The effects of showering in 48-72 h after coronary artery bypass graft surgery through median sternotomy on wound infection, pain, comfort, and satisfaction: randomized controlled trial.

AIMS: Time of showering after surgery is still a controversial issue for surgical patients and health professionals. We evaluated the effects of showering in 48-72 h after median sternotomy on sternal wound infections, pain due to sternotomy, patient comfort, and satisfaction levels. METHODS AND RESULTS: The study was a randomized controlled clinical trial. Fifty-one patients were randomly allocated (1:1) to the shower (n = 26) or non-shower group (n = 25). The patients in the shower group (intervention group) showered in the first 48-72 h after surgery and the patients in the non-shower group (control group) were not allowed to shower until their chest tube sutures were removed. They were instructed to shower on the next day after removal of the chest tube sutures. The rate of sternal wound infections was significantly lower in the shower group (n = 2, 7.7%) than in the non-shower group patients (n = 8, 32.0%; P = 0.038). A logistic regression analysis showed that early post-operative showering was protective and significantly reduced the risk of sternal wound infections independently of other variables [odds ratio (OR): 0.177; 95% confidence interval (CI): 0.033-0.940; P = 0.042]. The pain severity score was significantly lower in the shower group patients. Also, comfort and satisfaction scores were significantly higher in this group (P < 0.05). CONCLUSION: Early showering after sternotomy was found to be protective against sternal wound infections and had a positive effect on pain, comfort, and satisfaction. TRIAL REGISTRATION: Clinical Trials.gov registration number NCT04250961 (https://clinicaltrials.gov/ct2/show/NCT04250961).

Unilateral or bilateral cerebral perfusion in hemiarch replacement: A prospective randomized study.

BACKGROUND: We designed a prospective randomized clinical study to compare unilateral and bilateral antegrade cerebral perfusion (ACP) under moderate hypethermia in open distal aortic hemiarch replacement in ascending aortic aneurysm. METHODS: Forty-two patients were prospectively randomized into two groups; unilateral ACP to Group 1 and bilateral ACP to Group 2. Inclusion criteria were pathological aortic aneurysm in the ascending aorta and/or aortic arch, elective operation, normal preoperative carotid Doppler ultrasonography, and nonexistence of preoperative neurological event. Patients were evaluated with preoperative and postoperative biochemical blood analysis, magnetic resonance imaging (MRI), and neurological disorders. The primary endpoints were permanent neurological disorder and death. RESULTS: There were 21 patients in each group. Mean age was 56.57 ± 10.06 years in Group 1 and 50.95 ± 15.64 years in Group 2 (p = .170). No significant difference was found according to demographic data. ACP times were significantly higher in bilateral ACP (Group 1: 12.62 ± 5.04 min, Group 2: 18.23 ± 9.04 min, p = .018) whereas cross-clamp time and cardiopulmonary bypass times were not (p = .693 and p = .584 sequentially). Transient neurological disorder was found in seven patients in Group 1 and in 4 patients in Group 2 (p = .484). Postoperative MRI revealed new milimetric ischemic zones in three patients in Group 1 but none in Group 2. No permanent neurological disorder or mortality was seen. CONCLUSION: The present randomized clinical prospective study could not prove the superiority of one of the technique in cerebral protection probably because, our overall ACP time was too short.

Prosthetic valve endocarditis: A challenging complication of prosthetic valves.

BACKGROUND: This study aims to evaluate the surgical outcomes of prosthetic valve endocarditis. METHODS: A total of 21 patients (6 males, 15 females; mean age 58.9±12.6 years; range, 33 to 79 years) who were surgically treated for prosthetic valve endocarditis between January 2013 and January 2018 were retrospectively analyzed. Surgical indications included persistent fever for more than seven days after antibiotherapy, congestive heart failure refractory to medical treatment, vegetations larger than 1 cm on echocardiography, the presence of fungal endocarditis, severe valvular leak and valvular dysfunction, and staphylococcal prosthetic valve endocarditis. RESULTS: Five patients had previous aortic valve replacement and three of the aortic prostheses were re-replaced. Two patients had coexisting native mitral valve endocarditis and double valve replacement was done. Thirteen patients had previous mitral valve replacement and 12 of the mitral prostheses were re-replaced. One patient had coexisting native aortic valve endocarditis and double valve re-replacement was done. Three patients had previous aortic valve replacement + mitral valve replacement. Mitral valve endocarditis was diagnosed in two patients and these patients had only mitral valve re-replacement. The other patient had double valve endocarditis, and double valve replacement was done. The mean time from the first operation to the development of endocarditis was 7.3±5.7 years. Of five lost patients, two died from multiple organ failure, one from low cardiac output, one from pneumonia, and one from respiratory failure. CONCLUSION: Radical resection of the infected tissues is critical to achieve favorable surgical outcomes. Single valve replacement of the infected valve may be preferred in patients having previous double valve replacement. Mechanical valves or bioprostheses can be used for re-replacement procedures.

