Reversed C sternotomy versus conventional sternotomy in cardiac surgery.

BACKGROUND: In this study, cardiac surgery with minimally invasive reversed C sternotomy was compared with conventional sternotomy in patients undergoing valve replacement or septal defect repair. METHODS: In this prospective randomized study, 35 patients were assigned into one of two groups for elective cardiac surgery under general anesthesia: Group A (reversed C sternotomy group) and Group B (conventional sternotomy group). Intraoperative variables, intubation time, postoperative drainage volume, pulmonary function tests, sleep quality and quality of life, and requirement for blood transfusion were compared. RESULTS: A significant difference between the two groups was found in blood transfusion requirement, extubation time, and drainage volume. Forced expiratory volume in one second and functional vital capacity were significantly lower in Group B than in Group A at postoperative Month 1. Total sleep component score of Pittsburg Sleep Quality Index in Group B patients was significantly worse at postoperative Month 1. Postoperative assessment of quality of life (physical and mental) also showed a significant difference between the two groups. CONCLUSION: These preliminary findings suggest that creating an access point without compromising the integrity of the sternum seems to be an advantageous and appropriate technique for suitable patients undergoing cardiac surgery.

Long-term results of the single-patch repair technique for sinus venosus atrial septal defects.

BACKGROUND: Anomalous pulmonary venous drainage commonly accompanies sinus venosus atrial septal defects (SVASDs). Many techniques have been reported for avoiding postoperative complications, such as narrowing of the superior vena cava (SVC) or the pulmonary system, and arrhythmia. We perform a single V-Y pericardial patch plasty repair technique for SVASDs. The purpose of this study is to report on the long-term results of this surgical technique. METHODS: We retrospectively analyzed patients who had a diagnosis of ASD and who underwent their operations between 2000 and 2010 at the Gulhane Military Medical Academy Haydarpasa Training Hospital. Thirty-nine of the patients had an anomalous pulmonary return, and the single pericardial patch technique had been performed in 32 of these patients. RESULTS: The mean (±SD) postoperative extubation time was 5 ± 1.6 hours. The mean drainage volume was 384 ± 137 mL. All patients were discharged from the hospital at a mean of 4.6 ± 1.1 days after their operation and were prescribed anticoagulants for 3 months. No perioperative or late-term mortality was observed. Patients were followed up for 6 months to 2 years. There were no residual shunts and no stenosis-related findings in the pulmonary venous system or the SVC. CONCLUSION: Use of the single pericardial patch plasty technique might lower complication rates in patients with SVASD, especially those who have not completed their growth.

Comparison of conventional technique and ultrasonographic mapping in saphenous vein harvesting.

BACKGROUND: Saphenous vein mapping provides accurate identification of the graft diameter, location of the harvest side, and quality of graft and also led to a selective leg skin incision. In this article, we aimed to compare patients who underwent coronary artery bypass graft (CABG) surgery with or without vein mapping. METHODS: Patients who underwent CABG surgery with saphenous vein grafts (SVG) between January 2005 and January 2010 in our service were analyzed retrospectively. One hundred seventy-eight 178 SVGs were harvested with classical methods (Group A), and 136 SVGs were harvested after Doppler ultrasonography (USG) mapping (Group B). RESULTS: In Group A, 6.7% of patients needed additional incisions for graft harvesting than planned before CABG surgery due to unsuitable vein grafts. In Group B, SVGs were harvested from left lower extremity in 16 patients, and the saphenous vein was not suitable for grafting in 1 patient due to Doppler examination. In the postoperative period, complications at the incision site were reduced in Group B. CONCLUSION: Preoperative vein mapping for harvesting SVGs is an effective method in reducing wound site complications, hospital stay, and hospital costs and in increasing patient comfort and satisfaction.

Natural internal banding in adult patients with a large ventricular septal defect and a preserved pulmonary vascular system.

