Ischaemic mitral regurgitation: the effects of ring annuloplasty and suture annuloplasty repair techniques on left ventricular re-remodeling

To examine the mid-term results of patients on whom a coronary revascularization as well as a mitral ring and suture annuloplasty have been performed due to coronary artery disease [CAD] and ischaemic mitral regurgitation [IMR]. Totally 73 patients on whom a revascularization and a mitral valve repair due to CAD and IMR had been performed in our clinic between 2000-2008 were included in the study. Patients were divided into two groups one of which included 38 patients [52.05%] on whom a coronary artery bypass graft [CABG] and a ring annuloplasty on the mitral valve had been performed [Group 1] and the other one 35 patients [47.95%] on whom only suture annuloplasty as well as a CABG had been performed [Group 2]. The study was planned retrospectively and study data have been obtained by screening the hospital registries retrospectively. In the mid-term, patients were invited for a check and their intragroup and intergroup echocardiographic parameters and functional capacities were assessed statistically. In pre-operational and post-operational intragroup assessment in terms of echocardiographic findings; although LVEDD, LVESD, EDV, PAP and the degree of recurrent MR have been decreased in both groups, the decrease in LVESD and PAP and the low degree of recurrent MR were statistically significant in Group 1 patients [p=0.047, p=0.023, p=0.01, respectively]. When the mid-term intergroup echocardiograpic findings were assessed; PAP and recurrent MR have been determined statistically lower in Group 1 patients [p=0.005, p=0.08, respectively]. The length of intensive care unit stay, length of hospitalization and length of detachment from respiratory support were statistically significantly longer in ring annuloplasty performed group [p=0.012, p=0.033, p=0.029, respectively]. In moderate to severe IMR patients, a positive contribution can be provided to ventricular remodeling by a ring annuloplasty through a significant decrease in left ventricular diameter and a low recurrent MR and PAP

Surgical management of iatrogenic vascular injuries

Iatrogenic vascular injury is an abnormal state that occurs in patients as a result of inadvertent or erroneous treatment by physicians or surgeons. We describe our 10 year experience with patients who underwent surgical repair of iatrogenic vascular injuries after catheterization or operation. Thirty one patients with iatrogenic vascular injury incurred between February 2001 and February 2011 who were surgically managed in our Department were reviewed retrospectively. The clinical presentation, localization and type of vascular injury were each analyzed. This study group consisted of 19 males and 12 females, ranging in age from 16 to 69 years with an average age of 47.8 years. Of the 31 iatrogenic vascular injuries, 19 resulted from a percutaneous procedure and 12 were sustained intraoperatively. The intraoperative iatrogenic injuries affected the inferior vena cava in three patients, left renal vein in one, external iliac artery in four, common carotid artery in three, and internal carotid artery in one. Eleven patients associated with catheterization were operated on immediately. The remaining eight were operated on an elective surgical basis [Pseudoaneurysm or arteriovenous fistula]. All patients made an uneventful recovery. Although experience and thorough knowledge of the vascular anatomy can prevent many potential iatrogenic vascular injuries, the risk of iatrogenic vascular injury cannot be completely eliminated. Therefore, we recommend that major operations requiring dissection in proximity to the vascular structures, and catheter based diagnostic or therapeutic procedures should be performed only in hospitals with an established vascular surgery department

Our experience of infrapopliteal revascularization of lower extremity in ten years

In this study the long term results of infrapopliteal arterial revascularization procedure was evaluated. The efficiency of distal revascularization was also searched for the treatment of critical limb ischemia. From 1999 to 2009 32 patients underwent infrapopliteal revascularization procedure in our hospital for the treatment of critical limb ischemia. Demographic data of patients are: 23 male, 9 female and mean age was 60.5. Hypertension [n:15, 46.3%], diabetes mellitus [n:16, 50%], smoking [n:29, 90.6%] were the risk factors. The patients were classified in Fontaine III [n:25] and Fontaine IV [n:7]. Extremity viability and long term patency was detected with limb examination, Doppler Ultrasonography and angiography. The cases were evaluated for post operative mortality, morbidity and primary graft patency for one year. Mean follow up period was 21.3-/+15.9 monthes [12-60 monthes]. Two patients died in early post operative period. Eight patients underwent re-operation. Re-operations were performed on six patients for the treatment of acute graft thrombosis and two patients for the control of surgical bleeding. The long term graft patency was 38% and extremity recovery rate was 46%. In post operative early period two minor and one major amputation was performed. Infrapopliteal arterial revascularization procedure is an efficient method for the treatment of critical limb ischemia and high rate of long term patency is the main advantage of this procedure

