Saphenous vein wrapping for the treatment of a perigraft seroma: report of a case.

A 61-year-old man who had undergone an iliofemoral bypass with an expanded polytetrafluoroethylene (PTFE) graft was readmitted to our hospital for the investigation and treatment of a possible complication of the surgery. A tender, pulsatile, bulging mass, about the size of an adult fist, was palpated around the left lower abdominal region. Diagnostic procedures showed a large low-density area around the PTFE graft and angiography revealed a patent graft with no anastomotic leakage. An operative inspection revealed the mass to be a large perigraft seroma. The PTFE graft was covered with a saphenous vein strip, a treatment that has not previously been mentioned in the literature. The success of this strategy was confirmed by clinical observations and diagnostic procedures including ultrasonography and computed tomography, with no sign of recurrence for 5 months.

Comments on "Asymptomatic hypoxia in a young pregnant lady--unusual presentation of atrial septal defect", Krishnamoorthy S, et al.

In their recently published article, Krishnamoorthy and coworkers describe a case of an asymptomatic hypoxia due to atrial septal defect in a pregnant woman. However, before accepting their conclusion, some issues require further clarification: (a) What were the patient's haemodynamic findings in cath-angio before the closure of ASD? (b) What was the final arterial saturation after device closure of the ASD?

The importance of transesophageal echocardiography in diagnosis of pericardial tamponade after cardiac surgery.

BACKGROUND AND AIM OF THE STUDY: Despite the fact that there is a simple and effective treatment for pericardial tamponade (PCT), delayed diagnosis can cause serious morbidities or even mortality. In this study, we discuss the management and the diagnostic procedures of PCT. MATERIALS AND METHODS: Sixty-two patients with suspected PCT were initially evaluated with transthoracic echocardiography (TTE) and then with transesophageal echocardiography (TEE). Forty-nine (79%) patients were chosen for surgery after TEE displayed a suspected PCT diagnosis. Patients with suspected PCT were divided into two groups: Early-phase PCT (symptoms developed within 72 hours) and late-phase PCT (symptoms developed after 72 hours). RESULTS: Thirty-five (56%) patients were in the early phase and 27 (44%) patients were in the late phase. In 13 out of 22 (59%) cases, from both early and late phases, TTE findings showed no PCT, but TEE findings showed a positive PCT diagnosis. All 13 of the cases where TEE was positive after a negative TTE were confirmed by surgery. Overall, the PCT diagnoses in 48 out of 49 patients were confirmed during surgery. DISCUSSION: The role of echocardiography in PCT diagnosis is shown to be extremely important in some clinical cases, such as in patients during the postoperative period after cardiac surgery. Furthermore, particularly when TTE does not provide complete imaging of the pericardial sac, TEE should be mandatory. We recommend that even patients with a negative diagnosis of PCT from TTE should undergo further evaluation with TEE.

Bronchopericardial fistula, an unusual complication of oxytetracycline sclerosis therapy.

Here we report a rare case of bronchopericardial fistula following intrapericardial instillation of oxytetracycline. A 63-year-old female patient was admitted for management of malignant pericardial effusion secondary to right-sided bronchogenic carcinoma. Medical therapy and recurrent percutaneous catheter drainage failed in resolving the problem, so subxiphoid pericardiostomy and drainage tube insertion was performed. There was no decrease in the drainage so we decided to perform pericardial sclerosis by intrapericardial tetracycline instillation. After the second time oxytetracycline instillation, the patient developed respiratory arrest with hemodynamic instability. A huge amount of yellow frothy secretion aspirated through the endotracheal tube. The presence of tetracycline in the bronchial secretion was proved by microbiological methods. The hemodynamic status of the patient deteriorated rapidly and despite all resuscitation measures we lost the patient within a few hours.

Preoperative beta-blocker use reduces atrial fibrillation in off-pump coronary bypass surgery.

