Coronary Arteriovenous Fistulas in Adult Patients: Surgical Management and Outcomes.

Objective: The aim of this study was to describe the demographic, clinical and anatomic characteristics of coronary arteriovenous fistulas in adult patients who underwent open cardiac surgery and to review surgical management and outcomes. Methods: Twenty-one adult patients (12 female, 9 male; mean age: 56.1±7.9 years) who underwent surgical treatment for coronary arteriovenous fistulas were retrospectively included in this study. Coronary angiography, chest X-ray, electrocardiography and transthoracic echocardiography were preoperatively performed in all patients. Demographic and clinical data were also collected. Postoperative courses of all patients were monitored and postoperative complications were noted. Results: A total of 25 coronary arteriovenous fistulas were detected in 21 patients; the fistulas originated mainly from left anterior descending artery (n=9, 42.8%). Four (19.4%) patients had bilateral fistulas originating from both left anterior descending and right coronary artery. The main drainage site of coronary arteriovenous fistulas was the pulmonary artery (n=18, 85.7%). Twelve (57.1%) patients had isolated coronary arteriovenous fistulas and 4 (19.4%), concomitant coronary artery disease. Twenty (95.3%) of all patients were symptomatic. Seventeen patients were operated on with and 4 without cardiopulmonary bypass. There was no mortality. Three patients had postoperative atrial fibrillation. One patient had pericardial effusion causing cardiac tamponade who underwent reoperation. Conclusion: The decision of surgical management should be made on the size and the anatomical location of coronary arteriovenous fistulas and concomitant cardiac comorbidities. Surgical closure with ligation of coronary arteriovenous fistulas can be performed easily with on-pump or off-pump coronary artery bypass grafting, even in asymptomatic patients to prevent fistula related complications with very low risk of mortality and morbidity.

Coronary arteriovenous fistulas in adult patients: surgical management and outcomes

Abstract Objective: The aim of this study was to describe the demographic, clinical and anatomic characteristics of coronary arteriovenous fistulas in adult patients who underwent open cardiac surgery and to review surgical management and outcomes. Methods: Twenty-one adult patients (12 female, 9 male; mean age: 56.1±7.9 years) who underwent surgical treatment for coronary arteriovenous fistulas were retrospectively included in this study. Coronary angiography, chest X-ray, electrocardiography and transthoracic echocardiography were preoperatively performed in all patients. Demographic and clinical data were also collected. Postoperative courses of all patients were monitored and postoperative complications were noted. Results: A total of 25 coronary arteriovenous fistulas were detected in 21 patients; the fistulas originated mainly from left anterior descending artery (n=9, 42.8%). Four (19.4%) patients had bilateral fistulas originating from both left anterior descending and right coronary artery. The main drainage site of coronary arteriovenous fistulas was the pulmonary artery (n=18, 85.7%). Twelve (57.1%) patients had isolated coronary arteriovenous fistulas and 4 (19.4%), concomitant coronary artery disease. Twenty (95.3%) of all patients were symptomatic. Seventeen patients were operated on with and 4 without cardiopulmonary bypass. There was no mortality. Three patients had postoperative atrial fibrillation. One patient had pericardial effusion causing cardiac tamponade who underwent reoperation. Conclusion: The decision of surgical management should be made on the size and the anatomical location of coronary arteriovenous fistulas and concomitant cardiac comorbidities. Surgical closure with ligation of coronary arteriovenous fistulas can be performed easily with on-pump or off-pump coronary artery bypass grafting, even in asymptomatic patients to prevent fistula related complications with very low risk of mortality and morbidity.

Biventricular transient systolic dysfunction after mitral valve replacement: Pericardial decompression syndrome.

BACKGROUND: Pericardial decompression syndrome is defined as paradoxical hemodynamic instability, left ventricular or bi ventricular systolic dysfunction and pulmonary edema after pericardial fluid drainage. Pericardial Decompression Syndrome is an unexpected clinical scenario with an incidence less than 5% in all surgically or percutaneously managed pericardial tamponade patients. The aim of this manuscript was to describe a case with cardiac tamponade in whom acute biventricular heart failure and pulmonary edema developed after surgical creation of a pericardial window, and to discuss this case in light of the literature. CASE REPORT: A 43-year-old woman who underwent mitral valve replacement three weeks ago admitted to our hospital with dyspnea, tachycardia, and atrial fibrillation. Large quantity of pericardial fluid (35mm in the posterior wall, 25mm in the anterior wall) with partial compression of the right ventricle and 50% left ventricle ejection fraction (LVEF) was determined via transthoracic echocardiography (TTE). After creation of pericardio-pleural window, more than 1000ml of serosanguineous fluid were quickly removed from the pericardial space. During the following hours of the decompression, the patient's condition deteriorated and overt pulmonary edema developed. On the second day, biventricular systolic dysfunction, global diffuse hypokinesia and 15-20% LVEF was observed via TTE. High-dose inotropic support and diuretics was continued. During follow up she was progressively weaned off inotropes, LVEF were raised to 35%. Two weeks later, repeated TTE showed normal biventricular systolic function and LVEF was 50%. CONCLUSION: We recommend gradual removal of pericardial effusion under hemodynamic monitoring, especially in patient with postcardiotomy tamponade.

Management of Traumatic Aortic and Splenic Rupture in a Patient With Ascending Aortic Aneurysm.

