Comparison of the one-year patency rates of radiocephalic arteriovenous fistulas created using no-touch versus conventional technique.

BACKGROUND: This study aims to compare the patency rates of radiocephalic arteriovenous fistulas prepared preserving the perivenous vascular tissues versus those prepared using the conventional technique. METHODS: A total of 169 patients (107 males, 62 females; mean age 59.5 years; range, 39 to 87 years) who underwent a radiocephalic arteriovenous fistula construction were included in this study. In 95 patients, the tissues surrounding the cephalic vein were stripped off as per the conventional method, while the no-touch technique preserving the perivenous vascular tissues was utilized for vein harvesting in 74 patients. Patients were followed-up to compare primary and secondary patency rates of the arteriovenous fistulas at one year. RESULTS: Fistula failure developed in 22 patients within the first year resulting in primary patency rates of 90.5% versus 84.2% for the no-touch and the conventional groups, respectively (p=0.225). Likewise, secondary patency rates were 94.6% versus 93.7% for the no-touch and the conventional groups, respectively (p=0.803). The two groups did not differ with regards to primary or secondary patency rates. CONCLUSION: Findings of this study were not in favor of the no-touch technique compared to the conventional methods in terms of arteriovenous fistula patency at one year.

Proximal Aortic Surgery: Upper "J" or Conventional Sternotomy?

BACKGROUND: While minimally invasive procedures are being used in cardiac surgery, experience with minimally invasive proximal aortic surgery has been limited to certain centers. METHODS: Between January 2010 and March 2015, 54 patients with an upper "J" hemi-sternotomy and 75 patients with a conventional sternotomy due to proximal aortic pathology were included in this study. Forty-five patients from the "J" hemi-sternotomy group were matched with 45 patients from the conventional sternotomy group with respect to age, sex, ejection fraction, diabetes, hypertension, smoking history and operative type. Perioperative variables were in-hospital mortality, surgery for revision, amount of blood loss, requirement for blood transfusion, cardiopulmonary bypass (CPB), aortic cross-clamp and unilateral cerebral protection times, duration of ventilation, and length of intensive care unit (ICU) and total hospital stay. RESULTS: Patients were between 21-76 years with a mean age of 58.14 ± 11.06 years; 73.3% (n = 66) were male and 26.7% (n = 24) were female. Of all the cases included, 36.7% (n = 33) had isolated ascending aortic replacement, 41.1% (n = 37) had concomitant aortic valve replacement and ascending aortic replacement, and 22.2% (n = 20) had a Bentall procedure. Statistically, the amount of bleeding (P = .026), length of ventilation (P = .001), ICU (P = .001) and total hospital stay (P = .004) in the "J" hemi-sternotomy group were all found to be significantly lower than those in the conventional group. CONCLUSIONS: Minimally invasive techniques like an upper "J" hemi-sternotomy can be safely performed without prolonging the aortic clamp time, and with less blood loss, less ventilatory support, and shorter ICU and total hospital stays when compared to conventional methods.

Double J ureteral stent displaced through the right ventricle.

We report a 59-year old patient with a double J ureteral catheter displaced out of the ureter through the inferior vena cava and right ventricle. The catheter was removed successfully under cardiopulmonary bypass.

Emergency management for critical left main coronary artery stenosis.

BACKGROUND: Increased experience and improvements in technology seem to have encouraged the use of percutaneous interventions for left main coronary artery (LMCA) occlusions. There is no consensus, however, and the data are inadequate on whether surgery or percutaneous procedures should be the intervention of choice for critical occlusions. METHODS: From January 2002 to December 2006, 108 patients with unprotected LMCA stenosis >80% were treated at our center. Eighty-three patients (77%) underwent bypass grafting and 20 (18%) underwent percutaneous intervention for the purpose of myocardial revascularization. We analyzed parameters demonstrated as risk factors for myocardial revascularization and their predicted effects on outcome. RESULTS: Five patients (5%) died following emergency cardiopulmonary resuscitation before any intervention was performed. The early survival rate was 84.1% in the coronary bypass group and 63% in the percutaneous intervention group. The mean (±SD) survival time was 55.7 ± 2.6 months in the bypass group and 7.6 ± 1.3 months in the percutaneous group. The late-survival rate was also significantly higher in the bypass group. The mean late-survival time was 44.5 ± 3.6 months in the bypass group and 2.3 ± 0.8 months in the percutaneous group. CONCLUSION: Although emergency percutaneous interventions are lifesaving in some cases, these results clearly demonstrate that coronary bypass grafting should be the intervention of choice for myocardial revascularization in patients with critical LMCA occlusion.

