Mobile atheromatous plaque of the aortic arch diagnosed by transthoracic echocardiography prior to coronary artery bypass surgery. Which one would you choose: scepticism or wishful thinking?

A routine pre-operative chest X-ray of a patient admitted to our institution for an elective coronary artery bypass operation revealed a mildly dilated mediastinal silhouette, which led the cardiovascular surgery resident to schedule emergency transthoracic echocardiography (TTE), with a special note asking for detailed evaluation of the ascending aorta and aortic arch. TTE revealed a mobile atheroma at the aortic arch, which obliged the cardiac surgery team to modify their strategy to combined hemi-arcus aortae replacement and coronary artery bypass grafting (CABG). Although with transoesophageal echocardiography (TEE) a small portion of the ascending aorta may be obscured by the trachea, TEE provides higher resolution images than TTE. Therefore one can conclude that TEE is the imaging modality of choice for detecting aortic atheromatous plaques but in patients with low risk for stroke and aortic atheromas, a detailed TTE may be sufficient for the pre-operative assessment.

Glenn shunt as an alternative procedure for rheumatoid triple valve disease with tricuspid stenosis.

A 41-year-old woman with rheumatoid triple valve disease was operated. Mitral and aortic valves were replaced with prosthetic valves. The tricuspid valve annulus was highly stenotic (valve area: 1.4 cm (2)), therefore a bidirectional Glenn shunt procedure was performed to preserve the right ventricular function. In the long term, 4 years after the operation, the patient is still hemodynamically stable.

General anesthesia with thoracic epidural anesthesia in the cardiopulmonary bypass surgery reduces apoptosis by upregulating antiapoptotic protein Bcl-2.

AIM: The aim of the paper was to investigate whether thoracic epidural anesthesia (TEA) together with general anaesthesia (GA) play a role on apoptosis in humans before cardiopulmonary bypass (CPB), before aortic cross clamp (ACC) and at 15 min after ACC release (after ischemia and reperfusion). METHODS: Eighty patients scheduled for elective CABG were randomized to receive either GA group (n: 40) or TEA+GA group (n: 40). The right atrial biopsy samples were taken before CPB, before ACC and at 15 min after ACC release from all patients. Human heart tissues were obtained from patients of TEA+GA group and GA group. The number of Bcl-2 positive cardiomyocytes was counted in multiple tissue sections of biopsies of 80 patients using light microscopy (magnification x 40) with an ocular micrometer system (Olympus). RESULTS: In the TEA+GA group, the Bcl-2 positive cardiomyocytes were distinctly statistically increased compared to the GA group (P<0.001). In addition, the intensity of the immunostaining was also increased in the TEA+GA compared with the GA group. The number of immunoreactive cardiomyocytes is as follows: before CPB, TEA+GA group 396+/-61, GA group 92+/-41, before ACC, TEA+GA group 333+/-47, GA group 94+/-18, at 15 min after ACC release, TEA+GA group 346+/-68.8, GA group 85+/-9.5. There were statistically significant differences between groups, (P<0.001). Between groups, at 4 h and at 24 h after the end of CPB, in the TEA+GA group, the CI was significantly higher than GA group respectively; (3.4+/-0.8 L/min/m(2) vs 2.5+/-0.8 L/min/m(2); P<0.001), (3.8+/-1.1 L/min/m(2) vs 3.1+/-1.1 L/min/m(2); P<0.008). Within groups, at 4 and 24 h after the end of CPB, in the TEA+GA group, the CI was significantly higher than baseline values, respectively, (3.4+/-0.8 L/min/m(2) vs 2.4+/-0.7 L/min/m(2); P<0.001), (3.8+/-1.1 L/min/m(2) vs 2.4+/-0.7 L/min/m(2); P<0.001). Whereas no difference was found in the GA group respectively, (2.6+/-0.8 L/min/m(2) vs. 2.5+/-0.8 L/min/m(2); P>0.05), (2.6+/-0.8 L/min/m(2) vs. 3.1+/-1.1 L/min/m(2); P>0.05). The number of patients showing ventricular fibrillation (VF), atrial fibrillation or heart block after release of the ACC was 11 of 40 (27.5%) in the TEA+GA group versus 25 of 40 (62.5%) in the GA group. The number of patients showing VF after release of ACC was 9 out of 20 patients (22.5%) in the TEA+GA group which was significantly lower than in the GA group (21 of 40 patients 52.5%); (P<0.006). Sinus rhythm after release of ACC, in the TEA+GA group was observed in 29 of 40 patients (72.5%) and was significantly higher than in the GA group (15 of 40 patients 37.5%); (P<0.002). CONCLUSION: The result of the present study indicate that TEA plus GA in coronary surgery had preserved cardiac function during intraoperative and postoperative period by means of reduced apoptosis, improved hemodynamic function and reduced arrhythmias after release of the ACC.