OBJECTIVE: Hypertrophied anomalous muscle bands (AMBs) in the right ventricular outflow tract (RVOT) may develop in the context of ventricular septal defects (VSDs) and limit persistent pulmonary overflow. In adult patients with a large VSD, persistent AMBs in the RVOT therefore can simulate the role of an externally placed pulmonary artery band. We termed such alterations natural internal bands (NIBs). Our goal was to establish the morphologic nature of the obstructive muscular lesions of the RVOT in patients with a large VSD. METHODS: Patients who underwent operations for a large VSD in our center, which has a high volume of adult patients with congenital defects, were retrospectively reviewed, and the nature of the NIBs in these patients was documented. All patients underwent transthoracic echocardiography and cardiac catheterization evaluations preoperatively and at postoperative month 3. Histopathologic examination of the AMBs was performed. RESULTS: Of 96 adult patients who underwent operations for a large isolated VSD (mean defect size, 16.9 ± 3.5 mm), 16 patients had a hemodynamically significant NIB. Two different patterns of obstruction were found. Ten of the 16 patients revealed an os infundibulum morphology, and 6 patients revealed systolic bulging of the conal septum. Four of the patients with os infundibulum also had classic tetralogy-type septal malalignment. The mean peak systolic gradient on the RVOT was 56.5 ± 17.2 mm Hg and 53.6 ± 12.3 mm Hg in the patients with os infundibulum and in the patients with systolic bulging of the conal septum, respectively. Surgical repair of the VSD was completed successfully in all patients. Resection of the os infundibulum was performed concomitantly in patients with os infundibulum. At the third postoperative month, the mean peak systolic gradient was 16.8 ± 3.5 mm Hg in patients with os infundibulum and 26 ± 5.9 mm Hg (range, 20-35 mm Hg) in patients with systolic septal bulging. CONCLUSIONS: Some mechanisms in adult type VSDs are essential for protecting the pulmonary vasculature. We tried to review these protective mechanisms: hypertrophied AMBs and NIBs.

Bilateral renal artery occlusion due to intraoperative retrograde migration of an abdominal aortic aneurysm endograft.

Retrograde (proximal) migration of an abdominal aortic aneurysm endograft is an extremely rare event during endovascular insertion and may lead to occlusion of the bilateral renal arteries and dialysis-dependent renal failure. This case report describes the intraoperative retrograde migration of a bifurcated abdominal aortic endograft during the initial endovascular procedure after deployment of an extender limb graft into the right iliac artery and associated bilateral renal artery occlusion. This was treated with renal artery bypass, and the patient had a favorable outcome.

Posterior root enlargement for aortic valve replacement associated with unexpected anomalous right coronary artery.

Anomalous right coronary artery (ARCA) generally follows a course between the aorta and pulmonary artery. When ARCA follows a course posterolateral to the aortic root behind the noncoronary sinus of Valsalva, the vessel can be at risk of injury during posterior aortic root enlargement. We present the case of a 21-year-old man with congenital aortic stenosis and small aortic root, who had an intraoperative diagnosis of ARCA. After posterior root enlargement through the noncoronary sinus, ARCA was mobilized from the aortic root and reimplanted into the right coronary sinus. Postoperative follow-up of the patient was uneventful.

Hybrid repair of an acute type B dissection with subclavian-to-subclavian bypass and stent-grafting.

Hybrid repair of an acute type B aortic dissection with endovascular stenting and aortic arch debranching is an acceptable treatment in complicated type B dissection. We present the case of a 71-year-old man presenting with acute type B aortic dissection and concomitant aneurysm of the distal aortic arch, who underwent an uneventful hybrid procedure, which involved subclavian-to-subclavian bypass before endovascular stent-graft placement to the aortic arch.

Free-floating tumor thrombus in the left atrium associated with non-small cell lung cancer.

A free-floating tumor thrombus in the left atrium is an unusual metastasis of non-small cell lung cancer. Surgical resection of free-floating tumor thrombus prior to adjuvant therapy relieves cardiac symptoms such as exertional dyspnea, and prevents life-threatening complications including systemic embolization, mitral obstruction, or sudden death.

Pulmonary vascular protective mechanisms in adult patients with an isolated large ventricular septal defect: a 21-year experience.