Unusual metastasis of the papillary thyroid adenocarcinoma.

Floating thrombus in the ascending aorta is rare and its association with papillary thyroid adenocarcinoma has not been documented. We report a case of a 64-year-old man who was referred to our emergency unit because of suspected type A aortic dissection. Computerized tomographic and transthoracic echocardiographic scans revealed a floating thrombus in the aneurysmatic ascending aorta. The thrombus was removed with the dilated aorta. Although the aortic wall was macroscopically normal, histologic examination revealed metastatic papillary adenocarcinoma.

Comparison of unilateral antegrade cerebral perfusion at 16 degrees C and 22 degrees C systemic temperature.

OBJECTIVES: Unilateral antegrade cerebral perfusion can be performed with minimal manipulations to arch arteries, but whether it provides adequate brain perfusion remains unclear. Some authors believe that this technique can be inadequate without deep hypothermia. We investigated the reliability of unilateral cerebral perfusion at 22 degrees C hypothermia and the advantages of avoiding deep hypothermia. METHODS: Study participants were 55 patients who underwent surgery with unilateral cerebral perfusion. Patients were divided into 2 groups; 18 patients underwent surgery at 16 degrees C hypothermia (group I) and 37 patients at 22 degrees C hypothermia (group II). The mean age of the patients was 59 +/- 10 years in group I and 55 +/- 14 years in group II. Supracoronary ascending aorta replacement was performed in 25 and hemiarch replacement in 15 patients. Nine patients underwent surgery for a Bentall procedure. Total arch replacement was performed in 4 patients and total thoracic aorta replacement in 2 patients. RESULTS: The hospital mortality was 11% in group I and 5.4% in group II (P = .59). Transient neurologic deficits were not detected in any of the patients. The rate of permanent neurologic deficits was 5.9% in group I and 2.8% in group II (P = .54). Although mean aortic cross-clamp and antegrade cerebral perfusion times were not significantly different, mean cardiopulmonary bypass time was longer in group I than group II (174 +/- 38 vs 142 +/- 37 minutes, P = .005). Postoperative bleeding, blood product usage, serum creatinine and hepatic enzyme level changes, inotrope usage, and arrhythmia occurrence were not different between the 2 groups. Mean mechanical ventilation time was longer in group I than group II (24 +/- 17 vs 16 +/- 6 hours, P = .02). CONCLUSIONS: Unilateral antegrade cerebral perfusion at 22 degrees C systemic hypothermia appears to be safe and reliable for brain protection. Advantages of this technique are avoidance of deep hypothermia and reduced cardiopulmonary bypass and mechanical ventilation times in patients undergoing aortic surgery.

Does the circadian rhythm of melatonin affect ischemia-reperfusion injury after coronary artery bypass grafting?

BACKGROUND: Melatonin is a potent scavenger of free radicals and an antioxidant. We studied the relationship between the protective effect of melatonin against ischemia-reperfusion injury (IRI) during cardiopulmonary bypass, the plasma level of melatonin, and the time of surgery. METHODS: Forty patients who were to undergo elective coronary artery bypass grafting (CABG) were divided into 2 groups, those who underwent their operations at 8 AM (group I; n = 20) and those who underwent their operations at 1 PM (group II; n = 20). The operations were carried out by the same surgical team and with the same standard surgical technique. Blood samples were collected before the operation (T1), when the aortic cross-clamp was removed (T2), and at 4 hours (T3) and 24 hours (T4) after the operation. RESULTS: Preoperative plasma levels of melatonin were substantially higher in group I than in group II. Intraoperative and postoperative melatonin levels were also significantly higher in patients who underwent their operations in the morning. The 2 groups had similar preoperative levels of intercellular adhesion molecule 1 and interleukin 8; however, intraoperative and postoperative values were lower in group I for all samples. This difference was statistically significant for both markers. Plasma levels of lactate dehydrogenase were significantly lower in group I. The 2 groups had similar aortic cross-clamp and cardiopulmonary bypass times. Preoperative and postoperative troponin I levels were lower in group I than in group II, but these differences were not statistically significant. The 2 groups showed no significant differences in plasma creatine kinase MB levels for either preoperative or postoperative measurements. CONCLUSION: High plasma levels of melatonin may be directly related to low levels of IRI markers. Melatonin may have a protective effect against IRI in CABG. This effect seems to be directly correlated with the plasma levels of melatonin and inversely related with light. If melatonin protects myocardium from IRI, additional studies may be planned for the preoperative use of melatonin in patients with coronary artery disease to improve myocardial protection.

