Posterior pericardial annuloplasty in ischemic mitral regurgitation.

BACKGROUND: Ischemic mitral regurgitation (IMR) is an important risk factor in coronary artery bypass grafting (CABG) operations. The decision to perform concomitant mitral annuloplasty along with the CABG depends on the surgeon's choice. The aim of this study was to evaluate the results of posterior annuloplasty procedures with autologous pericardium performed in patients with midadvanced and advanced functional ischemic mitral regurgitation. METHODS: Study participants were 36 patients with IMR (mean age 59 +/- 10 years) who underwent posterior pericardial annuloplasty and CABG operations between 2002 and 2007. Preoperative and postoperative (mean follow-up 18 +/- 1 months) MR grade, left atrium diameter, left ventricle end systolic diameter, left ventricle end diastolic diameter, left ventricle ejection fraction, and mitral valve gradients were measured with transthoracic echocardiography. RESULTS: There was one late mortality (2, 8%) but none of the patients required reoperation for residual MR. We did not observe thromboembolism, bleeding, or infective endocarditis. The mean MR grade decreased from 3.4 +/- 0.5 to 0.5 +/- 0.6 (P < .01), left atrium diameter decreased from 45.3 +/- 5.5 mm to 43.2 +/- 3.8 mm (P < .01), left ventricle end diastolic diameter decreased from 53.2 +/- 5.6 mm to 50.9 +/- 5.5 mm (P < .01), and left ventricle end systolic diameter decreased from 39.7 +/- 5.8 mm to 34.6 +/- 6.5 mm (P < .01), whereas mean left ventricle ejection fraction increased from 37.9% +/- 6.1% to 43.7% +/- 7.3% (P < .01). In the late postoperative term, the functional capacity of the patients increased from mean New York Heart Association class 2.6 +/- 0.9 to 1.1 +/- 0.5. We did not observe any gradient in the mitral valve preoperatively in any patient, but in the follow-up, the mean gradient increased to 1.3 +/- 2.1 mmHg (P < .01). CONCLUSION: Posterior pericardial annuloplasty with CABG in the treatment of IMR provides efficient mitral repair and significant decrease in the left atrium and left ventricle diameters, and provides a significant increase in left ventricular function. These results show IMR to be as effective as the other annuloplasty techniques. IMR is performed with autologous material and therefore does not entail any risk of complications from prosthetic material and is highly cost-effective.

Fenestration between the left atrial appendage and left superior vena cava in Kawashima operation.

The benefits of a baffle fenestration in essentially high-risk Fontan patients have been demonstrated. Described here is the use of a new fenestration between the left atrial appendage and the left superior vena cava after Kawashima operation in a patient with a double-outlet right ventricle with hypoplastic left ventricle, left atrial isomerism, bilateral superior vena cavae with no bridging vein, an interrupted inferior vena cava, and continuation of the hemiazygos vein to the left superior vena cava.

Complete transection of epicardial pacing lead during pregnancy.

Herein, we presented a case of pregnancy associated complete transection of epicardial pacing lead.

Pulmonary effects of noninvasive ventilation combined with the recruitment maneuver after cardiac surgery.

BACKGROUND: The aim of our study was to evaluate the pulmonary effects of noninvasive ventilation (NIV) with or without recruitment maneuver (RM) after open heart surgery. METHODS: One-hundred patients undergoing coronary artery bypass surgery were randomized into four groups after the operation: 1) RM with sustained inflation during mechanical ventilation postoperatively (RM group, n = 25); 2) RM combined with NIV applied for 1/2-h periods every 6 h in the first postoperative day after tracheal extubation (RM-NIV group, n = 25); 3) NIV after tracheal extubation (NIV group, n = 25); and 4) a control group consisting of patients receiving neither RM nor NIV (control group, n = 25). Pulmonary function tests, oxygenation index, and atelectasis on chest radiograph were evaluated and compared among the groups. RESULTS: RM provided higher arterial oxygen levels during mechanical ventilation and after tracheal extubation compared to other interventions. Oxygenation was better in the RM-NIV and NIV groups than in the control group (P = 0.02 and P = 0.008, respectively) at the end of the study. The postoperative atelectasis score of the control group (median: 1) was higher than those of the RM (1; P = 0.03), RM-NIV (0; P < 0.01) and NIV (0; P < 0.01) groups. Pulmonary function of the NIV groups on postoperative day 2 was better than in the other groups, whereas the tests were similar among the groups on postoperative day 7. CONCLUSIONS: NIV associated with RM provided better oxygenation both during and after the mechanical ventilation period. NIV either alone or in combination with RM provided lower atelectasis scores and better early pulmonary function tests compared to the control group, without a significant difference regarding the duration of mechanical ventilation, intensive care unit stay, and the length of hospitalization. NIV combined with RM is recommended after open heart surgery to prevent postoperative atelectasis and hypoxemia.

Interventricular hydatid cyst imitating pulmonary stenosis.

Cardiac hydatid cyst is known to be a rarely occurring disease. The appearance of large cysts in the interventricular septum in childhood is even more rare. Although such cysts are usually asymptomatic, they can behave like valvular disorders, depending on their location. In addition, cardiac hydatid cysts originating from the interventricular septum carry the risk of rupturing into both ventricular cavities, which may lead to fatal complications. Thus, early surgical treatment is of extreme importance. We describe the case of a 7-year-old girl with a cardiac hydatid cyst that originated in the interventricular septum.

Iatrogenic thrombosis on the tendinous cords of the tricuspid valve.

