The role of genetics in coronary artery bypass surgery patients under 30 years of age

Aim: We undertook genetic assessment of coronary artery disease (CAD) in 20 patients aged 30 years or less undergoing coronary artery bypass grafting (CABG) surgery, to investigate the prognostic value of pre-defined genes.Methods: Twenty patients, who underwent CABG surgery between December 2001 and May 2013, were retrospectively analysed to find out the role their genetic make-up played in their disease. We used three genetic diagnostic tests, the plasminogen activator inhibitor (PAI)-1 gene, the A1/A2 polymorphism of glycoprotein IIIa (GpIIIa) gene, and common polymorphisms of the methylenetetrahydrofolate reductase (MTHFR) gene.Results: The mean age of patients was 26.35 ± 3.51 (19­30) years, and 90% were male (n = 18). One patient had diabetes, three had hypertension, 11 (55%) had dyslipidaemia and 16 (80%) were smokers. Eight of the patients (40%) had left ventricular ejection fraction (LVEF) < 50%, and functional capacity was poor in only two (10%) patients (NYHA III­ IV). Follow up was completed in all patients (100%). We found five homozygous and 11 heterozygous mutations in the MTHFR gene, which predisposes individuals to coronary artery disease or deep-vein thrombosis. Eight patients were found to have a GpIIIa gene polymorphism, which is associated with increased risk of myocardial infarction (MI). Fifteen patients had a polymorphism in the promoter region of the PAI-1 gene, which is a major inhibitor of the fibrinolytic system. Conclusion: MTHFR C677T polymorphism, and GpIIIa and PAI-1 genes are risk factors for CAD. In young patients, genetic studies promise to revolutionise early diagnosis, treatment and prevention of CAD and MI

Late coronary stent dislodgement following coronary artery stenting.

Recently, coronary artery stenting has been successful when used as an intervention for percutaneous coronary artery disease. However, the procedure may frequently produce complications. Although rare, stent dislodgement is one such complication, which may result in serious problems including coronary artery dissection, myocardial infarction, peripheral embolisation and death. Stent dislodgement is known to be an early complication of the coronary artery stenting procedure. In this case report, we present a 53-year-old male with late coronary stent dislodgement. To the best of our knowledge, no such case has been addressed in the literature to date.

Alternative non-femoral accesses for intra-aortic balloon pumping.

Access from the femoral arteries to the thoracic aorta for intra-aortic balloon pump (IABP) insertion may not be feasible in a substantial number of patients with severe peripheral vascular disease. Since using an alternative access is inevitable in a certain number of patients requiring IABP support, all alternative accesses should be added to the surgical armamentarium. Herein, we present our 27-year experience with different alternative accesses for IABP insertion following failed contraindication to femoral artery cannulation. The alternative techniques described below were: transthoracic insertion with a tube graft, transthoracic insertion - direct, transaxillary/subclavian insertion and transbrachial insertion.

Effect of hypothermia in patients undergoing simultaneous carotid endarterectomy and coronary artery bypass graft surgery.

PURPOSE: We sought to determine whether hypothermia provided any benefit in patients undergoing simultaneous coronary artery bypass graft surgery (CABG) and carotid endarterectomy (CEA) using one of two different surgical strategies. METHODS: Group 1 patients (n = 34, 88.2% male, mean age 65.94 ± 6.67 years) underwent CEA under moderate hypothermia before cross clamping the aorta, whereas group 2 patients (n = 23, 69.6% male, mean age 65.78 ± 9.29 years) underwent CEA under normothermic conditions before initiating cardiopulmonary bypass (CPB). Primary outcome of interest was the occurrence of any new neurological event. RESULTS: The two groups were similar in terms of baseline characteristics. Permanent impairment occurred in one patient (2.9%) in group 1. One patient from each group (2.9 and 4.37%) had transient neurological events and they recovered completely on the sixth and 11th postoperative days, respectively. Overall, there was no statistically significant difference between the two groups with regard to occurrence of early neurological outcomes (n = 2, 5.8 % vs n = 1, 4.3 %, p = 0.12). CONCLUSIONS: This study could not provide evidence regarding benefit of hypothermia in simultaneous operations for carotid and coronary artery disease because of the low occurrence rate of adverse outcomes. The single-stage operation is safe and completion of the CEA before CPB may be considered when short duration of CPB is required.