Surgical repair of delayed chronic type A dissection after previous coronary artery bypass grafting

We report of a 57 years-old woman who had undergone coronary artery bypass three years previously. Computed tomography [CT] revealed that the ascending aorta was dilated to about 7cm in diameter, with type A dissection. Angiography revealed that left internal thoracic artery [LITA] graft to left anterior descending artery [LAD] and saphenous vein grafts to posterior descending artery [PDA] branch of the right coronary artery [RCA] and second obtuse marginal [OM] branch of the circumflex artery [CX] correspondingly were patent. Though the risk of surgical, treatment via repeat median sternotomy is usually very high in these cases, we successfully performed the reoperation using profound hypothermic circulatory arrest. We dissected the mediastinum by using a sternum retractor for ITA and saphenous vein grafts dissection. We didn't use cardioplegia during profound hypothermic circulation

Management of giant venous aneurysms secondary to arteriovenous fistula in hemodialysis patients

An aneurysmal fistula can continue to provide hemodialysis access for along time, but giant aneurysms should be operated on to prevent complication. The purpose of this study was to describe our experience of the surgical management of giant venous aneurysms that have developed as a complication of dialysis access. Twenty patients with giant venous aneurysms of the AVF underwent surgical procedures at our hospital from December 2003 to December 2010. The diagnoses were made by physical examination and Color Doppler Ultrasonography. There were 12 male and 8 female patients ranging in age from 29 to 68 years with a mean age of 44.6 +/- 12.3 years. Plication of the aneurysmal dilatations was performed in 17 patients. In two patients, aneurysmal dilatations were excised with restoration of the artery. The remaining one patient who received a successful renal transplantation was also associated with brachial artery aneurysm. Venous aneurysmal dilatations were excised and arterial aneurysms were repaired. All patients experienced a marked decrease in the size of venous dilatations. There were no vascular complications during the follow-up period. We suggest that plication is safe and effective in controlling venous dilatation and achieving patency. Reinforcing the suture line using an external mesh may not be required. However, prospective randomized studies will be required to assess the long-term outcomes

Penetrating cardiac injuries 10 year experience

To evaluate clinical findings and surgical interventions and their results in the patients referred to our hospital with cardiac injuries. Penetrating heart injury is potentially a life-threatening condition due to cardiac tamponade or exsanguinating hemorrhage. The data of 20 patients undergoing surgical intervention due to penetrating cardiac injury between 2001 and 2010 were retrospectively evaluated. In this series of 20 patients all were male between the ages of 14-65 years, with a mean age of 33.2 +/- 14.15 years. Age interval of the participating patients was between 14 - 65. Eighteen of these patients were diagnosed with right ventricular injuries while two were diagnosed with left ventricular injuries. All the diagnoses were established with clinical examination, direct radiograph, CT, echocardiography and ECG. Four of the patients admitted in emergency service were in agony, four were in shock, and six presented with hypotensive hemodynamic, and four with stable hemodynamic. Right anterior thoracotomy was applied to four patients in agony in the emergency service. Two of these patients died. None of other patients died. All the postoperative patients were followed with echocardiography. Post - pericardiotomy syndrome was detected in one of the patients. Our experience shows that early diagnosis and immediate surgical intervention are the main factors affecting patient survival after penetrating heart injuries. Penetrating cardiac injuries have high mortality. This rate may be 80% in those patients in agony. Emergent intervention in emergency services for the patients under emergent conditions may be life- saving

