Spontaneous retrograde dissection of the ascending aorta in a patient with a bicuspid aortic valve.

Bicuspid aortic valve (BAV) is a congenital anomaly associated with structural weakness of the aortic wall. Sudden onset of symptoms in patients with BAV, such as sudden severe back pain, and pulse inequality between the extremities or tension disparity should alert clinicians to acute aortic syndromes, as they require prompt diagnosis and management. Retrograde aortic dissection, which is a rare form of acute aortic syndrome, is an uncommon life-threatening entity and may produce atypical computed tomography (CT) or magnetic resonance imaging findings, leading to difficulty in diagnosis. We report on a 51-year-old male patient with BAV and spontaneous retrograde ascending aortic dissection. CT findings were confusing and the diagnosis was made via transoesophageal echocardiography. After the diagnosis, the patient was treated with a modified Bentall procedure. He did not have any complications and was stable four months after the operation.

Does cardiopulmonary bypass change serum neuron-specific enolase levels?

OBJECTIVE: The effects of cardiopulmonary bypass (CPB) on serum neuron-specific enolase (NSE) levels in patients without cognitive dysfunction and neurological deficit are not yet clarified. This study was designed to see the sole effect of extracorporeal circulation on serum NSE levels in patients without any clinically observed neurological deficit. METHODS: Thirty-two consecutive patients undergoing first elective open-heart surgery were included in this prospective study. Neurological status was assessed by clinical examination before surgery, and on the postoperative first and second days. Blood samples were obtained after anesthesia induction before the administration of heparin, within the first hour post CPB, 24 and 48 hours after the end of operation. Each blood sample was assayed for hemoglobin (Hb), hematocrit and NSE levels. The Friedman's Test to compare the serial measurements of NSE and hemoglobin samples and the post-hoc Tukey test for paired comparisons between pre and postoperative values were applied Pearson correlation test was used to examine the correlation between NSE concentration and aortic cross-clamping time and CPB time, age, postoperative hematocrit and hemoglobin levels and the amount of blood products transfusion. RESULTS: There were no significant differences between NSE values at any sampling time: 11.6+/-8.0 mg/dL, 8.7+/-4.7 mg/dL, 9.3+/-5.4 mg/dL and 8.9+/-5.8 mg/dL, measured preoperatively, at the end of operation, on the first and second post-operative days, respectively. There was no significant correlation between NSE values with any of the compared variables including CPB time. CONCLUSION: This study demonstrated that the possible damage of CPB on central nervous system and on blood cells did not reach to the extent of causing any significant increase in serum NSE levels in non-complicated patients undergoing open-heart surgery.

Lipoma of the diaphragm: a rare presentation.

Lipoma of the diaphragm is an extremely rare entity. A 67-year-old asymptomatic man who had a tumor located in the posterior region of the left hemi-diaphragm is presented. The tumor was removed through a left mini-thoracotomy. The diaphragm was reconstructed primarily by using nonabsorbable suture material. The final pathologic examination revealed a mature lipoma. The patient remains without evidence of recurrence 60 months after the operation.

Is remote preconditioning as effective as direct ischemic preconditioning in preventing spinal cord ischemic injury?

BACKGROUND: Spinal cord injury remains a devastating complication of thoracic and thoracoabdominal aortic operations. The aim of this study was to assess the affectivity of direct ischemic preconditioning (PC) and remote PC in preventing spinal cord ischemic injury in an experimental model. MATERIALS AND METHODS: Thirty-eight New Zealand white rabbits were divided into five groups: One group served as Sham group (n = 7). Rabbits in other groups had their abdominal aorta cross-clamped for 40 min. Before aortic occlusion, aorta was clamped twice at the same site of aortic occlusion for 5 min followed by 15 min of reperfusion after each ischemic episode in one group (Direct PC, n = 8), left renal artery was clamped twice for 5 min followed by 15 min of reperfusion after each renal ischemic episode in one group (Remote PC, n = 8), left renal artery was first clamped for 5 min followed by 15 min of reperfusion and then aorta was clamped for 5 min followed by 15 min of reperfusion in one group (Remote + Direct PC, n = 8), and no PC method was used in Control group (n = 7). RESULTS: In all PC groups, neurological status of rabbits (Tarlov score) at post-ischemia 24th and 48th hours was better than the control group (P < 0.05), but worse than Sham group (P < 0.05). Mean viability index values in PC groups were higher than control group (P < 0.01). Post-ischemia serum NSE and MDA levels obtained in all three PC groups were significantly lower than control group (P < 0.05 and P < 0.01). CONCLUSIONS: The use of direct ischemic PC and/or remote PC is an effective way of reducing spinal cord ischemic injury because of aortic occlusion, while direct PC is more effective. The combined use of direct PC and remote PC did not provide better protection.

Effects of cyclosporin a on neurological outcome and serum biomarkers in the same setting of spinal cord ischemia model.