Primary cardiac angiosarcoma.

Primary malignant cardiac tumors are extremely rare neoplasms. About three-quarters of all cardiac tumors are histologically benign. A 24-year-old man presented to the hospital with dyspnea and chest pain. A solid, dense, nonhomogeneous and rough-surfaced mass (89 x 90 x 36 mm) with protrusion into the right heart cavities was observed on transthoracic echocardiography. The findings were confirmed by transesophageal echocardiography and magnetic resonance imaging. The histopathology of the mass confirmed a diagnosis of angiosarcoma. No evidence of an extracardiac origin of the tumor was found by radiological body imaging. The patient died 2 months after presentation to the hospital.

Paravalvular leakage after mitral valve replacement: is left atrial enlargement an additional indication for reoperation?

BACKGROUND AND AIM OF THE STUDY: Prostheses used to treat heart valve disease improve patient survival, but have certain disadvantages. Paravalvular leakage (PVL) is a rare complication after mitral valve replacement (MVR), and can impair cardiac function and reduce the patient's functional capacity, depending on the degree of periprosthetic regurgitation. METHODS: Between 1985 and July 1999, 2,502 patients underwent MVR with or without concomitant cardiac procedures. Of these patients, 33 (18 males, 15 females; mean age 39.8+/-15.3 years; range: 12-62 years) had PVL of differing degree. The interval between MVR and observation of PVL was 30.5+/-31.5 months (range: 1-126 months), and the period after diagnosis was 22.6+/-31.5 months (range: 2-114 months). Fourteen patients (42.4%) underwent reoperation (RO group), and 19 (57.6%) were followed medically (ME group). Indications for reoperation were reduction of functional capacity, echocardiographically proven serious mitral regurgitation, and hemolysis. RESULTS: Reoperative mortality was 3.0% (1/33), and late mortality 3.1% (1/32) for all patients. Cumulative survival after PVL was 90.2+/-6.7% at both five and ten years. Annular calcification (33.0%) and infective endocarditis (18.2%) were important predictive factors for development of PVL. Only one patient required second re-do surgery. Univariate and forward stepwise logistic regression analyses showed that there was no predictor for the development of severe PVL requiring a second reoperation. No difference was observed between left ventricular dimensions before and after periprosthetic regurgitation. The only significant finding between groups was an increase in left atrial diameter in RO patients after the development of PVL (p <0.05). CONCLUSION: Among patients undergoing MVR there are no clinical features to distinguish who will develop severe PVL during follow up. If PVL reduces the patient's functional capacity or causes serious hemolysis, or if severe PVL is evaluated echocardiographically, then reoperation must be performed. Mild or moderate mitral regurgitation without impairment of functional capacity may be followed medically. In asymptomatic patients, enlargement (>5%) of the left atrial diameter following development of moderate PVL may be a valuable criterion for deciding when to reoperate.

Fifteen-year clinical experience with the biocor porcine bioprostheses in the mitral position.

BACKGROUND: Bioprosthetic valve use represents a crucial improvement in surgical treatment of mitral valve disease. The aim of this study is to determine the long-term durability of the Biocor porcine bioprosthetic mitral valve. METHODS: Between 1985 and 1989, a total of 158 Biocor porcine bioprosthetic valves were placed in the mitral position, and long-term results of these patients were investigated retrospectively in 1999. RESULTS: Thirty-day mortality was 4.4% (7 patients). Total follow-up was 1,499 patient-years. Actuarial survival was 83.66% +/- 3% at 5 years, 77.78% +/- 3.36% at 13 years (1.8% patient-year). Multivariate analysis demonstrated younger age, duration of implantation, congestive heart failure, and functional class to be significant predictors of late mortality. Actuarial freedom from valve-related mortality was 98.58% +/- 1% at 15 years (0.13% patient-year). Actuarial freedom from structural valve deterioration was 95.49% +/- 1.8% at 5 years, 70.2% +/- 4.12% at 10 years, and 64.82% +/- 5.34% at 13 years (2.6% patient-year). Actuarial freedom from structural valve deterioration-related reoperation was 98.43% +/- 1.1% at 5 years, 89.15% +/- 2.85% at 10 years, and 76.82% +/- 7.91% at 14 years. Multivariate analysis showed younger age and duration of implantation to be significant predictors of structural valve deterioration and its related reoperation. CONCLUSIONS: By studying a 15-year time period, it is seen that this new generation porcine bioprosthetic valve should be considered an alternative for mechanical valves in selected patients.