BACKGROUND: Ventricular septal defects (VSDs) are one of the most common congenital heart defects in adults. In adult patients with an anatomically large VSD and relatively preserved pulmonary vascular system, several pulmonary flow-limiting cardiac morphologic alterations (PFMA) are encountered. PATIENTS: Ninety-eight male patients (mean age 22.5 +/- 2 years) operated for an anatomically large VSD in our institution were retrospectively reviewed. PFMA in patients with an anatomically large but functionally mild-to-moderate VSD (when ratio of pulmonary to systemic flow (Q(p)/Q(s)) < 2.2 and ratio of pulmonary to systemic vascular resistance (R(p)/R(s)) < 0.3) were recorded. RESULTS: Thirty patients (31.2%) revealed a mild-to-moderate VSD in functional severity. Five PFMA were encountered in these patients: (1) ostium (os) infundibulum (n = 10, 33.3%), (2) aneurysm of the membranous septum (AMS) (n = 10, 33.3%), (3) systolic bulging of the conal septum toward the right ventricular outflow tract (n = 6, 20%), (4) prolapse of the aortic cusps (n = 2, 6.7%), and (5) attachment of the tricuspid septal leaflet to the septal crest (n = 2, 6.7%). Double-chambered right ventricle was encountered in four patients with os infundibulum and classic tetralogy-type septal malalignment in one patient with aortic cusp prolapse. Concurrent to VSD repair, resection of the os infundibulum and the AMS and aortic valve repair were performed. CONCLUSION: Presence of a large VSD and relatively preserved pulmonary vascular system in adults is associated with several PFMA. Preoperative awareness and concurrent surgical treatment of these alterations seem to be crucial to improve the expected benefit of surgical repair of VSD in this subgroup of the patients.

Left main coronary artery and supravalvular aortic stenosis in adult: treatment with ostial patchplasty and modified Brom procedure.

Left main coronary artery (LMCA) stenosis accompanying to supravalvular aortic stenosis is a very uncommon, serious congenital abnormality. Aortic valve leaflet fusions and intimal thickening of the aortic valve leaflets and coronary artery are the underlying pathologies for the LMCA stenosis. We operated on a 21-year-old male patient for supravalvar aortic stenosis with LMCA ostial stenosis. We enlarged the LMCA with a pericardial patch (ostial plasty) and reconstructed the aortic root with a modified Brom procedure. Postoperative course was uneventful; echocardiographic evaluation revealed a normal functioning aortic valve with a normal left ventricular function. Gradient at left ventricular outflow tract was decreased a great deal. Although supravalvular aortic stenosis with LMCA stenosis is a very rare congenital abnormality, this clinical entity can be successfully corrected with detailed and selected surgical procedures.

Combined surgical approach to multiple giant coronary artery aneurysms.

Multiple giant coronary artery aneurysms are rare but can develop in the presence of an underlying atherosclerotic vessel disease. Nevertheless, there is no consensus on the ideal surgical treatment or on operative procedures, including aneurysm resection, ligation, distal bypass, and graft interposition. We present the case of a 72-year-old woman with a history of multiple arterial aneurysms who was admitted to the emergency clinic with sudden-onset chest pain and dyspnea. The patient's diagnosis was ischemic heart disease and multiple giant coronary artery aneurysms involving the left anterior descending coronary artery and the proximal and distal segments of the right coronary artery. We present a combined surgical approach to multiple giant coronary artery aneurysms associated with atherosclerosis.

Safety Pericardiocentesis with Fluoroscopy Following Cardiac Surgery.

PURPOSE: In the treatment of the postsurgical pericardial effusions via pericardiocentesis, determination of the puncture site might be difficult. Contrast echocardiography may not be efficient due to surgical artefacts and pulmonary problems and therefore may lead to inaccurate evaluation. Alternative imaging methods might be helpful to perform the pericardiocentesis with decreased complications. METHODS: We retrospectively analyzed the patients who had undergone pericardiocentesis in our department from January 2008 through April 2018. The procedure was performed in slightly semi-seated position with the guidance of the echocardiography and fluoroscopy. Following the catheterization, percutaneous drainage was performed. RESULTS: There were 63 patients needed intervention due to pericardial effusion. 67% of the patients were using warfarin and the next patients were using acetyl salicylic acid and/or clopidogrel. All effusions were in the posterolateral localization. The mean volume of aspirated pericardial fluid was 404 ± 173 mL (150-980 mL). Control echocardiograms showed that almost all fluid was drained in all patients and there were no procedural or follow-up complications. CONCLUSION: In the treatment of postoperative pericardial effusion, fluoroscopy is an alternative method to locate the catheter accurately in challenging situations following cardiac surgery. Thus, procedural risk minimizes and drainage of pericardial fluid is performed safely.