Diagnosis and treatment of carotid body tumors

Carotid body tumors [CBTs], especially familial paragangliomas, are rare benign neoplasm, accounting for < 0.5% of all tumors; and they are the most common extra-adrenal paraganglioma. Because of peripheral vascular and neural invasion or compression of tumors, early diagnosis and treatments are very important, whereas this kind of tumors have got slow progression and low malignity potential. The aim of this study was to review an institutional experience in the management of paragangliomas. In this study, CBTs were clinically suspected in 33 patients but diagnosed by histopathology in between 1999 and 2011 at our department. Three of these patients presented with bilateral tumors. All but one was operated upon. The ages of the 48.3 surgically treated patients ranged 32-58 years. A mass in the neck was the common symptom in all patients. The patients were classified according to the Shamblin classification. There were 17 patients [11 women 6 men] in the first group, 13 patients [9 women, 4 men] in the second group, and 3 patients [2 women 1 man] in the third group. All of these 33 surgically treated patients had confirmed CBT by histopathology. CBTs were resected without a shunt procedure. No mortality occurred, however one patient experienced Horner syndrome post operatively. In the follow up period, no recurrences were observed. Three of the patients was had hoarseness, but improved after six months. No stroke occurred in the patients. CBTs are infrequent neoplasm; their surgical treatment is highly dependent on the ability and experience of the surgeon. The diagnostic and therapeutic relevance reside in making a timely diagnosis to propose a surgical treatment aimed at preventing complications and neurological damage. Surgical resection is usually definitive therapy for these lesions

Emergent surgical retrieval of an embolized septal occluder from the main pulmonary artery

Surgical closure of ASD has been used for over 50 years and appears to be a safe and effective operation. However, over the past decade, transcatheter closure techniques have been increasingly practiced. We present a case of 51 -year old woman with atrial septal defect [ASD]. She presented with progressive decrease in exercise tolerance. Echocardiographic examination-showed the ASD and a 26mm septal occluder device [Cardio-fix septal occluder] was successfully deployed under fluoroscopic and echocardiographic guidance. However, the patient suddenly complained of palpitation and sustained ventricular tachycardia thirty minutes after the procedure. A repeat echocardiographic examination confirmed embolization of the device into main pulmonary artery. Due to failure of capture of the device via multisnare, the patient was immediately taken to the operating room for removal of the device and surgical closure of the defect. The embolized device was grasped and retrieved from proximal pulmonary artery between index and middle fingers inserted into the main pulmonary artery via the tricuspid and pulmonary valves. The ASD was closed by running nonabsorbable polypropylene suture. Postoperative recovery was uneventful. The patient was discharged home after a total of six days of hospitalization

Surgical management of atrial septal defect in patients over 40 years of age

Atrial septal defect [ASD] makes up about 10% of all congenital heart diseases diagnosed after delivery and up to 30-40% of heart defects diagnosed in patients aged over 40 years. The objective of this study was to evaluate the effects of surgical ASD repair on functional status, right ventricular size, cardiothoracic ratio and pulmonary hypertension in patients over 40 years of age. Between the period of August 2001 and August 2010, 20 of the patients who had undergone surgical repair of a secundum ASD when they were aged >40 years at our institution were included in this study. To evaluate the effects of surgery on clinical outcome, we compared functional status, echocardiographic and radiographic findings of the patients before and after surgery. The defect was closed with either a running nonabsorbable suture or an autologous pericardial patch. Postoperatively, clinical status of the patients improved significantly. The mean NYHA functional class decreased from 2.8 +/- 0.4 to 1.5 +/- 1.1 [P < 0.001]. Postoperatively, mean right ventricle diameter was found regressed from 38.2 +/- 9.3 mm to 34.8 +/- 6.2 mm [P < 0.002] at a median interval of four months. The pulmonary artery pressures were also significantly decreased [p < 0.002]. The data provided by this study suggest that surgical repair of ASD improves functional status and relieves symptoms. Therefore, we suggest that ASDs that are unsuitable for transcatheter closure or requiring additional surgical intervention should undergo surgical repair to reduce subsequent morbidity and mortality, in patients including over 40 years of age