Spinal cord ischemic injury is one of the feared complications during aortic cross-clamping. The aim of this study was to investigate whether cyclosporin A (CsA) has a protective effect on spinal cord during ischemia in a rabbit model. A total of 22 New Zealand white rabbits were studied in three groups. One of the groups served as a sham group (n=7), in which only laparatomy was performed and closed. One group served as a control group (n=7), in which rabbits had their abdominal aortas cross-clamped for 40 min following median laparatomy. The last group was the CsA group (n=8), in which rabbits underwent the same procedure as the control group as well as CsA infusion at 20 mg/(kg . hr) over 60 min starting with aortic cross-clamping and continuing in the first 20 min of reperfusion. Neurological outcome of rabbits was evaluated according to Johnson's scale at postoperative hours 24 and 48 in all groups, and then they were killed. Their spinal cords were harvested, and segments corresponding to L4-L6 were prepared for pathological examination. Serum neuron-specific enolase (NSE) and nitric oxide (NO) levels were measured prior to and following aortic occlusion, and comparisons were made. Physiological data were similar in all groups. Rabbits in the sham group did not have any neurological deficit. However, all rabbits in the control group showed severe neurological deficits, including total paraplegia in five. According to Johnson's scale, neurological status of the rabbits at postoperative hour 48 was better in the CsA group compared to controls (p<0.01). Pathological examination of spinal cord specimens revealed a higher viability index in the CsA group compared to controls (p<0.01). Serum NSE and NO levels were lower in CsA-treated animals compared to controls. Our results demonstrate that CsA, when administered during ischemia and in the early period of reperfusion, may reduce neuronal damage in the spinal cord in a rabbit model of transient spinal cord ischemia.

Acute proximal aortic intramural hematoma: a case report.

The case presented here is of a 72-year-old man with an acute proximal aortic hematoma. He was hospitalized and underwent close monitoring and blood pressure control. Typical aortic dissection developed during his hospital admission. This case emphasizes the importance of frequent follow-up imaging during medical therapy of patients with aortic intramural hematoma. However, the frequency of imaging is yet to be determined.

Left atrial free-floating ball thrombus in a case of hyperthrophic cardiomyopathy.

Left atrial free-floating ball thrombus is a rarely seen pathology in the absence or presence of mitral valve disease. This pathologic condition carries high risks of embolic complications and deterioration of hemodynamics. The case reported here is a 34-year-old woman who had been followed-up by another center with the diagnosis of hypertrophic cardiomyopathy (HCM) was admitted to our emergency department in cardiogenic shock due to left atrial free-floating ball thrombus partially obstructed the left ventricular inflow. Emergency surgery was undertaken to remove the ball mass, additionally septal myectomy and mitral valve replacement were performed. Pathologic examination of the mass confirmed the thrombus formation. This rare case of left atrial free floating ball thrombus associated with HCM is presented and current literature is reviewed.

Myocardium utilizes more oxygen and glucose during tepid blood cardioplegic infusion in arrested heart.

The aims of this study were to evaluate myocardial metabolic activity during tepid blood cardioplegic infusion in the arrested heart in comparison with cold blood cardioplegia and to assess the early clinical outcomes of these patients. Thirty patients undergoing first elective coronary artery bypass grafting surgery were included and randomized to two groups (T for tepid and C for cold), 15 patients in each. Myocardial protection was similar in both groups except for the reinfusion of blood cardioplegia, which was 6 degrees C in group C and 28 degrees C in group T (same temperature as the body perfusion). The route of cardioplegic reinfusion was antegrade during the first reinfusion and retrograde during the second reinfusion. In order to assess myocardial metabolic activity, myocardial oxygen consumption (MVO2), myocardial glucose uptake, and myocardial lactate and acid production were all calculated. Arterial and coronary venous blood samples were obtained from the aortic root cannula and coronary sinus. During cardioplegic re-infusions in the ischemic period, the calculated values of myocardial oxygen extraction, oxygen consumption, and glucose uptake were higher in group T than in group C (P < 0.05). This difference was observed during both antegrade and retrograde delivery of cardioplegic solution. Myocardial lactate production was greater in group C than in group T during cardioplegic reinfusion, both antegradely and retrogradely (P < 0.05). In all patients, cardiopulmonary bypass was terminated in the first attempt. The clinical outcome was similar in both groups. The results of this study indicate that globally ischemic myocardium is able to utilize more oxygen and glucose during cardioplegic re-infusions at a tepid temperature in comparison to cold. In addition, the data showed evidence of less myocardial injury and better left ventricular function throughout the critical period of recovery from global ischemia for the heart protected by tepid cardioplegia.

Transpulmonary surgical closure of patent ductus arteriosus with hypothermic circulatory arrest in an adult patient.

Untreated patent ductus arteriosus carries a higher risk in adults than in children, especially when the defect is large (>4.0 mm in diameter), short, or friable. Therefore, various technical precautions have been suggested for application during surgical closure of a patent ductus arteriosus in an adult. We report the case of a 47-year-old woman with a patent ductus arteriosus who underwent transpulmonary surgical closure of the ductus under hypothermic total circulatory arrest. We discuss the technique in light of the current English-language medical literature.

Replacement of a Björk-Shiley Delrin aortic valve still functioning after 25 years.

We report the case of a patient who had undergone implantation of a Björk-Shiley Delrin valve in the aortic position 25 years earlier and who now presented with severe mitral stenosis. The patient underwent mitral valve replacement and aortic valve re-replacement. We review the justification for prophylactic replacement of Björk-Shiley Delrin heart valves.