Subepicardial left ventricular aneurysm with an intraventricular narrow neck on the avascular apical area: report of a case.

A 48-year-old hiatus hernia patient with a history of an occasional epigastric burning sensation for the last 10 years presented with a new onset of chest pain in addition to the persistence of his other symptoms. An apical left ventricular aneurism was found on 64-slice computed tomographic angiography. Coronary angiography confirmed the diagnosis. No coronary lesion was found and the apical region of the left ventricle was avascular. He was operated on under the suspected preoperative possible diagnoses of left ventricular apical aneurysm, a pseudoaneurysm, or a diverticulum. Macroscopically, a subepicardial whitish aneurysmal region with a weakened wall was seen at the apical part of the left ventricle. The size of the lesion was 3 x 3 cm. The aneurysm did not have an extracardiac neck. When the aneurysm site was opened, a sclerotic aneurysm wall and a narrow neck below the incised sac was found; and the neck was communicating with the left ventricular cavity. The aneurysm site was resected and closed with a linear closure technique by using pledget-supported sutures. The termination of cardiopulmonary bypass was uneventful. The patient left the intensive care unit on the first postoperative day and was discharged from hospital on the 4th postoperative day. A subepicardial left ventricular aneurysm should therefore also be considered in the differential diagnosis of atypical chest pain.

[The role of multislice tomography to prevent postoperative strokes related with atherosclerotic plaques in the ascending aorta after coronary artery bypass]. / Koroner baypas operasyonu sonrasi assandan aorttaki aterosklerotik plaklara bagli inmenin önlenmesinde çok kesitli tomografinin rolü

OBJECTIVE: Atheromatous plaques in the ascending aorta are major risk factors for strokes caused by macroembolization after coronary artery surgery. Detection of plaque formations and changes in the surgical strategy are very important. This study was planned to compare value direct palpation and multislice computerized tomography to establish aortic plaques and to establish clinical predictors of aortic calcification. METHODS: Fifty-four patients who underwent coronary bypass surgery were included in this prospective and diagnostic study. Proximal portion of each patient's aorta was evaluated with multislice computerized tomography and was compared with direct palpation. The efficacy of intraoperative palpation to predict calcifications was studied with ROC analysis and the predictors of aortic plaque formation were analyzed using logistic regression analysis. RESULTS: Atheromatous plaques were detected with palpation in four patients (7.4%), and with multislice tomography in six patients (11.1%). The aortic instrumentation was changed in two patients (3.7%) and strategy was changed in one patient 1.8%). According to the ROC analysis, when multislice computerized tomography was taken as the reference, intraoperative direct palpation was 67% sensitive and 100% specific to predict aortic plaques. Logistic regression analysis of the risk factors showed that the older age was the only significant risk factor (OR-1.3, 95% CI -1.114-1.568, p=0.001) for plaque formation in the aorta. Neither stroke nor other neurological disorders have been observed during the study. CONCLUSIONS: It can be stated that multislice computerized tomography is more effective to show aortic plaques, but it is not sufficient. Multislice tomography may give additional information about the ascending aorta and the opportunity to visualize the aortic arch. It can be preferred in patients with aortic aneurysm or dissection.

New use of teflon to reduce bleeding in modified bentall operation.

We analyzed the postoperative short- and mid-term outcomes of a series of patients with annuloaortic ectasia who underwent a modified Bentall operation in our clinic from September 2000 through March 2006. The study included 44 patients. Their average age was 53.4 +/- 14.1 years. The underlying disease was degenerative aortic aneurysm in 42 patients (95.5%) and acute aortic dissection in 2 patients (4.5%). Six patients (13.6%) had Marfan phenotype. Aortic insufficiency was moderate in 30 patients (68.2%) and severe in 14 patients (31.8%). In our modification of the Bentall technique, we completed the resection of the aortic root while leaving 5 to 10 mm of native aortic wall tissue to support the anastomosis. A long piece of Teflon felt (width, 0.5-1 cm) was laid on the annulus, and nonpledgeted 2-0 polyester sutures were passed in turn through the Teflon felt, the preserved aortic tissue, and the aortic annulus. A thin piece of Teflon felt was also used in the coronary artery reimplantation sites. Fibrin glue was routinely applied to all anastomoses. There were no intraoperative deaths. One patient died in the hospital after surgery for acute type I aortic dissection. Another patient died 1 year after the operation from prosthetic-valve endocarditis. No patient required surgical correction of excessive postoperative bleeding. Kaplan-Meier curves showed overall survival of 0.94 (95% confidence intervals, 0.9-0.99). We consider our approach an easy, effective way to minimize bleeding from the anastomoses and at the aortic root--a common challenge in aortic surgery.

