Posterior pericardial ascending-to-descending aortic bypass for interrupted aortic arch in an adult.

Interrupted aortic arch (IAA) in the adult population is an extremely rare condition. In this case report, we present a 35-year old male patient with Type A interrupted aortic arch (IAA) and discuss the successful surgical treatment.

Effects of glucose-insulin-potassium solution on cardiac cytokines and enzymes.

OBJECTIVE: The aim of this study was to assess the effects of glucose-insulin-potassium (GIK) solution on intraoperative cardiac cytokines and cardiac enzymes in coronary artery bypass surgery patients. METHODS: The study group consisted of 49 patients with unstable angina who required urgent CABG. Patients were randomized to a GIK (n = 25) or a non-GIK (n = 24) group. The GIK group received 500 ml of 30 % dextrose solution, containing 100 IU insulin and 80 mEq of potassium, at a rate of 1 ml x kg (-1) x h (-1). The control group received an equivalent rate of 5 % dextrose. Serum cytokine levels were measured in blood samples obtained from coronary sinus blood samples. Cardiac enzymes such as creatinin kinase (CK), myocardial band of creatinin kinase (CK-MB) and Troponin-T were measured immediately after operation and at 6, 24 and 48 hours after operation. RESULTS: No patient in the two groups developed ECG or enzyme changes after surgery suggestive of acute myocardial infarction and myocyte damage. Interleukin-10 concentrations were greater in the GIK group (31.10 +/- 3.36) than in the non-GIK group (19.10 +/- 4.32) ( P < 0.05). CONCLUSION: We conclude that a GIK solution increases the serum cardioprotective interleukin-10 concentrations in CABG patients with unstable angina pectoris. We found no significant difference in any of the other parameters respecting myocyte damage.

Fifteen-year clinical experience with the biocor porcine bioprostheses in the mitral position.

BACKGROUND: Bioprosthetic valve use represents a crucial improvement in surgical treatment of mitral valve disease. The aim of this study is to determine the long-term durability of the Biocor porcine bioprosthetic mitral valve. METHODS: Between 1985 and 1989, a total of 158 Biocor porcine bioprosthetic valves were placed in the mitral position, and long-term results of these patients were investigated retrospectively in 1999. RESULTS: Thirty-day mortality was 4.4% (7 patients). Total follow-up was 1,499 patient-years. Actuarial survival was 83.66% +/- 3% at 5 years, 77.78% +/- 3.36% at 13 years (1.8% patient-year). Multivariate analysis demonstrated younger age, duration of implantation, congestive heart failure, and functional class to be significant predictors of late mortality. Actuarial freedom from valve-related mortality was 98.58% +/- 1% at 15 years (0.13% patient-year). Actuarial freedom from structural valve deterioration was 95.49% +/- 1.8% at 5 years, 70.2% +/- 4.12% at 10 years, and 64.82% +/- 5.34% at 13 years (2.6% patient-year). Actuarial freedom from structural valve deterioration-related reoperation was 98.43% +/- 1.1% at 5 years, 89.15% +/- 2.85% at 10 years, and 76.82% +/- 7.91% at 14 years. Multivariate analysis showed younger age and duration of implantation to be significant predictors of structural valve deterioration and its related reoperation. CONCLUSIONS: By studying a 15-year time period, it is seen that this new generation porcine bioprosthetic valve should be considered an alternative for mechanical valves in selected patients.

Is posterior leaflet preservation in the surgical treatment of rheumatic mitral insufficiency without left ventricular dysfunction necessary?

Preservation of the mitral valve leaflet and tensor apparatus during valve replacement is believed to maintain left ventricular performance. To determine the effect of posterior leaflet preservation in pure severe mitral insufficiency without left ventricular dysfunction 56 patients were operated on between 1993 and 2000. Twenty-three patients underwent mitral valve replacement with posterior chordal preservation and 33 patients underwent mitral valve replacement with chordal transection. Preoperative data in the both groups were similar. After 30days there were no mortalities observed. Dimensions of the left ventricle had significantly decreased within one group, but there was no difference in the other group. The improvement of the functional and cardiac performance in all patients was significant without any difference between the two groups. Actuarial freedom from death was not significantly different at 6yr (P=0.23). To preserve left ventricular function in pure severe mitral regurgitation without left ventricular dysfunction, mitral valve replacement is very effective with or without posterior leaflet preservation. But, it is difficult to suggest that posterior leaflet preservation alone can increase cardiac performance.

Location, size and morphological characteristics of left atrial thrombi as assessed by echocardiography in patients with rheumatic mitral valve disease.