Different CABG methods in patients with chronic obstructive pulmonary disease.

BACKGROUND: Pulmonary dysfunction is still a major problem in coronary artery bypass grafting (CABG). The purpose of this randomized study was to determine the effect of different CABG techniques on pulmonary function. METHODS: Fifty eight patients with severe obstructive pulmonary disease had elective isolated coronary surgery. The surgical methods for the patients with chronic obstructive pulmonary disease (COPD) were standard CABG in 18 patients (group 1), beating heart surgery in 19 patients (group 2), and minimally invasive direct coronary artery bypass grafting (MIDCABG) in 21 patients (group 3). RESULTS: The earliest extubation time was from group 3 (p < 0.001). The average stay in the intensive care unit was significantly longer in group 1 (2.6 +/- 1.5 days) than in groups 2 (1.4 +/- 0.8 days) and 3 (1.1 +/- 0.8 days) (p < 0.05). The most prevalent respiratory morbidity was atelectasis that developed in 6 patients from group 1, in 2 patients from group 2, and in 3 patients from group 3. Forced expiratory volumes in 1 second (FEV1) obtained in the second postoperative month were significantly lower than preoperative values only in group 1 (p < 0.05). Forced vital capacity (FVC) values were significantly lower than the preoperative values in all three groups (p < 0.05). CONCLUSIONS: Off-pump bypass surgical procedures are more advantageous than on-pump methods for patients with COPD. These patients can be operated on using the beating heart technique or by using MIDCABG to prevent side effects of CPB on pulmonary function and effects of sternotomy.

Mechanical versus biological valve prosthesis in the mitral position: a 10-year follow up of St. Jude Medical and Biocor valves.

BACKGROUND AND AIM OF THE STUDY: During the past 30 years, the development of mechanical and biological valves has led to major improvements in patient survival. Here, we present long-term results obtained with both types of prosthesis. METHODS: At our institution, between 1985 and 1989, 158 patients received a Biocor porcine bioprosthesis, and 100 patients a St. Jude Medical (SJM) mechanical valve. Preoperatively, mean age, male:female ratio, NYHA functional class and pathology of mitral valve disease were similar in both groups. RESULTS: The 30-day mortality was 4.4% in the Biocor group and 4% in the SJM group, the major cause being congestive heart failure. Late mortality was 17.9% and 15.6% respectively in the two groups, but valve-related mortality was very low in both (1.3% versus 4.2%). Ten-year survival was similar in each group (77.8+/-3.4% versus 81.0+/-3.9%; p = 0.538). Ten-year freedom from anticoagulant-related hemorrhage was higher with Biocor prostheses (99.3+/-0.7% versus 90.9+/-3.1%; p = 0.007). Valve thrombosis was seen only in the SJM group, and structural valve degeneration (SVD) only in the Biocor group. Ten-year freedom from reoperation was lower in the Biocor group (84.9+/-3.2% versus 92.2+/-2.8%; p = 0.206). The significant causes of reoperation were SVD in the Biocor group and valve thrombosis in the SJM group. Freedom from prosthetic valve endocarditis was similar in both groups (96.3+/-1.6% versus 95.5+/-2.2%). CONCLUSION: As no difference was seen in survival and reoperation rates between patients receiving either bioprostheses or mechanical valves, the valve used will depend on the surgeon's choice and the type of patient, notably elderly patients who are intolerant of anticoagulation, and young women wishing to have children.

Is posterior leaflet preservation in the surgical treatment of rheumatic mitral insufficiency without left ventricular dysfunction necessary?