Surgically Treated Pelvic Pain Caused by Nutcracker Syndrome and Worsened by Cockett Syndrome in a Child.

Nutcracker syndrome is rarely seen in the young. Most of the symptoms regress during follow-up. Rarely surgical intervention is necessary. This case presentation is unique for being the first case of nutcracker syndrome and coexistent Cockett syndrome that is treated with surgical intervention.

Effects of endovenous laser ablation on vascular tissue: molecular genetics approach.

BACKGROUND: Endovenous laser ablation (EVLA) is a treatment option for lower extremity varicose veins. In the present study, we investigate to the genetic changes and possibility of living tissue in the saphenous vein wall after the EVLA procedure. METHODS: Eleven saphenous vein grafts were randomized in two groups: (1) 4 cm SVG segments of performed EVLA procedure in study group, (2) 4 cm segments of SVG none performed EVLA procedure in control group. SVG were taken from the remnants of distal saphenous vein grafts prepared for the bypass procedure but not used. SVG was approximately 8 cm in length and was divided into two parts 4 cm in length. One half was exposed to laser energy, while the other half of the same vein graft was untreated as a control. EVLA was performed on complete saphenous veins in the study group. Abnormal genetic changes of the SVG were observed with a Tri-Reagent method and quantified with a Nanodrop™ spectrophotometer. RESULTS: Histopathological changes indicated that the intima including the endothelium was completely necrotized in the study group. It was observed that intimal thermal-energy-induced injury did not reach the media. Histopathological examination showed that homogenous eosinophilic discoloration and coagulation necrosis characterized the laser related thermal damage as well. CONCLUSIONS: In this preliminary study, we found that living tissue remained in the SVG wall after application of laser ablation, and we also detected abnormal genetic changes in the study group compared with the control group.

Surgical treatment of giant cardiac aneurysm with pseudoaneurysm in a colon carcinoma patient.

Left ventricular pseudoaneurysm is a rare and lethal condition associated with a high risk of rapid enlargement and rupture. It develops after transmural myocardial infarction (MI), cardiac surgery, trauma, or infection. When a left ventricular pseudoaneurysm is detected, surgical repair is recommended due to the high possibility of rupture. In this report, we present surgical treatment of a giant cardiac pseudoaneurysm that occurred after MI in a colon carcinoma patient.

Bileaflet versus posterior-leaflet-only preservation in mitral valve replacement.

In the present study of mitral valve replacement, we investigated whether complete preservation of both leaflets (that is, the subvalvular apparatus) is superior to preservation of the posterior leaflet alone. Seventy patients who underwent mitral valve replacement in our clinic were divided into 2 groups: MVR-B (n=16), in whom both leaflets were preserved, and MVR-P (n=54), in whom only the posterior leaflet was preserved. The preoperative and postoperative clinical and echocardiographic findings were evaluated retrospectively. No signs of left ventricular outflow tract obstruction were observed in either group. In the MVR-B group, no decrease was observed in left ventricular ejection fraction during the postoperative period, whereas a significant reduction was observed in the MVR-P group (P=0.003). No differences were found between the 2 groups in their need for inotropic agents or intra-aortic balloon pump support, or in cross-clamp time, duration of intensive care unit or hospital stays, postoperative development of new atrial fibrillation, or mortality rates. Bileaflet preservation prevented the decrease in left ventricular ejection fraction that usually followed preservation of the posterior leaflet alone. However, posterior leaflet preservation alone yielded excellent results in terms of decreased left ventricular diameter. Bileaflet preservation should be the method of choice to prevent further decreases in ejection fraction and to avoid death in patients who present with substantially impaired left ventricular function.

Unexpected cause of cyanosis and dyspnea in an adult: direct communication of the right pulmonary artery and left atrium.

Direct communication of the right pulmonary artery and the left atrium is an extremely rare congenital malformation of the pulmonary vasculature. A 41-year-old woman with a history of cyanosis since childhood presented with mild exertional dyspnea. On physical examination, she had central cyanosis, clubbing of the fingers, and an upright position caused by orthodeoxia. Imaging studies showed a very large aneurysm in the distal right pulmonary artery with a direct communication to the left atrium. The patient underwent successful repair, with resolution of hypoxia and exertional symptoms.

Proximal aortic arch cannulation for proximal ascending aortic aneurysms.