BACKGROUND: Atrial fibrillation (AF) after coronary artery bypass graft surgery constitutes the most common sustained arrhythmia and results in many complications. The purpose of this study was to assess the effects of prophylactic use of beta-blockers against atrial fibrillation in off-pump surgery patients in the early postoperative period. METHODS: From 2002 to 2005, 78 patients were enrolled and 41 patients received 50 mg metoprolol succinate daily, which was initiated minimum four days before surgery. Preoperative beta-blocking therapy was continued until the morning of surgery. Thirty-seven patients were free of beta-blocker therapy. Esmolol was used within same range of doses in both groups during operations. Both groups received metoprolol succinate following operations. The frequency of AF occurrence was analysed from the operation time to the sixth postoperative day. RESULTS: Sixteen patients developed AF with an overall incidence of 22.5%. Four patients from the study group and three patients from the control group were excluded from the study because of transfer to on-pump surgery. There was no difference with regard to the number of grafts carried out, duration of operations and ventilation, intensive care unit stay and inotropic need among groups. Length of hospital stay did not differ among groups either. There was a higher incidence of postoperative AF in patients without beta-blocker prophylaxis (11.7-32.4% P=0.049). CONCLUSION: Low-dose postoperative beta-adrenergic blockade is valuable for patients who receive these medications before off-pump coronary artery bypass grafting procedures and may be beneficial against AF in all patients.

An overview of energy sources in clinical use for the ablation of atrial fibrillation.

Recent years have seen many developments in the field of alternative energy sources for arrhythmia surgery. The impetus behind these advances is to replace the traditional, "cut-and-sew" Cox maze III procedure with lesion sets that are simpler, shorter, and safer but just as effective. There is demand for technology to make continuous, linear, transmural ablations reliably with a versatile energy source via an epicardial approach. This would make minimally invasive endoscopic surgical ablation of atrial fibrillation (AF) without cardiopulmonary bypass and with a closed chest feasible. These advances would shorten cardio-pulmonary bypass and improve outcomes in patients having surgical ablation and concomitant cardiac surgery. This review summarizes the technology behind alternative energy sources used to treat AF. Alternative energy sources include hypothermic sources (cryoablation) and hyperthermic sources (radiofrequency, microwave, laser, ultrasound). For each source, the biophysical background, mode of tissue injury, factors affecting lesion size, and advantages and complications are discussed.

A rare intracardiac mass: cardiac paraganglioma.

It is very rare for heart tissue to give rise to a primary paraganglioma. Here, we report the observation of such a tumour in a 34-year-old woman who presented with symptoms of pulmonary venous congestion. The findings from echocardiography were consistent with the diagnosis of a myxoma that was partially occluding the left atrium. Surgery was performed in which a large (6 cm x 5 cm x 3 cm), non-lobulated solid tumour was resected from the posterior wall of the atrium. Upon histologic evaluation, this was determined to be a cardiac paraganglioma.

WITHDRAWN: A Rare Intracardiac Mass: Cardiac Paraganglioma.

The Publisher regrets that this article is an accidental duplication of an article that has already been published in Heart Lung Circ, 16 (2007) 116-117, doi:10.1016/j.hlc.2006.12.002. The duplicate article has therefore been withdrawn.

Effects of atypical pneumonia agents on progression of atherosclerosis and acute coronary syndrome.

BACKGROUND: The aim of this study was to investigate the presence of various atypical pneumonia agents (Chlamydia pneumoniae, cytomegalovirus, Mycoplasma pneumoniae), which are considered to have a role in the ethiopathogenesis of atherosclerosis, in aortic biopsies without macroscopically visible plaque and in internal thoracic artery biopsies. MATERIAL AND METHODS: Thirty-three patients (group 1), who had undergone coronary bypass operation and 10 non-atherosclerotic patients (group 2), were included in the study. Seventy-six tissue biopsies were taken. Biopsies from the patients in group 1 a were obtained from the atheroma plaque-free aortic tissue and 33 biopsies (group Ib) were obtained from their internal thoracic arteries. Following DNA extraction, nested PCR was used to detect Chlamydia pneumoniae DNA, and real time PCR was used to detect cytomegalovirus and Mycoplasma pneumoniae DNA. Blood parameters (lipid profile, CRP, fibrinogen) of the patients and operation characteristics were recorded. RESULTS: Chlamydia pneumoniae DNA was detected in 5 of 33 biopsy samples from coronary bypass patients, whereas none of the control patients (group 1b and group 2) were positive for this agent (P = 0.001). Neither CMV nor Mycoplasma pneumoniae was detected in IMA and aortic biopsies of both bypass and control patients. Elevated total cholesterol levels (P = 0.02) and positive CRP (P = 0.001) was found in C. pneumoniae positive patients. Prevalence of acute coronary syndrome was significantly higher in C. pneumoniae detected patients compared (P = 0.00 1). CONCLUSIONS: Detection of C. pneumoniae DNA in the atheroma free aortic biopsies might indicate that this micro-organism intervened in the progression of atheroma plaque. There was a strong relationship between the detection of this micro-organism in the aortic wall and acute coronary syndrome. The absence of DNA of the corresponding micro-organisms in the IMA wall may show its resistance to infective agents and in turn to atherosclerosis, which is a result of the prevailing endothelial functions of this artery.