Preservation of the mitral valve leaflet and tensor apparatus during valve replacement is believed to maintain left ventricular performance. To determine the effect of posterior leaflet preservation in pure severe mitral insufficiency without left ventricular dysfunction 56 patients were operated on between 1993 and 2000. Twenty-three patients underwent mitral valve replacement with posterior chordal preservation and 33 patients underwent mitral valve replacement with chordal transection. Preoperative data in the both groups were similar. After 30days there were no mortalities observed. Dimensions of the left ventricle had significantly decreased within one group, but there was no difference in the other group. The improvement of the functional and cardiac performance in all patients was significant without any difference between the two groups. Actuarial freedom from death was not significantly different at 6yr (P=0.23). To preserve left ventricular function in pure severe mitral regurgitation without left ventricular dysfunction, mitral valve replacement is very effective with or without posterior leaflet preservation. But, it is difficult to suggest that posterior leaflet preservation alone can increase cardiac performance.

Midterm angiographic assessment of coronary artery bypass grafting without cardiopulmonary bypass.

BACKGROUND: Coronary bypass surgery that provides good long-term graft patency can be performed on the beating heart as a viable alternative to conventional coronary artery bypass grafting (CABG). METHODS: From September 1993 to December 1996, 696 patients underwent CABG on the beating heart at the Kosuyolu Heart and Research Hospital in Istanbul. Among them, 70 patients were chosen randomly for angiographic assessment of off-pump coronary artery bypass grafting. RESULTS: The interval from operation to angiography varied from 24 to 61 months (mean, 36.1+/-10.9 months). The patency rate of left internal mammary-left anterior descending artery anastomoses was 95.59% (patency achieved in 65 of 68 patients) and of vein grafts was 47.06% (patency achieved in 16 of 34 patients) (p < 0.0001). The patency rates of grafts anastomosed to the left anterior descending artery were significantly higher than the rates of the grafts anastomosed to the other coronary arteries (95.71% versus 45.45%, p < 0.0001). Multivariate analysis showed that graft type (p < 0.0001) and hyperlipidemia (p = 0.023) were significant predictors for graft occlusion. Left ventricular function improved significantly after CABG (p = 0.04). Reintervention (using percutaneous transluminal cardiac angioplasty) and reoperation rates were 0.97% and 1.4%, respectively. CONCLUSIONS: Off-pump coronary artery bypass grafting appears to produce midterm and long-term patency rates that are comparable to those of conventional techniques; that is especially true in cases of arterial conduits and of conduits anastomosed to the left anterior descending artery.

Combined transdiaphragmatic MIDCAB with right gastroepiploic artery and abdominal aortic aneurysm repair.

Combined surgical repair for large abdominal aortic aneurysm and severe symptomatic coronary artery disease is a safe and effective procedure. Simultaneous operation for minimally invasive direct coronary artery bypass and abdominal aortic aneurysm repair were performed on a 75-yr-old man. First, we harvested the right gastroepiploic artery and passed it through the diaphragma for the right coronary artery revascularization on the beating heart. We then repaired the large abdominal aortic aneurysm (8 cm in diameter) using a Dacron tubular Y-graft. Using the arterial graft and off-pump technique reduces operation time and prevents complications of cardiopulmonary bypass in elderly patients with large abdominal aortic aneurysm, while the combined approach shortens hospital stay and cost.

Surgical repair in ruptured congenital sinus of Valsalva aneurysms: a 13-year experience.

BACKGROUND AND AIM OF THE STUDY: Rupture of congenital sinus of Valsalva aneurysm is a rare cardiac malformation that usually causes reduced cardiac performance. METHODS: Twenty patients (mean age 28.3 +/- 10.7 years; range: 14 to 55 years) with rupture of congenital sinus of Valsalva aneurysm were operated on at our institution between January 1985 and March 1999. The origin of the ruptured aneurysms was the right coronary sinus in 18 patients (90%) and the non-coronary sinus in two (10%). No ruptures were observed originating from the left coronary sinus. The aneurysms ruptured into the right ventricle in 14 patients (70%), into the right atrium in five (25%), and into the left ventricle in one patient (5%). Subarterial ventricular septal defect (VSD) was the most common associated defect (30%), and aortic insufficiency the second (20%). No correlation was found between subarterial VSDs and aortic insufficiency (p > 0.05). To achieve repair, the aorta and cavity into which the aneurysm had ruptured were opened. The aneurysmal sac was excised and the defect closed with a patch in 18 patients, and without patch in two. RESULTS: One patient died in hospital (mortality rate 5%); no late mortality was observed. Surviving patients were followed up for 4.4 +/- 3.3 years (range: 1 to 13 years). The actuarial survival rate was 95% at 12.35 years. Recurrence of fistula was observed in one patient (5%) in whom the ruptured aneurysm had been closed by primary suture without the use of a patch. At 12.35 years, the actuarial freedom from recurrence of fistula was 94.74% for all survivors, and 100% for patients with patch closure. No late complications have been observed. CONCLUSIONS: Following diagnosis of ruptured sinus of Valsalva aneurysm, surgical repair is the treatment of choice. Surgery performed as rapidly as possible after diagnosis in general leads to an excellent outcome.