Risk factors for posterior ventricular rupture after mitral valve replacement: results of 2560 patients.

OBJECTIVE: Posterior ventricular rupture is a rare and fatal complication of mitral valve surgery. This study is designed to define the risk factors for left ventricular rupture after mitral valve replacement and, especially, to find out if posterior leaflet preservation is protective for posterior ventricular rupture. METHODS: Between January 1996 and March 2007, 2560 patients underwent mitral valve replacement operation in our hospital. Risk factors for posterior ventricular rupture were studied with chi(2) and logistic regression analysis. RESULTS: The surgery was complicated with posterior ventricular rupture in 23 (0.8%) of 2560 patients. Nineteen patients (82.6%) were female, four patients (17.4%) were male. Mean age of the patients in this group was 60+/-10. Mortality rate of the patients with posterior ventricular rupture was 86% (20 patients). Twelve patients with posterior ventricular rupture were at the age of 60 and older. Age of 60 and above was found as a highly significant risk factor for posterior ventricular rupture (OR 4.53, 95% CI 1.98-10.38, p<0.001). Posterior leaflet was preserved in 513 patients (20%) and posterior ventricular rupture did not occur in these patients. Resection of posterior leaflet was also found as a highly significant risk factor (p=0.008) for posterior ventricular rupture. Reoperation was performed in 372 patients and posterior ventricular rupture occurred in 7 of them. Reoperation was also found as a significant risk factor (OR 2.563, 95% CI 1.03-6.34, p=0.042) for posterior ventricular rupture. CONCLUSIONS: Extreme annular traction and aggressive decalcification should be avoided during mitral valve resection. Posterior leaflet of the mitral valve should be preserved, especially in the older age group to prevent posterior ventricular rupture.

Safety of unilateral antegrade cerebral perfusion at 22 degrees C systemic hypothermia.

BACKGROUND: The superiority of antegrade cerebral perfusion (ACP) in aortic surgery is widely accepted, but the sufficiency of unilateral cerebral perfusion and the optimal systemic temperature during the operation are still controversial. METHODS: Thirty patients who underwent operation with unilateral ACP at a systemic temperature of 22 degrees C between January 2005 and September 2007 were included in this study. The mean age (+/-SD) of the patients was 58 +/- 11 years, and 21 (70%) of the patients were male. The indication for surgery was acute type A aortic dissection in 14 patients (47%), degenerative aortic aneurysm in 9 patients (30%), dissecting aortic aneurysm in 6 patients (20%), and intramural hematoma in 1 patient (3%). Supracoronary ascending aorta replacement was performed in 13 patients (43%). Eight patients (27%) underwent ascending aorta and hemiarch replacement. The Bentall procedure was performed with hemiarch replacement in 3 patients (10%). Three patients (10%) underwent total aortic arch replacement, and 2 patients (7%) underwent the Bentall procedure. The ascending aorta, aortic arch, and descending aorta were replaced in 1 patient (3%). RESULTS: Hospital mortality was limited to 1 patient (3.3%). A permanent or transient neurologic deficit was not detected in any of the survivors. The mean cardiopulmonary bypass, aortic cross-clamp, and ACP times were 144 +/- 40 minutes, 82 +/- 28 minutes, and 30 +/- 11 minutes, respectively. The mean mechanical ventilation time was 18 +/- 9 hours. The mean stay in the intensive care unit was 2.3 +/- 1.1 days, and the mean hospital stay was 12 +/- 6 days. CONCLUSION: Unilateral ACP with systemic hypothermia at 22 degrees C is safe and has satisfactory clinical results. Establishing ACP via cannulation of the right axillary artery is fast and simple. The presence of fewer cannulas in the operation field provides an operative condition as convenient as the deep hypothermic circulatory arrest technique.

Primary cardiac rhabdomyosarcoma of the right atrium: case report.

Rhabdomyosarcoma is a rare malignant tumor of the heart that accounts for 20% of all primary malignant neoplasms of the heart. Symptoms vary in accordance with the location of the mass; unfortunately, by the time the patient becomes symptomatic, the tumor has already metastasized to other organs. Diagnosis is frequently obtained via transthoracic or transesophageal echocardiography and nuclear magnetic resonance imaging. Surgery is indicated for malignant cardiac neoplasms to relieve cardiac symptoms and to prolong patient survival. Subsequent postoperative chemotherapy or radiotherapy is necessary, and the long-term prognosis is poor. We present a case of a primary cardiac rhabdomyosarcoma that arose from the lateral wall of the right atrium and required implantation of a permanent cardiac pacemaker after surgery.

