Long-segment patchplasty of diffuse left anterior descending artery disease on the beating heart.

OBJECTIVE: The rate of patients with diffuse left anterior descending artery (LAD) disease being referred for surgery has increased as a result of advances in endovascular techniques. In surgery of diffuse or multisegment LAD disease, surgical procedures with or without endarterectomy can be performed. In this article, we report our results of longsegment onlay patchplasty of the LAD with a left internal thoracic artery (LITA) graft without endarterectomy, on the beating heart, in patients with multisegment LAD disease. METHODS: We retrospectively analysed patients who underwent coronary artery bypass grafting surgery in our hospital between 1 January 2015 and 31 July 2017. We included LITA onlay patchplasty patients with multisegment LAD disease who had been operated on the beating heart. We excluded patients who underwent coronary endarterectomy and were operated on under cardiopulmonary bypass. RESULTS: In this period, 54 patients with multisegment LAD disease were treated with LITA patchplasty on the beating heart. The mean length of the arteriotomy was 42.8 ± 13.3 mm (25-75 mm). There were two postoperative myocardial infarctions (3.7%) and three deaths (5.5%). In the remaining patients, there was no haemodynamic instability that needed long-term (> 24 hour) inotropic support. Patients were discharged from hospital on postoperative 9.3 ± 7.1 days with dual antiplatalet therapy. CONCLUSIONS: Bypass grafting of the LAD with long-segment LITA onlay patchplasty can safely be performed in patients with multisegment LAD disease, with acceptable early-term results. In this procedure, proximal and distal segments of the diseased LAD are revascularised with LITA grafts, which may improve long-term survival and quality of life.

False Lumen Catheterization in a Patient Who Has Type A Aortic Dissection That Mimics Acute Inferior Myocardial Infarction: A Case Report.

We report a 61-year-old patient who suffered from a type A aortic dissection that mimicked an acute inferior myocardial infarction. During a routine cardiac catheterization procedure, diagnostic catheters can be inserted accidentally into the false lumen. Invasive cardiologists should keep this complication in mind.

Five-year follow up of Konno aortoventriculoplasty for repeat aortic valve replacement in an adult patient.

Konno aortoventriculoplasty (AVP) is performed for various types of left ventricular outflow tract obstruction. We report on a 32-year-old woman who had undergone double valve replacement five years earlier. She presented with increased interventricular septum thickness, small aortic root and gradient across the aortic mechanical valve. We performed Konno AVP with repeat aortic valve replacement (AVR). The control echocardiography showed no significant residual gradient. Konno AVP with repeat AVR may be safely performed with satisfactory results.

The effect of postoperative positive end-expiratory pressure on postoperative bleeding after off-pump coronary artery bypass grafting.

INTRODUCTION: To compare postoperative prophylactic use of two positive end-expiratory pressure (PEEP) levels in order to prevent postoperative bleeding in patients undergoing off-pump coronary artery bypass grafting (CABG) surgery. MATERIAL AND METHODS: Sixty patients undergoing an elective off-pump CABG operation were included in this prospective, nonrandomized clinical trial. Patients were divided into two groups as receiving either 5 cm H2O (group 1) or 8 cm H2O PEEP (group 2) after the operation until being extubated. Chest tube outputs, use of blood products and other fluids, postoperative hemoglobin levels, accumulation of pleural and pericardial fluid after the removal of chest tubes, and duration of hospital stay were recorded and compared. RESULTS: Low- and high-pressure PEEP groups did not differ with regard to postoperative chest tube outputs, amounts of transfusions and crystalloid/colloid infusion requirements, or postoperative hemoglobin levels. However, low-pressure PEEP application was associated with significantly higher pleural (92 ±37 ml vs. 69 ±29 ml, p = 0.03) and pericardial fluid (17 ±5 ml vs. 14 ±6 ml, p = 0.04) accumulation. On the other hand, high-pressure PEEP application was associated with significantly longer duration of hospitalization (6.25 ±1.21 days vs. 5.25 ±0.91 days, p = 0.03). CONCLUSIONS: Prophylactic administration of postoperative PEEP levels of 8 cm H2O, although safe, does not seem to reduce chest-tube output or transfusion requirements in off-pump CABG when compared to the lower level of PEEP. Further studies with larger sample sizes are warranted to confirm the benefits and identify ideal levels of PEEP administration in this group of patients.