AIMS: This study aimed to assess the use of transthoracic and transoesophageal echocardiography in diagnosing the thrombi located in the left atrium and/or left atrial appendage in patients with rheumatic mitral valve disease, and to investigate the characteristics of thrombi in comparison to intraoperative findings. METHODS AND RESULTS: The study group was comprised of 474 patients who underwent transthoracic and transoesophageal echocardiography prior to mitral valve surgery. Location, thickness and morphological characteristics of thrombi were determined by transoesophageal echocardiography. Intraoperative assessment disclosed left atrial thrombi in 105 patients. Thickness of thrombi < or = 1cm, and thrombi confined to left atrial appendage were associated with false-negative results by transthoracic echocardiography. However, diameter and morphological characteristics of thrombi, left atrial and left atrial appendage size, and the presence of the spontaneous echo contrast were not associated with the diagnosis of thrombi by transthoracic echocardiography. For overall left atrial thrombi, sensitivity and specificity of transthoracic echocardiography were 32%, and 94%, respectively. Sensitivity and specificity of transoesophageal echocardiography for thrombi in the left atrial appendage were 98%, and 98%, for thrombi in the main left atrial cavity were 81%, and 99%, and for thrombi located in both left atrium and appendage cavities were 100%, and 100%, respectively. CONCLUSION: In patients with rheumatic mitral valve disease, detection of left atrial thrombi by transthoracic echocardiography seems to be determined by thickness and location of thrombi. The multilobed structure of the left atrial appendage and artifacts over posterior wall of the left atrium may still prevent precise diagnosis even with transoesophageal echocardiography.

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.

Less invasive approaches for closed mitral commissurotomy.

OBJECTIVE: Recently, closed mitral commissurotomy (CMC) has been reexplored due to the concepts of less invasive valvular surgery. The feasibility of closed mitral commissurotomy via port access or limited thoracotomy by aid transesophageal echocardiography (TEE) was investigated in this clinical study. METHODS: Between August 1996 and April 1998, 42 patients (32 women, ten men with a mean age of 36.2+/-7.8 years) underwent less invasive CMC at the Kosuyolu Heart and Research Hospital. CMC procedure were done through a limited (12-16 cm) thoracotomy incision in 23 patients, a very limited or mini thoracotomy incision (7-8 cm) in 11 patients and port access by aid TEE in eight patients. Preoperative mean mitral valve area was calculated as 1.19+/-0.13 cm2 and mean mitral valve gradient was measured as 14.8+/-3.2 mmHg. TEE provided information about the mitral valve anatomy and functions during the procedure in all patients. RESULTS: Commissurotomy was successfully performed in all patients. In eight patients, a Tubbs dilator was inserted via port access at the 6th intercostal space from a 3-cm incision. Incision by guidance of TEE and CMC could be performed without thoracotomy in five patients. In three patients of the port access group, a very limited thoracotomy was required to perform CMC by digital guidance. Postoperative mean MVA was 2.37+/-0.29 cm2, minimal mitral gradient was 5.3+/-1.7 mmHg. In eleven patients, minimal mitral regurgitation was observed. The operations and postoperative period were free of complications in all patients. Following an average 12+/-2.8 h intensive care unit period, all patients were discharged after an average of 3.4+/-0.8 days of hospitalization. CONCLUSION: Limited thoracotomy has less detrimental structural effects in patients. Port access by aid TEE approach to CMC may offer less invasiveness, lower cost effectiveness and be an alternative to percutaneous balloon mitral valvotomy.

An uncommon complication of Behçet's disease: intracardiac thrombosis needing surgical treatment.

Behçet's syndrome is a multisystem disorder presenting with recurrent oral and genital ulcerations as well as uveitis often leading to blindness. Although vascular lesions are a common complication of this disease, cardiac involvement is extremely rare. In this unusual case a young man had symptoms primarily related to recurrent right-atrial and right-ventricular thrombi unresponsive to medical treatment. The intracardiac lesion was successfully treated by surgical excision with the use of cardiopulmonary bypass. Surgical treatment should be considered in Behçet's disease complicated by cardiac thrombi, when a thrombus recurs despite medical treatment.

Complete myocardial revascularization with left heart bypass without oxygenator on the beating heart.

BACKGROUND: Whereas the complete myocardial revascularization is necessary in high risk group patients, the CABG procedure on the beating heart on circumflex artery still presents a dilemma. METHODS: Between January 1994 and September 1996, we performed complete myocardial revascularization with left heart bypass in 62 patients (54 male, 8 female, mean age: 57) who had absolute or relative contraindications for CPB. RESULTS: The hospital mortality was 3.2%, late mortality was 1.6%. Peroperative MI was seen in 2 patients (3.2%). The mean number of distal anastomosis was 3.6 (ranged 2-6). CONCLUSION: Complete myocardial revascularization on the beating heart can be performed by using left heart bypass (LHBP) without using an oxygenerator safely in high risk patients.

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.

Surgical treatment of left-atrial myxoma in Carney's complex.

Although rare, cardiac myxomas are the most frequently encountered primary neoplasms of the heart. Cardiac myxomas are typically sporadic, benign, non-recurrent tumors, and they are usually seen in the left atrium. Patients who have myxoma-associated spotty pigmented skin lesions, endocrine neoplasms with overactivity, and noncardiac myxomatous tumors are said to have Carney's complex. This report presents a 21-year-old woman with Carney's complex. She was operated for tetralogy of Fallot and total correction was performed at another center when she was three years old. Two years ago, she was operated on for a primary pigmented nodular adrenocortical tumor and bilateral adrenalectomy was performed. Her present admission to our clinic was for left-atrial myxoma with associated symptoms. Patients with Carney's complex have distinctive clinical features which separate them from the larger group of patients with the more common sporadic myxoma. The most important distinction is that the myxoma syndrome appears to be a multisystem disease.