Iatrogenic thrombosis within the heart is rare following intracardiac operations. We undertook surgery to correct a 30-month-old girl with Fallot's tetralogy. After a period of 6 months following the operation, echocardiography revealed a thrombus measuring 16 by 12 millimetres attached to the tendinous cords supporting the antero-superior leaflet of the tricuspid valve. Medical treatment having failed, we proceeded to surgical excision so as to avoid pulmonary embolisation. Histological examination confirmed the thrombotic nature of the mass.

Sinus of Valsalva aneurysm: surgical approaches to complicated cases.

BACKGROUND: The authors herein report surgical experience with the aneurysms of sinus of Valsalva (SVA) complicated by coexisting pathologies. METHODS: Eight patients aged between 11 and 55 years underwent surgical repair of SVA. The aneurysms originated from the right coronary sinus in four patients, from the non-coronary sinus in four patients and from the left in one patient (one patient had aneurysms originating from both the left and right sinuses). Six of the aneurysms were ruptured into the right atrium (n = 3), right ventricle (n = 2) and left ventricle (n = 2). Aortic insufficiency (AI; n = 3), ventricular septal defect (n = 2), atrial septal defect (n = 4), Marfan's syndrome (n = 2), pulmonary stenosis (n = 1) and aortic stenosis (n = 1) were the coexisting anomalies. Double-chamber exposure (right atrial/ventricle and aortic) was used in all of the patients. Patch closure was preferred for defect closure. In three patients with AI, valve replacement was necessary. Two patients with endocarditis in New York Heart Association classes III-IV underwent urgent operation. RESULTS: The patient with annular narrowing was the only in-hospital death due to severe infection. The survivors were followed up for 85 months (range: 6-156 months). In two patients with Marfan's syndrome reoperation was necessary. All the surviving patients were asymptomatic with no unfavourable consequences. CONCLUSIONS: Although SVA can be treated successfully with low operative risk, the factors that influence patient outcome include infective endocarditis, Marfan's syndrome and the preoperative functional status of the patient.

Successful repair of a large aortic abscess causing apical displacement of the anterior mitral valve.

Anatomic continuity between the anterior mitral leaflet and the aortic root may predispose those patients with aortic root pathology to functional changes of the mitral valve without any involvement of this valve. A 34-year-old man presented with aortic valve endocarditis. Transthoracic echocardiograpy showed severe aortic regurgitation with a large aortic root abscess. The anterior leaflet of the mitral valve was displaced towards the apex of the heart causing moderate mitral regurgitation. The patient underwent aortic valve replacement with reconstruction of the aortic annulus and ventriculoaortic continuity. This procedure alone restored the mitral valve structure and function without any need for intervention on the mitral valve. Aortic abscess is a serious complication of aortic valve endocarditis and may alter the function of other structures of the heart, especially the mitral valve. Restoration of aortic wall integrity and left ventricular-aortic continuity usually restores the mitral valve structure and function if the valve is unaffected by the infection. A decision on the mitral valve should be made following correction of the aortic pathology.

Aortic arch reconstruction with pulmonary autograft patch in coarctation and interruption of the aorta.

The surgical management of the aortic arch pathologies is still subject to discussion. Primary end-to-end anastomosis has some complications such as bronchial compression, tension in the suture lines, and probability of recurrence. On the other hand, patch aortoplasties combined with end-to-end anastomosis carry the risk of aneurysm formation and recurrence. Considering the growth potential, pulmonary autograft patch use in aortic arch reconstructions has recently been introduced into clinical practice. In this study, we present the early findings of combined end-to-end anastomosis and pulmonary autograft patchplasty procedure in six patients. According to our experience the technique applied in this report seems to be more advantageous than other conventional approaches.

Remodelling of the superior caval vein after angioplasty in an infant with superior caval vein syndrome.

An 8-month old girl was presented with superior caval vein syndrome early after cardiac surgery. Angiography showed severe stenosis of the superior caval vein with 50 mmHg pressure gradient. Following balloon angioplasty, the pressure gradient was reduced to 7 mmHg with some residual stenosis of the superior caval vein. When the patient was reevaluated 5 months after the procedure, angiography revealed a normal diameter of the superior caval vein without a pressure gradient.

An unusual case of birdshot embolism.

There are numerous cases of arterial and venous bullet embolism to the heart. An unusual case of birdshot embolus to the right ventricle from the femoral vein caused diagnostic confusion. Distant migration of the foreign bodies via blood vessels has to be taken into consideration after gunshot wounds.

Tracheobronchial rupture: a considerable risk for young teenagers.

Tracheobronchial (TB) ruptures are ten times lower in children than in adults. Despite its rarity in the literature, we found that it is as common as in adults in our series. We investigated TB ruptures in childhood regarding age, trauma presentation, injury localization and treatment options. From 1994 through 2001, eight children (six male, two female) were admitted to our department with TB injury. All patients were healthy prior to trauma. The average and median ages were 9.8 and 11, respectively. All patients except one (iatrogenic) were suffering from blunt thoracic trauma. There were seven main bronchial (five right, two left) and one tracheal wounds. Six of the ruptures were circumferential. Urgent (n=6) and delayed (n=2) thoracotomies were performed; 'end-to-end' anastomosis (n=4), pneumonectomy (n=2) and 'primary suturing' (n=2) were applied. We had no mortality. Main bronchus rupture was overlooked in two patients as one of them had almost totally normal clinical appearance, and the other one had negative endoscopic findings. Both of these patients were successfully operated within 3 months. Our limited experience showed us that these kinds of injuries threaten school age population as well. False negative bronchoscopic results increase when additional injuries accompany. TB ruptures should be always taken into consideration after blunt chest trauma. Early or late repair of the lesion should be decided depending on the patient's clinical course.