Internal thoracic artery as main blood supply to the lower limbs. Case report.

A 70-year-old male patient was admitted with symptoms of unstable angina pectoris and claudication. He presented critical left main and right coronary artery disease and juxtarenal aortic occlusion at the same time. Internal thoracic artery increased in diameter with many collateral branch arteries distally. Coronary artery bypass graft operation was performed immediately. Saphenous veins were used for conduit. Internal thoracic artery was let intact to avoid any ischemic problem of the lower extremities. DSA performed postoperatively showed that the internal thoracic artery was the unique blood supply to the leg. In the absence of emergency of peripheral revascularization two staged surgical approach (CABG first and aortobifemoral bypass some months later) was considered. However, in patients with severe peripheral vascular disease or even in patients whom intraaortic balloon-pump indicated postoperatively, combined surgical approach is necessary. In all coronary artery disease patients with Leriche syndrome, ITA dependent lower extremity circulation should be thought preoperatively. Extra-anatomic peripheral bypass is a reasonable alternative choice in combined procedures with low morbidity, especially in elderly patients having coexisting disease.

An alternative application of sodium nitroprusside to overcome perioperative spasm of the internal thoracic artery.

OBJECTIVE: The internal thoracic artery (ITA) is currently the preferred conduit for myocardial revascularization; however, perioperative vasospasm of the internal thoracic artery may cause morbidity. Pedicle preparation and pharmacological vasodilatory treatment vary greatly. This clinical study was performed in order to define the effectiveness of two different applications of sodium nitroprusside as vasodilating agent. METHODS: Eighty-six (86) consecutive patients whose left internal thoracic artery was mobilized only by one surgeon for elective coronary artery bypass graft operations were randomly divided into two groups. The internal thoracic artery was allowed to bleed freely, and the flow was determined (flow 1). In group I (n=42) 3mg sodium nitroprusside in 10ml of 5% dextrose solution was sprayed with pressure on the pedicle with a thin 25 gauge needle. In group II (n=44) half of the solution was sprayed in the same manner, and the other half of the solution was injected into the pedicle in the periarterial tissue along the length of the pedicle. Free flows of the internal thoracic artery were registered before cardiopulmonary bypass (flow 2) and also just prior to performing internal thoracic artery anastomosis to the left anterior descending artery (flow 3). With each measurement hemodynamic parameters and the time between measurements were recorded. RESULTS: No statistically significant differences were found between the groups in respect to sex ratio, age, body surface area, heart rate 1 and 2, mean arterial pressure 1 and 3. There was no significant difference in the initial flow among groups. Significant differences were noted in the second flow measurement (P<0.05) and in the third flow measurement (P<0.01) between two groups. For each group there was a significant increase in flow from flow 1 to flow 2 and from flow 2 to flow 3 (P<0.02). CONCLUSION: Sodium nitroprusside injection to the pedicle provides a better flow than simple spraying of the same agent.

Chlamydia and atherosclerotic coronary arterial disease in Turkey.

OBJECTIVE: Chlamydia pneumoniae, which is a Gram(-) intracellular bacteria, besides being a respiratory pathogen, is thought to play an active role in the progress of acute myocardial infarction and chronic coronary artery disease. In this study we aim to determine the frequency of C. pneumoniae in coronary artery lesions of Turkish people. METHODS AND RESULTS: The atherosclerotic material taken from 8 cases by directional atherectomy and from 23 cases by surgical endarterectomy and examined by indirect immunofluorescence (IIFA) test and polymerase chain reaction (PCR). C. pneumoniae positivity was 32.3% (10/31) by IIFA and 29.0% (9/31) by PCR while the evaluation of the methods together yield a positivity of 35.5% (11/31). CONCLUSIONS: A statistically significant difference could not be established between C. pneumoniae positive and negative groups according to age and the classical atherosclerotic risk factors such as diabetes mellitus, smoking, hypercholesterolaemia, hypertension, family history; besides, a statistically significant difference could not be found between the presence of C. pneumoniae and the severity and clinical picture of coronary artery disease.

