follow-up results are needed with large case series.

Contribution of giant aneurysm of a membranous ventricular septal defect to right ventricular outflow tract obstruction.

Perimembranous defects are the most common types of ventricular septal defects (VSDs). In many cases, an aneurysm accompanies this defect. The aneurysm can have advantageous consequences on defect hemodynamics. However, it also has numerous complications that are frequently encountered in clinical practice. In this case, we describe a patient with a membranous VSD with giant aneurysm formation contributing to subpulmonic severe obstruction.

Urgent surgical management for embolized occluder devices in childhood: single center experience.

BACKGROUND: In this study, we sought to analyze our experience in urgent surgical management for embolized cardiac septal and ductal occluder devices resulting from trans-catheter closure of atrial septal defect, ventricular septal defect and patent ductus arteriosus in childhood patient group. METHODS: We retrospectively reviewed 9 patients (aged 2-15 years) who underwent urgent surgery due to cardiac septal and ductal occluder embolization between January 2007 and December 2010. Congenital defects were atrial septal defect (n = 6), ventricular septal defect (n = 1), and patent ductus arteriosus (n = 2). Risk factors for device embolization and urgent surgical management techniques for embolized device removal were discussed. RESULTS: Removal of embolized devices in all cases and repair of damaged tricuspid valve in 2 patients were performed. Inevitably, all congenital defects were closed or ligated up to the primary defect. Total circulator arrest necessitated in 1 patient with ascending aortic device embolization. All operations were completed successfully and no hospital mortality or morbidity was encountered. CONCLUSIONS: Although closure of left to right shunting defects by percutaneous occluder devices has a lot of advantages, device embolization is still a major complication. If embolized device retrieval fails with percutaneous intervention attempts, surgical management is the only method to remove embolized devices. In this circumstance, to provide an uneventful perioperative course, urgent management strategies should be well planned.

Treatment outcomes of postoperative mediastinitis in cardiac surgery; negative pressure wound therapy versus conventional treatment.

BACKGROUND: The aim of the present study is to compare negative pressure wound therapy versus conventional treatment outcomes at postoperative mediastinitis after cardiac surgery. METHODS: Between January 2000 and December 2011, after 9972 sternotomies, postoperative mediastinitis was diagnosed in 90 patients. The treatment modalities divided the patients into two groups: group 1 patients (n = 47) were initially treated with the negative pressure wound therapy and group 2 patients (n = 43) were underwent conventional treatment protocols. The outcomes were investigated with Kaplan-Meier method, log-rank test, Student's test and Fisher's exact test. RESULTS: The 90-days mortality was found significantly lower in the negative pressure wound group than in the conventionally treated group. Overall survival was significantly better in the negative pressure wound group than in the conventionally treated group. CONCLUSION: Negative pressure wound therapy is safe and reliable option in mediastinitis after cardiac surgery, with excellent survival and low failure rate when compared with conventional treatments.

Pericardial monocusp reconstruction for pulmonary valve vegetation secondary to patent ductus arteriosus.

A case of pulmonary valve endocarditis in a patient with a ductus arteriosus (PDA) is reported. The PDA was ligated, the septal leaflet of the pulmonary valve was excised, and a pericardial monocusp reconstruction was performed.

Off-pump versus on-pump coronary artery bypass grafting in acute coronary syndrome: a clinical analysis.

BACKGROUND: Although off-pump coronary artery bypass (OPCAB) surgery has many beneficial effects compared with on-pump surgery, switch to on-pump surgery has significantly higher risks of operative mortality. Benefits of OPCAB over on-pump surgery strategies concerning myocardial revascularization are still debatable. We have aimed to develop an "algorithm of off-pump surgical strategy" on preventing conversion to on-pump. This clinical study reports our clinical outcome of OPCAB in patients with acute coronary syndrome. METHODS: Between January 2006 and December 2008, 198 patients with acute coronary syndrome were enrolled in the study. Decision of OPCAB (142 patients) or on-pump surgery (56 patients) was made according to patients' present clinical status and our surgical background. Cardiac enzymes, duration of the surgery, graft numbers, stay in intensive care unit were recorded. RESULTS: OPCAP group has shorter operation time (82.78 min versus 164.22 min, p < 0.001), lesser necessity for intra-aortic balloon pumping (3.5% versus 12.5%, p = 0.053), shorter duration of intensive care unit stay (p < 0.05) and hospital stay (p < 0.001) compared to on-pump patients. EuroSCORE level was lower in OPCAP group (p < 0.001). None of the patients of OPCAB group required conversion to on-pump technique. CONCLUSIONS: The patients who admitted to the hospital with acute coronary syndrome within "golden hours" (within 6 hours after onset) had a greater chance for OPCAB surgery. This study proves that EuroSCORE is likely to be an important factor in deciding which surgical technique to use, but a further investigation is needed to verify. According to our findings, a careful evaluation of coronary angiography, hemodynamic status, quality of target coronary vessel and timing of surgery are important for OPCAB surgery to avoid conversion to on-pump. By a careful systematic evaluation of the patients as explained with this article, it can be prevent or reduce conversion to on-pump surgery during OPCAB surgery.

Primary cardiac angiosarcoma: a case report.

Primary tumors of the heart are rarely seen. Cardiac angiosarcomas are malignant tumors that almost always have a poor prognosis. We describe a 29-year-old man with primary cardiac angiosarcoma with multiple site metastases. The therapeutic approach includes surgery, chemotherapy and radiotherapy alone or in combination. New techniques of radiotherapy and combined chemotherapeutic agents may relieve symptoms and prolong a patient's life. We discuss the diagnosis and treatment of cardiac angiosarcoma in the light of a case report.

Ectopic thyroid gland on the ascending aorta with a partial pericardial defect: report of a case.

Intrathoracic ectopic goiters are rare. To our knowledge, only two reports of thyroid tissue on the aorta have been reported in the English literature. A 42-year-old woman was found to have a right paracardiac mass. Sternotomy revealed a firm and encapsulated tumor attached to the anterolateral surface of the ascending aorta and a defect in the right superior part of the pericardium. The mass was completely excised and histopathologic examination confirmed a multinodular goiter. We discuss the features of this rare tumor.