Intravenous thrombolytic treatment of mechanical prosthetic valve thrombosis: a study using serial transesophageal echocardiography.

OBJECTIVE: We analyzed the results of intravenous thrombolytic treatment under transesophageal echocardiographic (TEE) guidance in prosthetic valve thrombosis. BACKGROUND: Thrombotic occlusion of prosthetic valves continues to be an uncommon but serious complication. Intravenous thrombolytic treatment has been proposed as an alternative to surgical intervention. METHODS: In a four-year period, 32 symptomatic patients with prosthetic valve related thrombosis underwent 54 thrombolytic treatment sessions for the treatment of 36 distinct episodes. All patients had low international normalized ratio values at the presentation. Transesophageal echocardiography was performed at baseline and repeated after each thrombolytic treatment session (total 98 TEE examinations). Streptokinase was used as the initial agent with a repeat dose given within 24 h when necessary. Recurrent thrombosis was treated either with tissue plasminogen activator or urokinase. RESULTS: The initial success after first dose was only 53% (17/32) but increased up to 88% (28/32) after repeated thrombolytic sessions upon documentation of suboptimal results on TEE examination (p < 0.01). In addition, four asymptomatic patients with large thrombi were also successfully treated with single infusion. The TEE characteristics of thrombus correlated with clinical presentation and response to lytics. Success was achieved with single lytic infusion in 40% of the obstructive thrombi as compared with 75% of the nonobstructive ones (p < 0.05). The success rates of lytic treatment were similar for mitral versus aortic valves, and for tilting disk versus bileaflet valves. Rapid (3 h) and slow (15 to 24 h) infusion of streptokinase resulted in similar success rates. However, major complications (three patients) occurred only in the rapid infusion group. CONCLUSION: In patients with prosthetic valve thrombosis, intravenous slow infusion thrombolysis given in discrete, successive sessions guided by serial TEE and transthoracic echocardiography can be achieved with a low risk of complications and a high rate of success.

Simultaneous surgical intervention to coronary artery disease, peripheral arterial disease and superior mesenteric artery stenosis.

A patient, suffering from angina pectoris, claudicatio intermittens and postprandial abdominal pain underwent coronary and peripheral arteriographic examination; coronary arterial disease and aortoiliac occlusive disease was diagnosed. Color Doppler ultrasonography revealed superior mesenteric artery stenosis. CABG with MIDCAB (minimal invasive direct coronary artery bypass) technique was performed together with aortabifemoral graft interposition and graft bypass to superior mesenteric artery and considerable success was obtained.

Surgical repair in ruptured congenital sinus of Valsalva aneurysms: a 13-year experience.

BACKGROUND AND AIM OF THE STUDY: Rupture of congenital sinus of Valsalva aneurysm is a rare cardiac malformation that usually causes reduced cardiac performance. METHODS: Twenty patients (mean age 28.3 +/- 10.7 years; range: 14 to 55 years) with rupture of congenital sinus of Valsalva aneurysm were operated on at our institution between January 1985 and March 1999. The origin of the ruptured aneurysms was the right coronary sinus in 18 patients (90%) and the non-coronary sinus in two (10%). No ruptures were observed originating from the left coronary sinus. The aneurysms ruptured into the right ventricle in 14 patients (70%), into the right atrium in five (25%), and into the left ventricle in one patient (5%). Subarterial ventricular septal defect (VSD) was the most common associated defect (30%), and aortic insufficiency the second (20%). No correlation was found between subarterial VSDs and aortic insufficiency (p > 0.05). To achieve repair, the aorta and cavity into which the aneurysm had ruptured were opened. The aneurysmal sac was excised and the defect closed with a patch in 18 patients, and without patch in two. RESULTS: One patient died in hospital (mortality rate 5%); no late mortality was observed. Surviving patients were followed up for 4.4 +/- 3.3 years (range: 1 to 13 years). The actuarial survival rate was 95% at 12.35 years. Recurrence of fistula was observed in one patient (5%) in whom the ruptured aneurysm had been closed by primary suture without the use of a patch. At 12.35 years, the actuarial freedom from recurrence of fistula was 94.74% for all survivors, and 100% for patients with patch closure. No late complications have been observed. CONCLUSIONS: Following diagnosis of ruptured sinus of Valsalva aneurysm, surgical repair is the treatment of choice. Surgery performed as rapidly as possible after diagnosis in general leads to an excellent outcome.

