The role of transapical cannulation in the operative management of acute aortic dissection.

OBJECTIVES: The aim of the study was to investigate the usefulness of transapical cannulation as the routine cannulation site in patients with acute aortic dissection and to compare it with other cannulation methods. METHODS: Between January 2010 and December 2013, emergency surgery was performed in 111 consecutive patients with acute type A aortic dissection. Patients were divided into two groups: transapical cannulation group and other cannulation sites group (including femoral and axillary artery cannulation). Pre-, intra- and postoperative data were compared between these two groups of patients. RESULTS: Transapical cannulation was the most frequent cannulation site (78 patients, 70.3%), the femoral artery was selected in 24 patients (21.6%) and the axillary artery in 9 patients (8.1%). The mortality rate in the transapical group was 16.7% and 18.2% when other cannulation sites were chosen (p=0.85). No difference in postoperative stroke rate (6.4% vs 9.1%, p=0.62, transapical vs other cannulation sites group, respectively), myocardial infarction (6.4% vs 6.1%, p=0.94) and postoperative acute renal insufficiency incidence (9% vs 6.1%, p=0.61) was found. CONCLUSIONS: Routine transapical cannulation in patients with acute type A aortic dissection is a fast and safe way to establish cardiopulmonary bypass. There is no difference in major operative outcomes after transapical cannulation when compared to the other cannulation sites.

[Cardiac neoplasms: results of the surgical treatment between 2000. and 2008].

INTRODUCTION: The goal of this study was to show early and midterm results of surgical treatment of cardiac neoplasma. METHODS: Between 2000. and 2008., sixty-seven patients with a cardiac tumor or a subdiaphragmatic neoplasma with right atrial extension were operated in our institution. In 22 patients (32.8%), not only a simple extirpation of neoplasma, but an additional surgical procedure was done. RESULTS: A patient reoperated for a recurence of biatrial myxoma died early after operation (1.5% mortality rate). During follow-up period of 3.3 years, two patients (3.4%) out of 58 that were contacted died because of the neoplasma (Methastasis of adenocarcinoma, Carcinoma renis). CONCLUSION: Surgical treatment of cardic tumors resulted in low early mortality and an excellent survival rate after a follow-up period of 3.3 years.

[Rare case of quadricuspid aortic valve].

Quadricuspid aortic valve is rare congenital anomaly. There are only 197 cases published in literature so far. That includes clinical and autopsy reports. This congenital anomaly occurs more often in pulmonary valve but function stays normal in 10 of lies. On the other side, in aortic position valve is malfunctioning in 50% of cases. Valve regurgitation is more likely to occur than stenosis In this kind of malformation, valves are prone to early dysfunction and endocarditis due to different valve architecture and unequal distribution of mechanical stress along valve cusps. Aortic valve replacement is indicated in younger population of these patients. This is a case report of rare congenital anomaly of big blood vessels--aortic valve with four cusps. This anomaly produced significant aortic regurgitation so this patient was indicated for aortic valve replacement.

[Myocardial revascularization without extracorporeal circulation].

Contemporary treatment of coronary disease includes: drug treatment, percutaneous coronary angioplasty (PCI), with or without stent implantation and surgical myocardial revascularization. For more than 30 years, conventional coronary bypass (on-pump CABG), using cardiopulmonary bypass (CPB), represented the standard regarding myocardial revascularization, particularly in patients suffering from three vessel disease or left main coronary artery stenosis. Recent development of invasive cardiology and increased interest in coronary surgery on the beating heart (OPCAB), challenging traditional on-pump CABG procedure, as optimal strategy for the treatment of coronary artery disease. In order to improve clinical outcome, OPCAB seems to be a good choice in patients with co-morbidities critical for use of CPB. Results of OPCAB revascularization in general patient population are considerably different and require further evaluation. This review article shows the development of OPCAB and elaborates potential advantages and weaknesses of this method of revascularization, from both, theoretical and clinical point of view, compared to standard surgical myocardial revascularization.

[Alternative arterial cannulation site in acute aortic dissections].

INTRODUCTION: Acute aortic dissection is an urgent surgical disease. Often, due to hemodynamic instability, that is an indication for emergent surgical intervention. Majority of surgeons uses Femoral or Axillary artery as arterial inflow site forextracorporal circulation. Both approaches have disadvantages that potentially may cause devastating complications. Some of them have been described in literature such as inadequate flow on heart-lung machine, retrograde dissection and malperfusion syndrome. AIM OF STUDY: Aim of study is to show, that by using transventricular cannulation we are eliminating all technical problems and lowering peroperative morbidity and mortality. METHOD: Between 1996-2006 at Institute for Cardiovascular Disease "Dedinje" 107 patients were operated for acute ascending aortic dissection Femoral artery was used for arterial cannulation in 91 patients. Last 16 patients were operated by using transventricular approach to establish extracorporeal circulation. We used retrograde cerebral perfusion in 21 cases at the beginning of our experience. RESULTS: In group of patients where transapical cannulation was used, no neurological incidents were noticed. We didn't have any other problems related to extracorporeal circulation or placement of arterial cannula. Is this series we had only one death case. Patient passed away on eight postoperative day due to multiorgan insufficiency. CONCLUSION: Transapical cannulation is very simple and safe method for quick establishment of extracorporeal circulation. It always gives patient sufficient antegrade, physiological flow on heart-lung machine. This is the way to minimize possibility of malperfusion syndrome and to significantly diminish risk of neurological complication. By using this method all negative effects of other cannulation sites will be avoided.

