Comparison of inflow occlusion on the beating heart with cardiopulmonary bypass in the extraction of a mass lesion or a foreign body from the right heart.

OBJECTIVE: Two basic surgical techniques exist in the extraction of a mass lesion or a foreign body from the right atrium and/or the right ventricle. These are inflow occlusion of the right heart and with assistance of the cardiopulmonary bypass (CPB). In this study, these two methods were compared. METHODS: Between May 2001 and April 2010, 15 patients were operated upon for the extraction of a mass lesion or a foreign body from the right heart. Seven patients were operated upon using venous inflow occlusion technique, whereas eight patients were operated upon using CPB. These two groups were evaluated and compared in terms of clinical parameters. RESULTS: Intracardiac masses or foreign bodies were completely removed by using both methods. Patients who were operated upon using inflow occlusion on beating heart (IOBH) developed no postoperative complication, whereas two patients who were operated upon with CPB developed complications, postoperatively. Moreover, duration of hospital stay, duration of intensive care unit (ICU) stay, and intubation time were significantly lower in the IOBH group when compared with the CPB group. In the CPB group, the amount of blood transfused was significantly higher. CONCLUSIONS: In suitable patient groups, the IOBH technique could be safely performed by experienced centers.

Which is first: left anterior descending artery anastomosis or right coronary artery anastomosis in off-pump coronary artery bypass grafting?

OBJECTIVES: The sequence of the distal anastomosis for revascularization in off-pump coronary artery bypass grafting (OPCABG) surgery is under debate. The hypothesis in this study was that an analysis of cardiac markers would reveal that anastomosing the left anterior descending coronary artery (LAD) before the right coronary artery (RCA) would decrease myocardial damage in OPCABG surgery for 2-vessel disease. METHODS: Forty patients with stable angina who underwent OPCABG surgery and who had LAD and RCA lesions were randomized into 2 groups of 20 patients each. The LAD was revascularized first in group 1, and the RCA was revascularized first in group 2. Cardiac troponin I, creatine kinase (CK), and CK myocardial band (CK-MB) were measured in the 2 groups before surgery and at 8, 24, and 48 hours after surgery. RESULTS: No mortality occurred in the 2 groups. The groups were similar with respect to sex, age, durations of anastomosis of the left internal thoracic artery to the LAD and of the saphenous vein graft to the RCA, and preoperative CK, CK-MB, and troponin I levels. Postoperative CK-MB levels were significantly higher in group 2 in the eighth and 24th postoperative hours than in group 1 (P = .009 and .041, respectively). Similarly, troponin I levels were significantly higher in group 2 in the eighth, 24th, and 48th hours than in group 1 (P = .003, .003, and .006, respectively). CONCLUSIONS: Anastomosis to the LAD first in OPCABG surgery led to a slight reduction in myocardial enzyme release against the occlusion of the target vessels during anastomoses in patients with RCA and LAD stenoses.

Investigation of the embolic foci through echocardiographic evaluation in patients undergoing urgent femoral embolectomy.

OBJECTIVE: The determination of the source of embolism in patients with lower extremity arterial emboli is a major clinical problem. A review of the literature focusing on large patient series showed that the heart is the embolic source in 78% of these patients. The aim of this study was to determine the role of early postoperative echocardiographic investigations in the determination of embolic origin. METHODS: This retrospective study group consisted of 57 patients in whom we performed 63 unilateral and bilateral urgent femoral embolectomies. Bilateral urgent femoral embolectomy was performed in 6 of the 57 patients included in the study and unilateral intervention was performed in the rest. Besides the features regarding age and sex, the cardiac rhythms of the patients during their application to our clinic were evaluated. In order to determine the origin of the acute peripheral arterial occlusion, transthoracic echocardiography was performed in all patients in the first 24 hours after the embolectomy. RESULTS: In 6 patients who underwent bilateral femoral embolectomy, distinct heart valve pathologies were determined. As for the 51 patients who underwent urgent unilateral femoral embolectomy, it was determined that 28 (55%) had serious cardiac pathologies. Among these 28 patients, 14 (50%) underwent the required open-heart surgery interventions after the completion of further examinations. It was determined that, in our series, 14 (64%) of the 22 patients with serious mitral valve pathologies had a history of acute joint rheumatism. CONCLUSION: Regardless of whether the interventions are bilateral or unilateral, we believe that echocardiographic investigation should be performed in all patients during the early postoperative period in order to prevent recurrence by the determination of the thromboemboli source. Thus, accompanying serious intracardiac pathologies can be treated and the development of additional peripheral emboli can be prevented.