Three ventriculoplasty techniques applied to three left-ventricular pseudoaneurysms in the same patient.

A 59-year-old male patient underwent surgery for triple-vessel coronary artery disease and left-ventricular aneurysm in 1994. Four months after coronary artery bypass grafting and classical left-ventricular aneurysmectomy (with Teflon felt strips), a left-ventricular pseudoaneurysm developed due to infection, and this was treated surgically with an autologous glutaraldehyde-treated pericardium patch over which an omental pedicle graft was placed. Two months later, under emergent conditions, re-repair was performed with a diaphragmatic pericardial pedicle graft due to pseudoaneurysm reformation and rupture. A 3rd repair was required in a 3rd episode 8 months later. Sternocostal resection enabled implantation of the left pectoralis major muscle into the ventricular defect. Six months after the last surgical intervention, the patient died of cerebral malignancy. Pseudoaneurysm reformation, however, had not been observed. To our knowledge, our case is the 1st reported in the literature in which there have been 3 or more different operative techniques applied to 3 or more distinct episodes of pseudoaneurysm formation secondary to post-aneurysmectomy infection. We propose that pectoral muscle flaps be strongly considered as a material for re-repair of left-ventricular aneurysms.

Coronary bypass grafting via minithoracotomy on the beating heart.

BACKGROUND: Recently the availability and the superiority of less invasive coronary artery bypass grafting on some selected groups of patients in the meaning of patient comfort and short hospital stay has been shown by some authors. We present here the clinical results of 40 patients operated on by minithoracotomy incision on the beating heart without using cardiopulmonary bypass mostly harvesting the left internal thoracic artery by videothoracoscopic assistance. METHODS: Between March 1996 and September 1996, 40 patients were operated on by harvesting the left internal thoracic artery mostly by video-assisted thoracoscopy and performing bypass through a minitoracotomy incision. Two patients in whom the procedure was switched to conventional technique were not included in this series. Nine of the patients were female and the rest were male. The mean age was 43.2 +/- 7. RESULTS: Left internal thoracic arteries were harvested by video-assisted thoracoscopy completely in 11 patients, incompletely in 24 patients (the harvesting was completed by direct vision afterwards), and under direct vision in 5 through a mini-anterior thoracotomy incision. Thirty-six patients received a bypass graft to left anterior descending coronary artery only, whereas 4 received a diagonal branch graft also. Left internal thoracic arteries were used to bypass the left anterior descending coronary artery directly in 38 patients. The left internal thoracic artery was injured in the middle portion during harvesting in 1 of the remaining 2 patients. The length was not enough in the other. A short saphenous vein graft was interposed between the left internal thoracic artery and the left anterior descending coronary artery in these 2 patients. There was no mortality. One patient had perioperative myocardial infarction. We did not see serious morbidity except one lung injury due to the trochar. CONCLUSIONS: The results obtained from our experience suggest that coronary artery bypass grafting by minithoracotomy could be applied effectively and safely without overwhelming additional risk to the patient. Furthermore, it has some advantages in reducing operative trauma and cost and also improving patient comfort.

Congenital sinus of valsalva aneurysm dissecting into the interventricular septum with left ventricular communication.

In this report we describe a case of a right coronary sinus of Valsalva aneurysm dissecting into the interventricular septum with spontaneous rupture into the left ventricle. Sufficient information was provided by echocardiography, cardiac catheterization, and aortography to confirm the diagnosis. Surgical findings were in complete accordance with cross-sectional and color flow Doppler imaging by transthoracic and transesophageal approaches.