Traumatic aortic rupture is rupture of all or part of the aortic wall, mostly resulting from blunt trauma to the chest. The most common site of rupture is the aortic isthmus. Traumatic rupture of the ascending aorta is rare. A 62-year-old man with a family history of ascending aortic aneurysm was referred to our hospital after a motor vehicle accident. He had symptoms of cardiogenic shock. A contrast-enhanced computed tomographic scan revealed rupture of the proximal ascending aorta and an ascending aortic aneurysm with a diameter of 55 mm at the level of the sinuses of Valsalva. Transthoracic echocardiography at the bedside revealed severe aortic valvular insufficiency. We performed a successful Bentall procedure. During postoperative recovery, the patient experienced a cerebrovascular accident. Transesophageal echocardiography did not reveal thrombosis of the mechanical prosthesis. The patient's symptoms resolved in time, and he was discharged from the hospital on postoperative day 47 without any sequelae. He has been symptom free during a 6-month follow-up period. We suggest that individuals who have experienced blunt trauma to the chest and have symptoms of traumatic aortic rupture and a known medical history of ascending aortic aneurysm should be evaluated for a rupture at the ascending aorta and the aortic isthmus.

Aortic root abscess complicated by fistulization in a young patient with bicuspid aortic valve.

Aortic root abscess is a relatively common complication of aortic valve endocarditis. However, aortic root abscess and formation of a fistula from the aortic root to the right ventricular outflow tract in the setting of a native bicuspid aortic valve (BAV) is a rare event. We present consecutive echocardiographic images of unruptured periaortic abscess and fistulization of it to the right ventricle in 24 hours, in a patient with BAV and fever of unexplained origin.

Does the level of soluble intercellular adhesion molecule 1 predict myocardial injury before cardiac markers increase?

BACKGROUND: The measurement of cardiac markers is still the gold standard for diagnosing myocardial infarction (MI), but there is always a transition period between the time of infarction and when a marker can be measured in the blood. Therefore, clinicians are shifting their focus to the identification of potential new analytes capable of predicting MIs before the standard cardiac markers increase. In this study, we tested whether measurement of the concentration of soluble intercellular adhesion molecule 1 (sICAM-1) in plasma can be used for this purpose. MATERIALS AND METHODS: In this prospective study, we included 60 male patients who had a left main coronary artery lesion or a left main equivalent and who underwent elective (group I, n = 20), urgent (group II, n = 20), or emergent (group III, n = 20) coronary artery bypass grafting (CABG). We excluded patients who had increased cardiac markers at admission, and drew blood samples for sICAM-1 measurements from other patients immediately after coronary angiography evaluations. We divided the patients into 3 groups according to their clinical characteristics and cardiac marker levels. Only patients with increased cardiac markers underwent emergent CABG (group III). We measured sICAM-1 concentrations immediately after coronary angiography and measured creatine kinase MB (CK-MB) and cardiac troponin I (cTnI) just before CABG. We then evaluated the results for correlations. RESULTS: CK-MB, cTnI, and sICAM-1 levels were significantly higher in group III than in groups I and II (P < .05 for all). Our analysis for correlations between the sICAM-1 level and cardiac marker levels revealed no significant correlations in group I (CK-MB, r = 0.241 [P = .15]; cTnI, r = -0.107 [P = .32]) and group II (CK-MB, r = -0.202 [P = .19]; cTnI, r = 0.606 [P = .002]), but our analysis did reveal highly significant correlations in group III (CK-MB, r = 0.584 [P = .003]; cTnI, r = 0.605 [P = .002]). CONCLUSION: Measuring the plasma concentration of sICAM-1 before the concentrations of cardiac markers increase in patients with MI may provide clinicians with faster and reliable data for deciding on and administering the most appropriate procedures and/or therapies.

Native valve endocarditis due to Pseudomonas mendocina in a patient with mental retardation and a review of literature.

Pseudomonas mendocina, a Gram-negative non-fermentative rod, occurs in water and soil but is rarely recovered as a human pathogen. We report a native valve endocarditis due to Pseudomonas mendocina in a patient with mental retardation.

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.

Treatment of Brucella endocarditis: our surgical experience with 6 patients.

BACKGROUND: Endocarditis is a rare but life-threatening complication of brucellosis. Its mortality rate has recently been reduced with the use of combined medical and surgical treatment. METHODS: Between March 2002 and April 2004, 6 patients with Brucella endocarditis underwent surgery at the Siyami Ersek Cardiovascular Center in Istanbul, Turkey. The diagnosis of Brucellosis was based on the presence of clinical signs and symptoms compatible with brucellosis, serology and/or a positive blood culture. All patients with suspected Brucella endocarditis were studied by echocardiography. The diagnosis of Brucella endocarditis was made in accordance with Duke's criteria. RESULTS: The most commonly affected valve was the aortic valve (4 patients). Four patients had prosthetic valves because of a previous history of rheumatic fever. In 5 patients, elective surgery was performed. Five patients underwent valve replacement with prosthetic valves, but 1 patient underwent excision of the abscess cavity without valve replacement. There was no operative mortality. All patients continued antibiotic treatment for at least 3 months postoperatively. The median duration of follow-up after surgery was 12 months. During the follow-up period, 1 patient died, while the others remained alive with no recurrences. CONCLUSION: Prosthetic valve replacement is a safe procedure in patients with Brucella endocarditis. Surgical interventions combined with triple antibiotic therapy yield good results with no recurrence in the long-term follow-up.