Management of constrictive pericarditis: a comparative study between median sternotomy and left thoracotomy

Constrictive pericarditis [CP] requires pericardiectomy but the choice of surgical approach remains controversial. Hence we have reviewed our experience of pericardiectomy carried out for CP and compared the results of pericardiectomy performed by median sternotomy versus left thoracotomy with regard to functional outcomes. The study group consisted of 33 patients with CP who underwent pericardiectomy from May 1999 to January 2010 at our institution. There were 22 female and 11 male patients, ranging in age from 5 to 57 years with a mean age of 45 years. Pericardiectomy was performed via median sternotomy in 17 patients [Group A]. In the remaining 16 patients [Group B], pericardiectomy was performed via a left anterolateral thoracotomy in the fifth intercostal space. During the subsequent follow-up, both groups of patients showed a similar and significant improvement in New York Heart Association [NYHA] functional class. In the group A, the mean NYHA functional class decreased from 3.3 +/- 0.7 to 1.8 +/- 0.5 [P = 0.0004]. In group B, the mean functional class decreased from 3.2 +/- 0.9 to 1.6 +/- 0.6 [P = 0.00005]. Also, both groups had a similar and significant improvement in their mean CVP. In the group A, the mean central venous pressure [CVP] decreased from 15.2 +/- 3.1 mmHg to 8.3 +/- 3.2 mmHg [P<0.005]. In the group B, the mean CVP decreased from 15.1 +/- 4.9 mmHg to 7.7 +/- 2.4 mmHg [P<0.004]. Constrictive physiopathology is a problem primarily of the ventricles and can be alleviated by decorticating both the right and left ventricles. Therefore, CP could be relieved through the left thoracotomy or median sternotomy in most cases. However, echocardiographic findings should be considered to prefer thoracotomy or sternotomy approach

Management of penetrating heart and accompanying lung injuries

Penetrating heart injury is potentially a life threatening condition due to cardiac tamponade or exsanguinating hemorrhage. The aim of this study was to evaluate victims who were referred to our hospital with penetrating heart and accompanying lung injuries and to review our overall outcome with this type of combined injuries. Twenty patients with combined penetrating heart and lung injuries were operated at Yuzuncu Yil University Research Hospital, between May 1999 and January 2010. The diagnosis of combined heart and lung injuries was proved by surgical exploration in all cases. The surgical procedures mainly included the relief of cardiac tamponade, control of bleeding, repair of cardiac and pulmonary lacerations, and coronary artery bypass grafting if required. In this series of 20 patients; there were 18 males and two females between the age of 14 to 60 years, with a mean age of 34.8 +/- 13.5 years. Seventeen victims sustained stab wounds, and the remaining three were injured by a gunshot wounds. In 20 patients there were 22 cardiac chamber injuries. The most commonly injured cardiac chamber was the right ventricle followed by the left ventricle. In addition to the injuries to heart muscle, injuries to the coronary arteries were found in two patients. The most commonly injured lung lobe was the left upper lobe. Our experience shows that early diagnosis and immediate surgical intervention are the main factors affecting patient survival after penetrating heart and lung injuries. Therefore, heart injury should always be kept in mind in victims with penetrating thoracic injuries

Renal cell carcinoma extending into the inferior caval vein: report of two cases

Renal cell carcinoma [RCC] is rare neoplasm and rarely extends to IVC. Perinephric and venous system invasion is an important prognostic sign for RCC. The tumor may grow intraluminally into the renal vein and Inferior Vena Cava [IVC] as an extension of primary tumor. In this report, we present two unusual case of venous system involvement, invasion of RCC into SVC. RCC with tumor thrombus extension into the IVC remains a difficult operative challenge. However surgical intervention should be performed. Our cases were successfully operated and their post operative recovery was uneventful

Association between the left atrial diameter and radiofrequency ablation procedure at restoring sinus rhythm [mid term and long term results]