Posterior pericardial ascending-to-descending aortic bypass through median sternotomy.

BACKGROUND AND AIM: Adult patients with complex forms of descending aortic disease remain a surgical challenge and have a high risk of postoperative mortality and morbidity. Surgical management may be complicated when there is an associated cardiac defect, necessitating repair, or a hostile anatomy exists. We present our experience with extra-anatomic bypass through posterior pericardial route at the same stage with intracardiac/ascending aortic aneurysm repair. METHODS: Patients that underwent one-stage surgery with posterior pericardial bypass between ascending and descending aorta during 2003-2007 were reviewed. Data from early and mid-term follow-up, including mortality, perioperative blood loss, graft-related complications, patency, and persistent hypertension, were noted. RESULTS: Six male patients with a mean age of 20.8 +/- 0.7 years were operated for coarctation of the aorta associated with additional pathologies (three cases of ascending aortic aneurysm-one with associated aortic valve insufficiency, one case of isolated aortic valve regurgitation, two cases of mitral valve regurgitation). No early or mid-term mortality was observed during follow-up of a mean of 21.6 +/- 10.0 months. No late graft-related complications or reoperations were observed with patent grafts. Systolic blood pressure decreased after surgery by an average of 43 mmHg. CONCLUSIONS: Coarctation of the aorta with concomitant cardiac lesions can be repaired simultaneously through sternotomy and posterior pericardial approach, when patients present in adulthood, to minimize morbidity and mortality.

Our experiences on endovascular and hybrid treatment of peripheral arterial diseases.

BACKGROUND: This study aims to present our experiences on endovascular and hybrid treatment of peripheral arterial diseases. METHODS: Between March 2008 and April 2016, 86 patients who underwent endovascular treatment and 17 patients who underwent hybrid treatment for peripheral arterial disease in our clinic were retrospectively analyzed. The treatment approaches, success of treatments, complications and outcomes of these patients were studied. RESULTS: No mortality was seen during the procedures. Following the procedure, the patients were hospitalized in the intensive care unit under standard heparin treatment for six hours at least. Anticoagulation was maintained with low-molecular-weighted heparin for three days, followed by dual oral antiaggregant (acetylsalicylic acid 100 mg + clopidogrel 75 mg). Repeated Doppler ultrasonography revealed no in-stent thrombosis or restenosis at the site of ballooning during hospitalization. None of the patients with normal renal functions preoperatively experienced severe renal failure. Although nearly all femorodistal interventions were performed in the antegrade way, none of the patients had bleeding complications at the site of intervention. All patients were discharged within 1 to 16 days. CONCLUSION: Endovascular and hybrid modalities are safe and comfortable in the treatment of peripheral arterial diseases for vascular surgeons having a hybrid room.

Comparison of primary repair and patch plasty procedure on the P wave in adult atrial septal defect closure.

INTRODUCTION: In this study we compared the effects of two different surgical procedures for closure of adult atrial septal defect (ASD) on postoperative P-wave changes. METHODS: Patients who underwent cardiac surgery for secundum type ASD closure were evaluated retrospectively. Seventy-two patients with primary repair of ASD and 29 patients with pericardial patch plasty repair were compared according to Pmax, Pmin and P-wave dispersions (Pd). RESULTS: In each group, the increases in postoperative maximum P-wave duration (Pmax) and minimum P-wave duration (Pmin) were statistically significant. There was no statistically significant difference between post- and pre-operative Pd values. In the comparison between group 1 and group 2 in terms of postoperative P-wave changes (Pmax, Pmin, Pd) there was no statistically significant difference. CONCLUSION: Comparing patch plasty and primary repair for the surgical closure of ASD in the early to mid-postoperative period, no difference was found and both surgical procedures can be performed in adult ASDs.

The effect of serum, intestinal and peritoneal visfatin levels on early diagnosis of acute mesenteric ischemia.