Effects of different cardioplegic solutions on nitric oxide release from coronary vasculature in diabetic patients undergoing coronary artery bypass surgery.

OBJECTIVE: The aim of this study was to compare the effects of two different cardioplegic solutions on nitric oxide (NO) release from coronary vasculature in patients with type II diabetes mellitus undergoing coronary artery bypass grafting (CABG) surgery. METHODS: Forty patients undergoing elective CABG surgery were randomized to be given crystalloid (Group 1) or blood (Group 2) cardioplegia. Aortic and coronary sinus blood samples were taken at three different time periods and the release of NO from the coronary vasculature was determined by measuring its stable end-products, nitrite and nitrate. The difference between the aortic and coronary sinus concentrations of nitrite and nitrate represents the amount of NO released by coronary vascular bed. RESULTS: Before application of aortic cross-clamp, at T1 period, the levels of nitrite/nitrate from the coronary vasculature were similar in both groups (6.53+/-1.21 microM vs 6.07+/-1.24 microM , p>0.05). However after the removal of cross-clamp, a significant decrease in NO was observed in Group 1 as compared with Group 2 (4.21+/-0.73 microM vs 4.92+/-1.02 microM, p<0.01) . This decrease persisted at T3 period, after 30 minutes of reperfusion in group 1 being significantly different from group 2 (3.86+/-0.49 vs 4.37+/-0.72 microM, p<0.05). CONCLUSION: This study has shown that in patients with type II diabetes mellitus crystalloid cardioplegia causes a decrease in the release of NO from coronary vascular bed during aortic cross-clamp and reperfusion period whereas more physiologic blood cardioplegia did not. Our findings indicate that blood cardioplegia protects endothelial function better than crystalloid cardioplegia in diabetic patients.

Effect of coexisting Paget's disease on coronary artery bypass operations.

Paget's disease of the sternum is rare. In patients with sternal Paget's disease, sternotomy, and harvesting of internal mammary arteries may reveal problems because of a thickened sternum and substernal adhesions. Saphenous vein graft or other arterial grafts may be used. Especially in younger patients who received saphenous vein graft, a repeat revascularization operation, because of earlier saphenous vein graft degeneration, may be needed in subsequent years. During the repeat operation, opening and reclosing the chest will still be a major problem. In appropriate patients, an operation through a thoracotomy or noninvasive balloon and/or stent techniques may be good choices.

Comparative effects of tolazoline and nitroprusside on human isolated radial artery.

BACKGROUND: The radial artery is increasingly being used in coronary revascularization as an alternative conduit to a saphenous vein graft. Its perfect endothelial capacity provides a high patency rate comparable with the internal mammary artery (IMA). However, its spastic characteristics cause difficulties during its intraoperative preparation and may lead to early postoperative graft failure. Thus, treatment and/or prevention of radial artery spasm with an effective vasodilator agent is essential for its longevity. Endogenous vasoconstrictors, including noradrenaline, endothelin-1, and thromboxane A2, are likely to play a role in the pathogenesis of graft spasm. In the present study, we evaluated the vasorelaxant effect of tolazoline, a nonselective alpha-adrenoceptor blocker, against the contractions induced by various spasmogenic agents in an isolated human radial artery. METHODS: Tolazoline (10(-9)-10(-4) M) or sodium nitroprusside (SNP, 10(-9)-10(-4) M) were cumulatively applied on radial artery rings precontracted submaximally with noradrenaline, endothelin-1, thromboxane analogue, U46619, or potassium chloride. In addition, some rings were pretreated with tolazoline (4 x 10(-6) M) for 30 minutes and the contractile response curve to noradrenaline was assessed in its presence. RESULTS: Tolazoline effectively reversed noradrenaline-induced contractions in the radial artery, whereas it failed to produce remarkable relaxations on rings contracted with other spasmogenic agents, while SNP overcame the contractions induced by all spasmogens to a similar extent. In addition, brief pretreatment of radial artery rings with tolazoline significantly inhibited the contractions to noradrenaline. CONCLUSIONS: Tolazoline is not as broadly effective as SNP against all spasmogens investigated; however, it may be effective in counteracting alpha-adrenoceptor-mediated vasospasm in human radial arteries.