Atrial fibrillation [AF] is the most common arhythmia type among other arythmias. In this study, we aimed to search the effect of left atrium diameter in AF treatment with radiofrequency ablation procedure. Preoperative left atrium diameter and postoperative sinus rhythm restoration was prospectively studied in 84 patients who had undergone valve surgery and radiofrequency [RF] ablation procedure in Department of Cardiovascular Surgery from January 2004 to March 2009. The patients were classified in two groups. Group-I consisted of the patients with left atrial diameter less than 5 cm, and Group II consisted of the ones whose left atrial size was more than 5cm. Normal sinus rhytm restoration was followed by electrocardiography [ECG]. ECG monitoring was done in early postoperative period, 12[th], 24[th] and 36[th] monthes following the operation. In early post-operative period normal sinus rhythm [NSR] was recorded in 34 patients [Group I: 20, Group II: 14] in which unipolar RFA was performed. Supraventricular tachycardia [SVT] was observed in 20 patients [Group I: 10, Group II: 10] and NSR was restored with medical treatment in these patients. AF was permanent in 26 patients [Group I: 8, Group II: 18] and nodal rhythm was observed in 4 patients [Group I: 2, Group II: 2]. The ECG monitoring was done in the patients in early postoperative period at 12[th], 24[th] and 36[th] monthes. Datas were evaluated with statistical studies, too. Radiofrequency [RF] ablation is a feasible, efficient and safe method for the treatment for Atrial fibrillation [AF]. In our study we found that left atrial diameter is an important factor in restoring sinus rhythm. However, AF treatment with extended left atrium is more difficult

Comparision of retroperitoneal and transperitoneal procedures in aortoiliac occlusive diseases

Comparision of transperitoneal [TP] and retroperitoneal procedures at the surgical treatment of aortiliac occlusive diseases [AIOD] was aimed in this study. Advantages and disadvantages of the procedures were also evaluated. From October 2003 to March 2009, 110 patients underwent aortic surgery. TP technique was performed to 50 patients and retroperitoneal[RP] technique was performed to 60 patients. Demographic datas, risk factors, peroperative and postoperative medical datas [24 parameters] were analyzed and compared between two groups. No statistically significiant difference was observed in demographic datas and risk factors. Five of eight operative parameters resulted in favor of RP procedure. Length of intensive care unit [ICU] stay [p<0.01] length of hospital stay [p<0.01], return of bowel functions [p<0.01], time of beginning oral feding [p<0.01], effort pain score [p<0.01] were significiantly different in RP group and, results were better than TP group. Pulmonary complications were analyzed as lesser in RP group [p=0.02] There was no statistically significant difference at the rest of complication datas [wound complications p=0.09, paralitic ileus p=0.14, re-operation p=0.46, 30 day mortality p=0.30]. Comparision of Medical datas showed that RP procedure is more advantegous than TP procedure at the surgical treatment of AIOD

Brachial plexus injury due to median sternotomy and lima harvesting

Brachial plexus injury is an unusual and under-recognised complication of coronary artery bypass grafting especially when internal mammary artery harvesting takes place. It is believed to be due to sternal retraction resulting in compression of the brachial plexus. Although the majority of cases are transient, there are cases where the injury is permanent and may have severe implications as illustrated in the accompanying case history. We investigated that injury to the brachial plexus was retrospectively assessed in the results of eight patients who underwent median sternotomy for open heart surgery. Between March 2006 and October 2008, 455 patients underwent cardiac surgery with median sternotomy. In post operative period peripheric neuropathy symptoms were observed in eight [1.7%] patients. All patients were placed in the hands up position after right internal jugular vein cannulation, and internal mammary artery was prepared for all those patients. The symptoms were classified as pain, sensory impairment and motor impairment. Brachial plexus injury was detected postoperatively in these eight patients. The patients with injured nerves were older and had undergone longer operation times. There were no differences between the patients with injured nerves and the others with respect to mammary artery harvesting or other operative variables. Full recovery occured in seven of eight [87%] patients after six monthes, one [13%] patient suffered from disesthesia. It is known that heart surgery sometimes causes partial brachial plexus injury, especially in the lower trunk. However, these peripheral nerve problems are usually not considered clinically important and are not investigated. Patients undergoing open heart surgery must be closely followed up for peripheral nerve injury during the postoperative period