Surgical treatment of postinfarction left ventricular pseudoaneurysms.

OBJECTIVE: Left ventricular pseudoaneurysm is a rare but serious complication of acute myocardial infarction. It is under debate whether surgical intervention is mandatory in asymptomatic patients. The aim of this report was to present our experience based on surgical treatment and midterm outcomes of patients with postinfarction left ventricular pseudoaneurysm. METHODS: Eight consecutive patients who underwent left ventricular pseudoaneurysm operation between January 1, 1995, and January 1, 2006, were included in the study. There were 5 male and 3 female patients. Mean age was 62.87 +/- 5.03 years. All patients had echocardiography and coronary angiography before the operation. Two anterior and 6 posterior pseudoaneurysms were detected. Left ventricular pseudoaneurysm was repaired with a synthetic patch by the remodeling ventriculoplasty method of Dor in all patients. Coronary revascularization was performed if necessary. Preoperative, operative, and postoperative data were collected from the patient cohorts. RESULTS: The mean duration from myocardial infarction to diagnosis of the ventricular septal rupture was 13.5 +/- 12 days. Additional coronary artery bypass surgery was performed with a median of 1.2 grafts in 5 patients (62.5%). The mean postoperative mechanic ventilator support time was 20.12 +/- 29.22 hours. Overall 30-day mortality was 12.5% with 1 patient death. The mean intensive care unit stay was 3.75 +/- 2.1 days. The late mortality rate was 12.5%. In the follow-up period (mean, 30.66 +/- 16.86 months), of the 6 patients who were alive, 5 were in New York Heart Association class I or II and 1 was in class III because of pre-existing low left ventricular ejection fraction. Transthoracic echocardiography showed good left ventricular configurations without a false aneurysm together with increases in the ejection fractions. CONCLUSION: Prompt diagnosis and early surgical intervention is essential for patients with large or expanding left ventricular pseudoaneurysms due to the high propensity of fatal rupture. Associated coronary artery bypass grafting may reduce early mortality of patients with left ventricular pseudoaneurysm by resuscitating the ischemic myocardium.

Repair of post-infarct ventricular septal rupture with an infarct-exclusion technique: early results.

BACKGROUND: Ventricular septal rupture is a rare but life-threatening complication of acute myocardial infarction. The mortality rate with medical treatment is more than 90%, whereas the mortality rate after surgical repair varies between 19% and 60% in different studies. This study reviews our experience based on early closure of the septal rupture with an infarct-exclusion technique. METHODS: Eighteen consecutive patients who underwent post-infarct ventricular septal rupture operation between June 1, 2000, and November 1, 2005, were included in the study. There were 12 male and 6 female patients. Mean age was 65.72 +/- 5.21 years. All patients had echocardiography and coronary angiography before the operation. Rupture was closed with an infarct-exclusion technique in all patients. Preoperative, operative, and postoperative information were collected from patient cohorts. RESULTS: The median time from myocardial infarction to diagnosis of the ventricular septal rupture was 4.22 +/- 1.61 days. Fourteen of the patients had intra-aortic balloon pump support, and 5 had mechanic ventilator support preoperatively. Surgical repair was done 1 to 4 days after the diagnosis. Ten anterior and 8 posterior ventricular septal ruptures were found. Additional coronary artery bypass surgery was performed with a median of 1.27 +/- 0.8 grafts in 15 (83.3%) patients. The mean postoperative mechanic ventilator support time was 34.13 +/- 45.11 hours. Overall 30-day mortality was 16.7% with 3 patients. The mean intensive care unit stay was 3.3 +/- 1.6 days. Postoperative transthoracic echocardiography showed minimal residual shunts in 4 patients. CONCLUSION: Patch closure of the ventricular septal rupture with an infarct-exclusion technique provided acceptable results. Concomitant coronary artery bypass grafting might be beneficial to control additional risk of an associated coronary artery lesion. Prompt diagnosis followed by early surgical intervention is essential for patients with ventricular septal rupture.