Relationship between exercise-induced heart rate increase and the formation of microbubbles and high-intensity transient signals in mechanical heart valve implanted patients.

INTRODUCTION: The formation and collapse of vapor-filled bubbles near a mechanical heart valve is called cavitation. Microbubbles can be detected in vivo by doppler ultrasonography (USG) as HITS (high intensity transient signals) in cranial circulation. We investigated the relationship between exercise induced heart rate increase and HITS formation in cranial circulation. MATERIAL AND METHODS: Thirty-nine mechanical heart valve implanted (8 aortic valve replacement (AVR) + mitral valve replacement (MVR), 9 AVR, 22 MVR) patients aged 18-80 years old were included in our study. Microbubbles were counted in the left ventricular cavity via transthoracic echocardiography at rest per cardiac cycle. Afterwards transcranial Doppler USG was performed and HITS were counted in each patient's middle cerebral artery at 5 min duration. Subsequently an exercise test according to the Bruce protocol was performed. After achieving maximal heart rate, microbubbles in the left ventricle and HITS were counted again. RESULTS: Microbubbles in the left ventricle and transcranial HITS increased after exercise significantly compared to resting values (15.79 ±10.91 microbubbles/beat vs. 26.51 ±18.00 microbubbles/beat, p < 0.001; 6.13 ±8.07 HITS/5 min vs. 13.15 ±15.87 HITS/5 min, p = 0.001). There was a significant correlation between microbubbles and HITS counts after peak exercise (r = 0.55, p < 0.001). CONCLUSIONS: In our study, we found that the microbubbles were increasing as the heart rate increased and more HITS were propelled to the cerebral circulation. As previously shown, HITS can alter cognitive functions. Therefore heart rate control is essential in mechanical heart valve patients to protect neurocognitive functions.

Acute type-A aortic dissection with obstruction of the right coronary artery.

Occlusion of a coronary artery by an acute type A aortic dissection presents a life-threatening emergency that is rarely seen and easy to misdiagnose. We present the case of a 75-year-old male who experienced sudden onset of severe left-sided chest pain due to an acute type A aortic dissection that obstructed the right coronary artery. Following an initial misdiagnosis of acute coronary syndrome, imaging revealed the presence of an aortic dissection. An emergency modified Bentall procedure was performed, in which the damaged aorta and aortic valve were replaced.

Pressure-controlled mechanical ventilation is more advantageous in the follow-up of patients with chronic obstructive pulmonary disease after open heart surgery.

OBJECTIVE: Cardiopulmonary bypass deteriorates pulmonary functions to a certain extent. Patients with chronic obstructive pulmonary disease (COPD) are associated with increased mortality and morbidity risks in the postoperative period of open-heart surgery. In this study we compared 2 different mechanical ventilation modes, pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV), in this particular patient population. PATIENTS AND METHODS: Forty patients with severe COPD were assigned to 1 of 2 groups and enrolled to receive PCV or VCV in the postoperative period. Arterial blood gases, respiratory parameters, and intensive care unit and hospital stays were compared between the 2 groups. RESULTS: Maximum airway pressure was higher in the VCV group. Pulmonary compliance was lower in the VCV group and minute ventilation was significantly lower in the group ventilated with PCV mode. The respiratory index was increased in the PCV group compared with the VCV group and with preoperative findings. Duration of mechanical ventilation was significantly shorter with PCV; however, intensive care unit and hospital stays did not differ. CONCLUSION: There is not a single widely accepted and established mode of ventilation for patients with COPD undergoing open-heart surgery. Our modest experience indicated promising results with PCV mode; however, further studies are warranted.