INTRODUCTION: Different arterial inflow sites have been reported to date for particularly challenging cardiac operations. The ascending aorta, femoral artery, and subclavian artery are the most commonly used sites. Although its use has been reported, the aortic arch has not gained popularity in the performance of cannulation. According to a search performed in the PubMed database, aortic arch cannulation for ascending aorta replacement has not been examined in a separate study before. In the present study, we report the treatment outcomes of patients with ascending aortic aneurysms in whom the aortic arch was cannulated for arterial inflow. MATERIAL AND METHODS: Twenty-seven patients with aneurysmal dilatation of the ascending aorta underwent ascending aorta replacement from April 2010 to March 2013. The mean age of the patients was 64 years. All operations were carried out by cannulating the aortic arch distally from the origin of the innominate artery. RESULTS: There was no mortality or cannulation-related morbidity. In 23 patients, only the supracoronary ascending aorta was replaced, whereas in 4 patients, the button modification of the Bentall procedure was performed to replace the root and the ascending aorta. CONCLUSIONS: The technique of aortic arch cannulation distal to the origin of the innominate artery is worthy of consideration in the treatment of aneurysms limited to the ascending aorta due to its safety, simplicity, and low morbidity.

A good surgical option for ischemic mitral regurgitation in co-morbid patients: semicircular reduction annuloplasty.

BACKGROUND: Ring annuloplasty is the standard treatment of ischemic mitral regurgitation (MR), however, it has been associated with some drawbacks. It abolishes normal annular dynamics and freezes the posterior leaflet. In the present study, we evaluated Paneth suture annuloplasty in chronic ischemic MR and both early and mid-term outcomes of the technique on a selected population. METHODS: The study period was from June 2010 to June 2012. We operated on 21 patients who had the diagnosis of coronary artery disease and MR of grade 3 or 4. The patients had both a coronary artery bypass operation and the mitral semicircular reduction annuloplasty described by Paneth-Burr. The data on the patients were retrospectively collected. Patients were contacted by outpatient clinic controls for mid-term results. RESULTS: The male/female ratio was 10/11. The mean age of the patients was 71.0 ± 6.4 years. Preoperative and postoperative left ventricular ejection fraction was statistically similar (P = 0.973). Early postoperative MR grade (mean, 0.57 ± 0.51) was statistically lower than the preoperative MR grades (mean, 3.38 ± 0.50) (P < 0.001). There was no revision for excess bleeding. Two patients had prolonged hospitalization, one for sternal infection and the other for severe chronic obstructive pulmonary disease. No hospital or late postoperative deaths occurred. The mean late postoperative MR grade was 0.66 ± 0.97 degrees. One patient had progression of MR in the later follow-up, which was treated by mitral valve replacement. CONCLUSION: Semicircular reduction annuloplasty is an effective, inexpensive and easy surgical annuloplasty technique with low mortality and morbidity in severe symptomatic ischemic MR.

Surgical pitfalls of minimally invasive direct coronary artery bypass procedure from the viewpoint of a surgeon in the learning curve.

INTRODUCTION: Minimally invasive direct coronary artery bypass grafting (MIDCAB) offers arterial revascularization of the left anterior descending (LAD) coronary artery especially in lesions unsuitable for percutaneous coronary interventions. By avoidance of sternotomy and cardiopulmonary bypass its invasiveness is less than that of conventional bypass surgery. AIM: We in this study discuss our surgical experience in the MIDCAB procedure. MATERIAL AND METHODS: Thirteen patients were operated on with the MIDCAB procedure. The inclusion criteria for MIDCAB were pure LAD disease totally occluded or severely stenotic. Patient demographics and preoperative and postoperative data were analyzed. RESULTS: Mean age of the patients was 60.0 ±8.6 years. Patients' preoperative and postoperative levels of cardiac CK-MB (creatine kinase MB) were not significantly different (p = 0.993). However, cardiac troponin I (p < 0.001), hemoglobin (p < 0.001) and hematocrit (p < 0.001) were significantly different. No perioperative myocardial infarctions or cerebrovascular accidents were seen. The patients were discharged at a mean day of 4.77 with oral antiaggregant therapy. No mortality was seen in the study population. CONCLUSIONS: Minimally invasive direct coronary artery bypass is associated with few perioperative complications. Minimally invasive direct coronary artery bypass in our experience is a very good option for single vessel LAD disease.

[Subclavian-carotid transposition for subclavian artery stenosis causing recurrent brachial artery embolism: case report]. / Tekrarlayan brakiyal arter embolisi olusturan subklavyen arter stenozunda subklavyo-karotid transpozisyon: Olgu sunumu.

Subclavian artery stenosis represents a relatively lower rate for upper extremity emboli source. Subclavian artery stenosis with thrombus localized distal to the stenosis was diagnosed on the arteriography of a patient who had a history of three previous brachial artery embolectomies. In this report, a case with subclavian artery stenosis causing recurrent brachial artery embolism who was successfully treated using subclavian-carotid transposition is presented.

Ruptured profunda femoris aneurysm secondary to neurofibromatosis: vascular involvement in an unusual location.