Sequential revascularization of intramuscular left anterior descending coronary artery.

We present a new technique for avoiding possible kinking or angulation of the sequential left internal mammary artery to left anterior descending artery (LIMA-LAD) anastomoses when the LAD follows an intramuscular course. A 3- to 5-mm cusp of saphenous vein segment is interposed between the intramuscular LAD segment and internal mammary artery (IMA) at the sequential anastomotic site, to which the distal portion of the IMA was anastomosed in standard end-to-side fashion.

Coronary artery bypass surgery without cardiopulmonary bypass.

In the years 1994 and 1995, 1087 patients underwent coronary artery bypass grafting at our institution. Of these, 297 were operated on without cardiopulmonary bypass. 239 were male, and 58 were female. Their ages ranged from 28 to 81 years (54.43 +/- 9.63). Of the total, 294 were operated on electively, two as a coronary reoperations, and one as an emergency after a failed percutaneous transluminal coronary angioplasty procedure. In all patients complete revascularization was the aim, and a cardiopulmonary bypass team was kept on standby. Median sternotomy was performed as the exposure in all patients, except a patient who underwent a coronary reoperation through a left thoracotomy incision. The average of the distal anastomoses was 1.51 +/- 0.6, ranging from 1 to 3. The left internal thoracic artery was used in 292 operations, which was an individual graft in 284, a sequential graft in five, and a free graft in four. Major complications in the early postoperative period were noted in three patients as reoperation for excessive bleeding. One patient had reoperation for left internal thoracic artery spasm, and one patient had lower extremity ischemia caused by intraoartic balloon counterpulsation. Hospital mortality was 0.3% with one patient. It is our belief that in selected cases coronary artery bypass grafting without cardiopulmonary bypass is a safe procedure with the advantage of improvement in recovery during the postoperative period.

Combined internal mammary artery graft for coronary artery revascularization.

Five patients with multiple-vessel coronary artery disease underwent isolated coronary artery bypass grafting with a technique involving both internal mammary arteries and a small piece of interposed saphenous vein. The combined internal mammary artery grafts were used for sequential grafting. A total of 20 anastomoses were performed (average number, 4 anastomoses per patient). There were no operative deaths. Postoperative complications included reoperation for bleeding in 1 patient and diaphragmatic dysfunction in another. Postoperative coronary angiography 2 days before discharge (mean time, 10 days postoperatively) revealed that all the sequential anastomoses with the combined IMA graft were patent. Exercise tolerance tests performed 3 and 11 months postoperatively indicated excellent results and no ischemia. Based on this experience, we conclude that this method appears promising for multivessel coronary artery bypass grafting.

Surgical treatment of hydatid cysts of the lung: report on 1055 patients.

Of 1055 patients treated surgically for pulmonary hydatid disease, most (950) had isolated lung cysts, the other 105 having both liver and lung cysts. The chest radiograph was most valuable in diagnosis; the Casoni and Weinberg tests and blood eosinophil counts were found to be diagnostically unreliable. One thousand and seventy seven primary operations were performed. Cystotomy and capitonnage were carried out in 906 patients, 40 of whom also had decortication of the pleura. Other procedures included cystotomy with wedge resection of locally damaged lung (29 patients) and cyst removal with capitonnage by Ugon's method (33) or the Perez-Fontana procedure (8) and with costal resection for osteomyelitis in two cases. More radical surgery was carried out in 99 patients for longstanding infection or severe lung destruction. Postoperative complications occurred in 37 patients (3.5%) and the 30 day mortality rate was 1.7%. It is concluded that a lung conserving surgical operation is the treatment of choice for most patients with pulmonary hydatid disease. In patients with coexisting liver cysts the thoracic transpleural approach allowed the lung and liver cysts to be removed at the same session.

Platelet counts in children with iron deficiency anemia.

Platelet count was evaluated in 30 children with iron deficiency anemia. It was found elevated when compared with 40 normal controls. No significant difference was found between the platelet counts in patients with hemoglobin levels higher or lower than 7 g/dl. Although no relation was observed between platelet count and transferrin saturation, it was correlated with serum iron values. After oral and/or parenteral iron therapy platelet count decreased insignificantly, while reticulocytes were found to be increased.