Symptomatic intercostal lung hernia secondary to sternal dehiscence surgery.

Patient: Male, 60 Final Diagnosis: Iatrogenic intercostal lung hernia Symptoms: - Medication: No medication Clinical Procedure: Surgically cerrected Specialty: Thoracic surgery. OBJECTIVE: Unusual clinical course. BACKGROUND: Iatrogenic intercostal lung hernia is a rare thoracic pathology. Injury of intercostal muscles and costocondral separation during median sternotomy and sternal dehiscence surgery are important factors in the development of hernia. We report for the first time a case of a 60-year-old man with acquired lung hernia after sternal dehiscence surgery, presenting as chest pain and exertional dyspnea. CASE REPORT: A 60-year-old man presented with a 6-week history of progressive exertional dyspnea, particularly following vigorous coughing. Past medical history included slight chronic obstructive pulmonary disease and coronary artery bypass grafting surgery 8 weeks previously, using the left internal mammary artery for the left anterior descending artery via median sternotomy and sternal dehiscence by the Robicsek method. A chest X-ray showed intact sternal and parasternal wires, but the bilateral lung parenchyma appeared normal. A spiral computed tomography scan of the chest found intercostal herniation of the anterior segment of the left upper lobe. The lung hernia was repaired surgically to relieve exertional dyspnea and incarceration, and to improve respiratory function. The postoperative course was uneventful and the patient recovered well. CONCLUSIONS: Intercostal lung hernia after median sternotomy and sternal dehiscence surgery is rare, and it has been previously reported on. Preventive techniques include gentle manipulation of the sternal retractor, avoidance of rib fractures, and using a protective method of intercostal arteries and nerves such as Sharma technique. Thoracic surgeons should be aware of this rare complication in sternal dehiscence surgery.

Innominate artery as an alternative site for proximal anastomoses in patients with a severely calcified aorta.

BACKGROUND: Atheromatous plaques of the ascending aorta are one of the most important risk factors for postoperative mortality and morbidity in coronary artery bypass grafting (CABG). We have retrospectively analyzed the results of proximal anastomoses constructed on the innominate artery in patients with calcific atheromatous plaques (CAP) in their ascending aorta detected intraoperatively. PATIENTS AND METHODS: This study is a retrospective review of 16 consecutive patients who underwent CABG operations and had CAP on their ascending aorta between November 2006 and June 2009. The atheromatous lesions were detected intraoperatively and the operation plan was changed to off-pump surgery. All the proximal anastomoses were made on the innominate artery, left internal thoracic artery (LITA) or the other saphenous vein grafts (SVG). Thirteen patients were male and three were female with a mean age of 63.7 ± 5.3 (ranged, 53-71) years. RESULTS: A total of 56 distal anastomoses (3.5 per patient) and 25 proximal anastomoses on the innominate artery were performed. Of the 16 patients, seven (43.7%) had received a sequential SVG; two (12.5%) patients, sequential LITA graft; and one (6.25%) patient sequential SVG and LITA graft. One of the proximal anastomoses was performed on the SVG in four patients (25%) and on the LITA graft in one patient (6.2%). One patient (6.2%) died due to cerebrovascular morbidity. No other complications were observed. CONCLUSIONS: The innominate artery is an alternative site for proximal anastomoses in patients with calcific atheromatous aorta.

Simultaneous beating heart coronary artery bypass surgery and modified radical mastectomy.

Concomitant surgeries for unrelated diseases can be performed to minimize the risks associated with surgery and general anesthesia. In treating a male patient with breast cancer and severe coronary artery disease, we used the beating heart technique for a coronary artery bypass graft to avoid the negative effects of on-pump bypass on the possible acceleration of tumor growth. In this report, we present a unique case of concomitant off-pump coronary artery bypass graft surgery and modified radical mastectomy in a 56-year-old man.