Transaortic double valve replacement in difficult mitral valve exposure.

Adequate open exposure of the mitral valve is necessary to accomplish reconstruction or replacement of the diseased mitral valve apparatus. The technique employed by most cardiac surgeons for mitral valve access involves median sternotomy and vertical left atriotomy posterior to the interatrial sulcus. However, certain conditions can somethimes make this approach very difficult. Different approaches are discussed with particular emphasis on our case in which the transaortic double valve replacement have been performed.

The radial artery for coronary artery bypass grafting.

Coronary artery bypass grafting (CABG) is the standard surgical procedure for the treatment of advanced coronary artery disease. CABG surgery has been demonstrated to improve symptoms and, in specific subgroups of patients, to prolong life. Despite its success, the long-term outcome of coronary bypass surgery is strongly influenced by the fate of the vascular conduits used. Previous long-term studies have shown unsatisfactory patency of saphenous vein grafts used for myocardial revascularisation, compared with internal mammary artery grafts. Recently, the use of radial artery for CABG has enjoyed a revival, on the basis of the belief that it will help improving long-term results of coronary operations. The recent reports of encouraging mid-term and long-term patency rates of the radial artery, supports its continued use as a bypass conduit. In this paper, we review the current knowledge about the radial artery as a bypass graft, with special emphasis on the clinical results.

Postcardiotomy assisted circulation with roller pump--early and late results.

The incidence of postcardiotomy myocardial failure (PMF) requiring mechanical circulatory support beyond IABP is reported to be 0.2% to 1.2%. From Dec. 1989 through Dec. 1995, 18 patients (0.3% of the total pump cases) were supported with roller pump type of LVAD. Assisted flow ranged from 3.5 up to 5 L/min with average support time of 35.5 hours. Six (33.3%) patients died while on LVAD. The causes of additional seven deaths (pts weaned of LVAD) were: myocardial failure (4), stroke (2) and intractable bleeding during removal of the LVAD (1). Overall, five patients (27.8%) were successfully discharged from the hospital. Two out of five long-term survivors died later, 6 months and 4 years postoperatively, both of cardiac causes. The actuarial survival rate of long-term survivors was 60% at 7 years, all of them being in NYHA functional class II. These results have proved efficiency of roller pump driven LVAD for short-term circulatory support in pts with PMF. Results are comparable to so far published data on postcardiotomy support with the same, as well as other types of more versatile and costly devices.

[Combined general anesthesia and high thoracic epidural analgesia in myocardial revascularization of the failing heart in a patient on hemodialysis]. / Kombinacija opste anestezije i visoke torakalne epiduralne analgezije u revaskularizaciji miokarada na kucajucem srcu u bolesnika na hemodijalizi.

Terminal renal failure is often associated with severe coronary artery disease that should be treated with surgical myocardial revascularization. Since perioperative morbidity and mortality rates in these patients are high, the best way and the time for surgical intervention are still uncertain. We present the patient with end-stage renal disease, on chronic program of hemodialysis, who had underwent off-pump coronary artery bypass grafting and high thoracic epidural anaesthesia, followed by early extubation. To our knowledge, off-pump surgical myocardial revascularization in patients on hemodialysis using this anaesthetic technique has not yet been presented in our literature.

[Surgical revascularization of the myocardium]. / Hirurska revaskularizacija miokarda.

It has been 45 years ago when Longmire (1958.) used internal thoracic artery (ITA) for the first time in coronary artery bypass surgery (CABG). In this review, we are presenting novel surgical approaches in CABG surgery. We have also been summarized the best of knowledge, up to date, regarding histology, pharmacology and pathophysiology of conduits (VSM, ITA and alternative venous and arterial grafts) which have been used in CABG surgery, as well as factors influence on its short and long-term patency.

[Combined use of internal mammary and right gastroepiploic arteries in myocardial revascularization with and without extracorporeal circulation]. / Kombinovana primena unutrasnje mamarne i desne gastroepiploicne arterije u revaskularizaciji miokarda sa i bez primene vantelesnog krvotoka.

Use of arterial grafts represent the new approach in coronary artery bypass grafting (CABG) surgery these days. This article represents our experience in use of two or more arterial grafts in combination (internal mammary artery--IMA and right gastroepiploic artery--RGEA). Between March 2000 February 2002, 10 patients underwent CABG with exclusive use of left or both IMAs and RGEA, with or without extracorporal circulation (ECC). In the group without ECC fast truck anesthesia was used. Post CABG catheterization was performed in three patients. There were no 30 day mortality or morbidity. Post CABG catheterization in two patients showed excellent graft patency. One patient continued to have chest pain and after the catheterization we found ostial narrowing of the celiac trunck which was successfully dilated. One of participants had abdominal hernia repair. Our opinion is that use of arterial grafts in CABG surgery has much lower risk, excellent patency and good long term prognosis.