Surgical treatment of prosthetic valve thrombosis: ten years' experience.

BACKGROUND AND AIM OF THE STUDY: Prosthetic valve thrombosis (PVT) is a rare, but serious, complication of heart valve replacement with a mechanical substitute. Herein is presented the authors' surgical experience of 18 patients with PVT. METHODS: A total of 1,584 heart valve operations was performed in 1,365 patients at the authors' institution between June 1995 and September 2005. Surgical reports of prosthetic valve reoperations over the same period were screened. Preoperative, operative and postoperative data were collected from the patient cohorts. RESULTS: Since July 1997, 18 patients (12 females, six males; mean age 35.9 +/- 11.3 years; range: 22-60 years) presented with PVT. The subtherapeutic anticoagulation level was the major etiologic factor involved in the pathogenesis of PVT. Thrombosis occurred in the mitral position in 14 patients (78%), and in the aortic position in four (22%). All mechanical valves implanted were bileaflet (1,097 St. Jude Medical, 324 CarboMedics, and 163 Sorin). The mean duration from valve replacement to PVT was 48.3 +/- 15.4 months. The majority of patients presented with poor functional status (56% in NYHA class IV) and poor anticoagulation (INR < or = 2 in 72% of cases). Valve re-replacement was performed for all patients. The 30-day mortality was 16.7%. CONCLUSION: PVT is a potentially fatal complication of heart valve replacement. These acceptable results suggest that early surgical intervention might be a safe and effective treatment of choice in patients with PVT. Patients with mechanical valve prostheses should be informed adequately about the need for, and the importance of, an effective anticoagulation regimen.

Modified semicircular constricting annuloplasty (Sagban's annuloplasty) in severe functional tricuspid regurgitation: alternative surgical technique and its mid-term results.

OBJECTIVE: De Vega annuloplasty is one of the most effective methods used in surgical correction of functional tricuspid regurgitation (FTR). Physiologic annular motions are protected by De Vega annuloplasty. However, recurrent tricuspid regurgitation secondary to Bowstring (Guitar string) phenomenon may be seen after De Vega annuloplasty as a result of gliding (jiggle) effect. The aim of this new annuloplasty was to prevent Bowstring phenomenon seen in De Vega annuloplasty. METHODS: Twenty-five patients with severe FTR secondary to the left-sided valvular heart disease were included in this study. Modified semicircular constricting annuloplasty (Sagban's annuloplasty): The procedure is performed utilizing 0 and 2-0 polypropylene sutures. At first, 0 and 2-0 polypropylene sutures are fixed and knotted at anteroseptal and posteroseptal comissural regions (named as anchoring points). 2-0 Polypropylene sutures which come from anchoring points in clockwise and counterclockwise direction are used to encircle the free wall annulus as well as 0 polypropylene sutures in spiral fashion (spiral annulary suture technique). When both sutures get to the anteroposterior comissural region (tying point), they are passed through plastic snares. After the annuloplasty is completed, with the heart beating and the pulmonary artery clamped, competency of the valve is tested by injecting saline into the right ventricular chamber before the adjusting suture is tied. In this annuloplasty, 0 polypropylene sutures are used for reduction and constriction, 2-0 polypropylene sutures are used for the fixation of 0 polypropylene sutures in annular level. RESULTS: FTR improved totally in 16 patients (66.7%), 4 patients (16.7%) had first degree, 3 patients (12.5%) had second degree, and only 1 patient (4.2%) had third degree residual tricuspid regurgitation in an average follow-up period of 17.8 months. One patient died from low cardiac output in early postoperative period. CONCLUSION: There is no risk of recurrent regurgitation secondary to Bowstring phenomenon in this alternative annuloplasty technique and this annuloplasty is cost-effective and performed easily.