Comparison of inhaled nitric oxide and aerosolized iloprost in pulmonary hypertension in children with congenital heart surgery.

BACKGROUND: Pulmonary arterial hypertension is of importance in congenital cardiac surgery as being a significant cause of morbidity and mortality. Although therapy options are limited, inhaled nitric oxide (NO) is used as a standard therapy. The present study aimed to compare inhaled NO and aerosolized iloprost in children with secondary pulmonary hypertension who underwent congenital cardiac surgery. METHODS: Sixteen children included in the study were randomized into either inhaled NO or aerosolized iloprost group. For both groups, the observation period terminated at 72 h after cardiopulmonary bypass. RESULTS: There was no significant difference between the groups in terms of mean age, weight, cross clamp time, pump time, and extubation time. No significant change was observed in the arterial tension and central venous pressure of both groups before the operation, 30 min after the pump, 45 min after the pump, and after extubation, whereas an increase was observed in the heart rate and cardiac output, and a decrease was observed in the pulmonary artery pressure. The mean values at the above-mentioned time points showed no difference between the groups. No serious adverse event and mortality was detected. CONCLUSIONS: Both inhaled NO and aerosolized iloprost were found to be effective and comparable in the management of pulmonary hypertension.

Comparison between local and general anesthesia for carotid endarterectomy: early and late results.

BACKGROUND: The aim of this retrospective study was to compare the results between general and local anesthesia (LA) for carotid endarterectomy (CEA). METHODS: Three hundred and twenty-nine patients in whom 365 CEA procedures were performed between January 1990 and September 2001, were included in this study. RESULTS: Operation time, shunt usage rates, hospitalization time (P < .0001), and permanent stroke rates (P < .05) were significantly lower in group with LA. For long-term period (121.3 ± 37.45 vs 98.6 ± 28.98 months), no significant difference was observed in these 2 group with respect to restenosis rates, neurological events, and deaths. CONCLUSIONS: Despite the lack of significant difference between LA and general anesthesia in terms of restenosis, neurological events, and death in the long-term period; LA is more preferable due its associated advantages including availability of testing the consciousness of the patients by direct contact, reduced use of shunts, shorter hospitalization periods, and less prevalence of permanent stroke in the short-term period.

Left anterior descending artery revascularization in low-risk patients: early outcomes after off-pump versus on-pump surgery.

BACKGROUND AND AIM OF THE STUDY: This study aimed to compare the early outcomes of off-pump and on-pump myocardial revascularization in patients with stenosis in the left anterior descending artery (alone or with diagonal artery disease). METHODS: We retrospectively reviewed the medical records of 300 patients: 150 who underwent on-pump coronary artery bypass and 150 who underwent off-pump coronary artery bypass grafting. There were no significant differences between the 2 groups with respect to medical data and operative findings. On-pump and off-pump groups were compared in terms of mortality and morbidity within 30 days of the operation. RESULTS: Hospital mortality was 3.3% (5 patients) in the on-pump group and 2.6% (4 patients) in the off-pump group. Five patients (3.3%) in the on-pump group experienced myocardial infarction; 3 died of cardiogenic shock. Four patients (2.6%) in the off-pump group experienced myocardial infarction, and 2 of these patients died. Two patients (1.3%) in the on-pump group and 2 patients (1.3%) in the off-pump group experienced stroke; 1 patient in each group died. One patient (0.6%) in the on-pump group had mediastinitis and died of sepsis. CONCLUSIONS: Among low-risk patients (defined according to EuroSCORE criteria) who underwent left anterior descending coronary artery bypass, the results obtained with the on-pump and off-pump methods showed no significant differences with respect to morbidity or mortality.

Sternal wrapping for the prevention of sternal morbidity in elderly osteoporotic patients undergoing median sternotomy.