Neurofibromatosis is an autosomal dominant genetic disease characterized by abnormal growth that involves tissues of mesodermal and neuroectodermal origin. Aneurysms are rarely seen in peripheral arteries. This report presents a case of ruptured arterial aneurysm secondary to neurofibromatosis; the lesion occurred in the profunda femoris artery, a highly unusual location. Treatment of patients with ruptured arterial aneurysm secondary to neurofibromatosis may be interventional or surgical. In this case, a surgical approach was successful.

Retroperitoneal approach via paramedian incision for aortoiliac occlusive disease.

Aortoiliac occlusive disease is a frequently encountered occlusive arterial disease. Different surgical approaches to the infrarenal abdominal aorta have been reported. We retrospectively studied the postoperative outcomes of patients who were treated for aortoiliac occlusive disease via a retroperitoneal versus a transperitoneal surgical approach.From January 2005 through May 2009, 47 patients underwent surgery at our hospital for the correction of aortoiliac occlusive disease: 30 via a paramedian incision and retroperitoneal approach, and 17 via a midline sternotomy and transperitoneal approach. In the retroperitoneal group, the surgical procedures involved iliofemoral bypass in 15 patients, aortofemoral bypass in 12, aortoiliac bypass in 2, and aortobifemoral bypass in 1. All 17 patients in the transperitoneal group underwent aortobifemoral bypass. The preoperative characteristics and perioperative data of the patients were analyzed. We believe that the retroperitoneal aortoiliac approach with a paramedian incision may be considered as a surgical option for aortoiliac revascularization.

Which is first: left anterior descending artery anastomosis or right coronary artery anastomosis in off-pump coronary artery bypass grafting?

OBJECTIVES: The sequence of the distal anastomosis for revascularization in off-pump coronary artery bypass grafting (OPCABG) surgery is under debate. The hypothesis in this study was that an analysis of cardiac markers would reveal that anastomosing the left anterior descending coronary artery (LAD) before the right coronary artery (RCA) would decrease myocardial damage in OPCABG surgery for 2-vessel disease. METHODS: Forty patients with stable angina who underwent OPCABG surgery and who had LAD and RCA lesions were randomized into 2 groups of 20 patients each. The LAD was revascularized first in group 1, and the RCA was revascularized first in group 2. Cardiac troponin I, creatine kinase (CK), and CK myocardial band (CK-MB) were measured in the 2 groups before surgery and at 8, 24, and 48 hours after surgery. RESULTS: No mortality occurred in the 2 groups. The groups were similar with respect to sex, age, durations of anastomosis of the left internal thoracic artery to the LAD and of the saphenous vein graft to the RCA, and preoperative CK, CK-MB, and troponin I levels. Postoperative CK-MB levels were significantly higher in group 2 in the eighth and 24th postoperative hours than in group 1 (P = .009 and .041, respectively). Similarly, troponin I levels were significantly higher in group 2 in the eighth, 24th, and 48th hours than in group 1 (P = .003, .003, and .006, respectively). CONCLUSIONS: Anastomosis to the LAD first in OPCABG surgery led to a slight reduction in myocardial enzyme release against the occlusion of the target vessels during anastomoses in patients with RCA and LAD stenoses.

Iloprost and pentoxifylline attenuate ischemia-reperfusion injury in skeletal muscle in rabbit model.

BACKGROUND: We investigated the effects of iloprost and pentoxifylline on skeletal muscle ischemia-reperfusion injury in a rabbit model. METHODS: Forty New Zealand white rabbits were grouped into four. In Group 1, iloprost was continuously infused starting half an hour before the reperfusion following a 2-hour ischemia formed by abdominal aortic occlusion, and it was continued during the 4-hour reperfusion period. Group 2 was treated with pentoxifylline, and Group 3 received saline solution. Group 4 was the sham group. Malondialdehyde levels and edema scores in gastrocnemius muscle were evaluated. RESULTS: Edema score was significantly lower in Group 1 when compared with the control group (Group 1 vs Group 3, p=0.040; Group 2 vs Group 3, p=0.145; Group 1 vs Group 2, p=0.580). Malondialdehyde levels of the medicated groups were significantly lower when compared with the control group (Group 1: 60+/-11 nmol/g tissue, Group 2: 74+/-11 nmol/g tissue, Group 3: 95+/-10 nmol/g tissue; Group 1 vs Group 2, p=0.010; Group 1 vs Group 3, p<0.001; Group 2 vs Group 3, p<0.001; Group 1 vs Group 4, p<0.001; Group 2 vs Group 4, p<0.001; Group 3 vs Group 4: p<0.001). CONCLUSION: Acute skeletal muscle ischemia is a common problem. We are of the opinion that in the early phase of skeletal muscle ischemia, iloprost and pentoxifylline medication may reduce ischemia-reperfusion injury.