BACKGROUND: Acute mesenteric ischemia (AMI) is a rapidly progressive disease where early diagnosis is life-saving. As a new cytokine, levels of thevisfatin might be affected during the ischema and reperfusion. In our study, we obtained changes of visfatin levels in the serum, peritoneal and intestinal lavage samples in rats, to investigate the effectiveness of these changes in the early diagnosis of AMI. METHODS: In group 1 (Sham group) the intestine was exteriorated after the laparotomy was performed and allowed to stand for 3 hours without ischemia. In group 2 (acute mesenteric ischemia-reperfusion group) the mesenteric artery was ligated and, mesenteric blood flow was restored after 60-minute ischemia. To compare with intestinal injury, in group 3 (acute pancreatitis group) the ductus pancreaticus was ligated, and the abdomen was closed for 3 days in expectation of the formation of pancreatitis. In all of the groups, the intestinal lavage, peritoneal lavage and blood samples were analyzed to evaluate the levels of visfatin, TNF-alpha, IL-6 and IL-8. Samples were taken before the procedure in all groups; additionally 60 minutes after ischemia and 120 minutes after reperfusion in group 2; and after the development of the pancreatitis in group 3. RESULTS: Serum, intestinal and peritoneal lavage visfatin levels were found to be increased in group 2 and group 3 (P<0.05). In group 2, while serum TNF-alpha levels were increased in both ischemia and reperfusion; in intestinal lavage sample the increase was only in the ischemic phase (P<0.05). In group 2, IL-8 levels were significantly increased after ischemia in serum (P=0.03) and after reperfusion in intestinal lavage (P=0.004) samples. CONCLUSIONS: Serum, intestinal and peritoneal visfatin levels were increased not only in the case of mesenteric ischemia, but also in acute pancreatitis. In these two clinical pathologies, the visfatin levels of the intestinal and peritoneal cavitiesmay increase parallel to the serum visfatin levels.

Gastrointestinal complications after cardiopulmonary bypass: sixteen years of experience.

BACKGROUND: Gastrointestinal (GI) complications are one of the serious complications of cardiac surgery. Although rarely seen, they cause major morbidity and mortality. The aim of the present study was to retrospectively analyze the risk factors acting on the GI complications seen after cardiac operations performed under cardiopulmonary bypass. METHOD: The present study was designed to retrospectively evaluate 13,544 patients who underwent cardiac surgery under cardiopulmonary bypass, between 1988 and 2004 in the authors' clinic. RESULTS: The overall mortality was 346 (2.55%) of 13,544 patients. GI complications developed in 128 patients (0.94%). Among those, 18 (14.1%) died because of GI complications, the most common of which was bleeding. Mesenteric ischemia had the highest case-fatality rate at 71.4%. Valve surgery, concomitant valve and coronary artery bypass grafting surgery, preoperative chronic renal dysfunction, postoperative acute renal failure, deep sternal infection, prolonged ventilation, need for intra-aortic balloon pump and ejection fraction less than 30% were found to be risk factors acting on GI complications. CONCLUSION: GI complications remain a significant concern after cardiac surgery under cardiopulmonary bypass. Higher-risk patients can be identified and treated prophylactically and in the postoperative period.

Removal of broken catheter piece with snare device during endovascular treatment of post-traumatic brachial artery pseudo-aneurysm.

Post-traumatic pseudo-aneurysm is a rare complication of penetrating vascular injury. Endovascular stent implantation has become an alternative approach in the management of this pathology. In our case, we present a brachial artery pseudo-aneurysm that was treated with endovascular stent implantation, and removal of a broken catheter part with a three-dimensional snare device.

Coronary artery bypass grafting following simultaneous treatment of abdominal aortic aneurysm and peripheral arterial disease.

Atherosclerosis might affect all arterial segments of the vascular system, thus peripheral arterial disease (PAD) accompanying coronary artery disease (CAD) is not uncommon. In addition to this coexistence, abdominal aortic aneurysm (AAA) is frequently associated with CAD. Although treatment strategies of CAD and PAD or CAD and AAA has been reported previously, treatment of these three pathologies has not been reported. The management of a therapeutic strategy is important for avoiding perioperative mortality and morbidity in CAD associated with AAA and PAD. We are reporting our simultaneous treatment strategy of three pathologies with endovascular AAA repair, stent implantation into the superficial femoral artery (SFA) and coronary artery bypass grafting (CABG).