Osteoporosis, a major risk factor for sternum-related morbidity after median sternotomy, is quite prevalent among the elderly. In this prospective study, we investigated the potential of sternal protection by use of the "sternal wrapping method" in elderly osteoporotic patients who were undergoing median sternotomy.For this study, we chose 100 elderly osteoporotic patients who were scheduled to undergo median sternotomy. During surgery, we wrapped the sternal edges with polyvinyl chloride tubing in 50 patients (group 1) and omitted the sternal wrapping in the remaining 50 patients (group 2). We then compared the groups with regard to postoperative pain, bleeding, early and late sternum-related morbidity, sternal fractures, and duration of hospitalization.Sternal wrapping was associated with fewer sternal fractures, less chest pain, and shorter hospital stays. Overall sternal morbidity was significantly less common among patients with sternal wrapping (4% vs. 20%, P = 0.03); however, the difference in individual rates for early and late dehiscence or deep sternal infection did not reach statistical significance.Sternal wrapping using polyvinyl chloride tubes provides mechanical protection and, apparently, less postoperative chest pain and shorter hospitalizations. Probably, it reduces sternum-related complications, particularly in high-risk patients. Its benefits, however, should be confirmed in larger studies.

Sternal dehiscence in patients with moderate and severe chronic obstructive pulmonary disease undergoing cardiac surgery: the value of supportive thorax vests.

OBJECTIVE: Sternal dehiscence after open surgery is a major cause of morbidity and mortality, and chronic obstructive pulmonary disease is a significant risk factor. Therefore, we aimed to determine whether moderate and severe chronic obstructive pulmonary disease had an effect on the development of sternal dehiscence and whether the use of the Robicsek technique for sternal closure along with sternal support vest postoperatively would reduce the incidence of sternal dehiscence in patients with moderate/severe chronic obstructive pulmonary disease undergoing cardiac surgery. METHODS: Two studies were performed. In study 1, 842 patients undergoing cardiac surgery and figure-of-8 wire closure were retrospectively evaluated in 2 groups: group 1a (328 patients with chronic obstructive pulmonary disease) and group 1b (514 patients without chronic obstructive pulmonary disease). In study 2, 221 patients with moderate and severe COPD who were scheduled for open surgery were prospectively enrolled. The Robicsek technique was used for sternal closure. The postoperative thorax support vest was used in 100 patients (group 2a), and no additional procedure was applied in 121 patients (group 2b). RESULTS: In study 1, the dehiscence rate was significantly higher in group 1a (7.9%) than in group 1b (1.2%; P < .001), and mortality rates in patients with dehiscence were 53.8% and 33.3%, respectively. In study 2, the dehiscence rate was significantly lower in group 2a (1%) than in group 2b (11.5%; P = .002). None of the patients with dehiscence in group 2a died, and 35.7% of patients died in group 2b. CONCLUSIONS: The Robicsek technique for sternal closure and the use of a thorax support vest postoperatively are highly effective in preventing sternal dehiscence after cardiac surgery in patients with moderate and severe chronic obstructive pulmonary disease.

Mitral regurgitation secondary to anterior leaflet rupture during percutaneous balloon valvuloplasty: case report.

Rheumatoid heart disease and the mitral stenosis secondary to it in the long term are still important cardiovascular problems in developing countries. Percutaneous balloon mitral valvuloplasty is a valid treatment option with low complication rates for relieving the signs and symptoms of selected patients with mitral valve stenosis. In this report, we describe subacute mitral regurgitation secondary to anterior leaflet rupture following percutaneous balloon mitral valvuloplasty and the management strategy in a 54-year-old female patient. Such a complication is rare in experienced hands in the current era.

Mitral valve repair in a patient with thrombocytopenia-absent radius syndrome: case report.

Thrombocyte level and functions are vital factors during cardiac surgery. Thrombocytopenia-absent radius syndrome (TAR) is a rare genetic disorder consisting of skeletal abnormalities and thrombocytopenia. In this report, we present the management strategy for a 23-year-old female patient with TAR syndrome who underwent mitral valve repair.