The management of complicated sternal dehiscence following open heart surgery.

BACKGROUND: Wound infection after median sternotomy for cardiac or thoracic surgery is a serious complication, and there is a lack of agreement regarding the best treatment method. We present our results in patients with mediastinitis treated with longitudinally affixed titanium plates on sternal halves. METHODS: The technique was composite closure using titanium fixation plates to buttress the sternum in combination with circumferential stainless steel wires. The series included 21 patients who developed sternal non-union resulting from mediastinitis. Mobilization of muscular flaps was performed in 8 cases. This technique also consists of sternal and soft tissue debridement and wound closure over mediastinal tubes with continuous irrigation and drainage. Antibiotherapy based on culture and sensitivity data continued for 4 to 7 weeks. RESULTS: Twenty patients achieved complete wound healing without further operative intervention or major complication. Nineteen patients treated with this technique survived. One patient died from sepsis after developing residual focus of chondritis and undergoing wide resection of cartilage, and 1 patient died from complications of severe stroke. CONCLUSION: We had good success using aggressive early debridement, closure of the sternal halves with titanium plates, mobilization of muscular flaps, high-volume mediastinal irrigation, and intravenous antibiotics. This approach was a successful salvage technique for revision cases in achieving sternal stability and union when standard methods of closure failed or were unlikely to succeed.

Giant right atrial aneurysm: case report.

A 15-month-old boy with atrial fibrillation was found to have gross cardiomegaly on a chest radiography; further evaluation by echocardiography showed a giant right atrial aneurysm which is in the form of a cyst like lesion. The patient underwent successful surgical reduction of the right atrium converting his heart rhythm to normal. The operative measure was taken to prevent thrombus formation in the right atrium and lower the risk of atrial arrhythmias. The morphologic features of the resected atrial tissue showed a thin wall with a central aneurysm and focal endocardial fibrosis without inflammatory response consistent with a diagnosis of idiopathic dilatation of the right atrium.

A different intracardiac mass: retained sponge.

We report a case involving a surgical sponge retained following an aortic valve replacement. The surgical sponge was placed into the left ventricle to protect calcified debris from falling down into the left ventricular cavity. However, the sponge was forgotten and left inside the patient. We identified the retained surgical sponge by transesophageal echocardiography, which was performed because of a difficulty in weaning the patient from the cardiopulmonary bypass.

Ventricular fibrillation following removal of temporary epicardial pacemaking wires.

Temporary wires are routinely sutured to both the atrial and ventricular epimyocardium after open heart surgery. Despite their rarity, complications related to removal of such pacemaking wires may cause life threatening situations. We describe here a patient who developed ventricular fibrillation immediately after removal of temporary epicardial pacemaking wires.

Brucella endocarditis with repeated mitral valve replacement.

Brucella endocarditis, although a rare complication of brucellosis, is a life threatening and often under-diagnosed complication. Despite its high mortality rate with combined medical and surgical treatment, has a low occurrence rate in cases of brucellosis. Here we describe a patient who underwent mitral valve replacement for 3 times due to underdiagnosis of Brucella endocarditis. If a valve replacement fails because of an unknown reason, the doubt of a Brucella infection should be kept in mind for accurate treatment of such patients.

Left atrial dissection following mass removal from right ventricle: non-surgical therapy.

Left atrial dissection is a severe but rare complication, and it is generally associated with mitral valve interventions. But other predisposing factors should be considered in pathogenesis. Here we describe a patient who developed interatrial dissection following a mass removal from right ventricle. The dissection was recognised with transesophageal echocardiography and it was spontaneously cured with conservative therapy. Transesophageal echocardiography is strongly recommended during and after operations in patients with heart valve interventions in order to recognise such rare but severe complications.