An uncommon complication of Behçet's disease: intracardiac thrombosis needing surgical treatment.

Behçet's syndrome is a multisystem disorder presenting with recurrent oral and genital ulcerations as well as uveitis often leading to blindness. Although vascular lesions are a common complication of this disease, cardiac involvement is extremely rare. In this unusual case a young man had symptoms primarily related to recurrent right-atrial and right-ventricular thrombi unresponsive to medical treatment. The intracardiac lesion was successfully treated by surgical excision with the use of cardiopulmonary bypass. Surgical treatment should be considered in Behçet's disease complicated by cardiac thrombi, when a thrombus recurs despite medical treatment.

Coronary bypass grafting via minithoracotomy on the beating heart.

BACKGROUND: Recently the availability and the superiority of less invasive coronary artery bypass grafting on some selected groups of patients in the meaning of patient comfort and short hospital stay has been shown by some authors. We present here the clinical results of 40 patients operated on by minithoracotomy incision on the beating heart without using cardiopulmonary bypass mostly harvesting the left internal thoracic artery by videothoracoscopic assistance. METHODS: Between March 1996 and September 1996, 40 patients were operated on by harvesting the left internal thoracic artery mostly by video-assisted thoracoscopy and performing bypass through a minitoracotomy incision. Two patients in whom the procedure was switched to conventional technique were not included in this series. Nine of the patients were female and the rest were male. The mean age was 43.2 +/- 7. RESULTS: Left internal thoracic arteries were harvested by video-assisted thoracoscopy completely in 11 patients, incompletely in 24 patients (the harvesting was completed by direct vision afterwards), and under direct vision in 5 through a mini-anterior thoracotomy incision. Thirty-six patients received a bypass graft to left anterior descending coronary artery only, whereas 4 received a diagonal branch graft also. Left internal thoracic arteries were used to bypass the left anterior descending coronary artery directly in 38 patients. The left internal thoracic artery was injured in the middle portion during harvesting in 1 of the remaining 2 patients. The length was not enough in the other. A short saphenous vein graft was interposed between the left internal thoracic artery and the left anterior descending coronary artery in these 2 patients. There was no mortality. One patient had perioperative myocardial infarction. We did not see serious morbidity except one lung injury due to the trochar. CONCLUSIONS: The results obtained from our experience suggest that coronary artery bypass grafting by minithoracotomy could be applied effectively and safely without overwhelming additional risk to the patient. Furthermore, it has some advantages in reducing operative trauma and cost and also improving patient comfort.

Surgical treatment of left-atrial myxoma in Carney's complex.

Although rare, cardiac myxomas are the most frequently encountered primary neoplasms of the heart. Cardiac myxomas are typically sporadic, benign, non-recurrent tumors, and they are usually seen in the left atrium. Patients who have myxoma-associated spotty pigmented skin lesions, endocrine neoplasms with overactivity, and noncardiac myxomatous tumors are said to have Carney's complex. This report presents a 21-year-old woman with Carney's complex. She was operated for tetralogy of Fallot and total correction was performed at another center when she was three years old. Two years ago, she was operated on for a primary pigmented nodular adrenocortical tumor and bilateral adrenalectomy was performed. Her present admission to our clinic was for left-atrial myxoma with associated symptoms. Patients with Carney's complex have distinctive clinical features which separate them from the larger group of patients with the more common sporadic myxoma. The most important distinction is that the myxoma syndrome appears to be a multisystem disease.