The Efficacy of Percutaneous Transluminal Angioplasty on the Limb Salvage and Recovery of Symptoms in Patients With Buerger's Disease With Critical Limb Ischemia.

INTRODUCTION: Buerger's disease, or thromboangiitis obliterans, is associated with limb-threatening chronic arterial lesions. In this study, we sought to investigate the efficacy of the percutaneous transluminal angioplasty method for the treatment of critical limb ischemia (CLI) in patients with Buerger's disease in our modest cohort. METHODS: Patients diagnosed with CLI secondary to Buerger's disease who underwent percutaneous transluminal angioplasty between May 2014 and June 2017 were retrospectively investigated. Patient demographics, presentations, procedural details, responses to percutaneous treatment, complications, limb salvage, wound healing, reinterventions, and early follow-up data were recorded. RESULTS: The cohort included 24 patients with Buerger's disease presenting with CLI observed in 46 limbs. Presentations were gangrene in 12 patients, ulcer formation in 7 patients, and rest pain in the remaining 5 patients. All patients received percutaneous balloon angioplasty, with limb salvage in 21 patients (87.5%). Revascularization was achieved in 87.5% of the destination arteries at the primary intervention and overall technical success rate including reinterventions reached 95.8%. Following the procedures, a total of 22 patients had clinical response with at least ≥1 Rutherford category and mean Rutherford category significantly improved from 5.2 ± 0.74 to 1.6 ± 0.7 (P<.001). Limb salvage rate was 87.5%. Complete wound healing was achieved in all patients with ischemic ulcers at 3.9 ± 2.6 months (range 1-13 months) post revascularization. Mean follow-up duration was 16.07 ± 3.4 months and 6 patients (who were especially subjected to cigarette smoke) required reinterventions. CONCLUSION: Percutaneous treatment of arterial occlusions in patients with Buerger's disease seems feasible in the current era of improving devices and angioplasty materials. Procedures may be safely performed with good technical and clinical success rates, and without mortality or complications as experience increases.

Relationship between exercise-induced heart rate increase and the formation of microbubbles and high-intensity transient signals in mechanical heart valve implanted patients.

INTRODUCTION: The formation and collapse of vapor-filled bubbles near a mechanical heart valve is called cavitation. Microbubbles can be detected in vivo by doppler ultrasonography (USG) as HITS (high intensity transient signals) in cranial circulation. We investigated the relationship between exercise induced heart rate increase and HITS formation in cranial circulation. MATERIAL AND METHODS: Thirty-nine mechanical heart valve implanted (8 aortic valve replacement (AVR) + mitral valve replacement (MVR), 9 AVR, 22 MVR) patients aged 18-80 years old were included in our study. Microbubbles were counted in the left ventricular cavity via transthoracic echocardiography at rest per cardiac cycle. Afterwards transcranial Doppler USG was performed and HITS were counted in each patient's middle cerebral artery at 5 min duration. Subsequently an exercise test according to the Bruce protocol was performed. After achieving maximal heart rate, microbubbles in the left ventricle and HITS were counted again. RESULTS: Microbubbles in the left ventricle and transcranial HITS increased after exercise significantly compared to resting values (15.79 ±10.91 microbubbles/beat vs. 26.51 ±18.00 microbubbles/beat, p < 0.001; 6.13 ±8.07 HITS/5 min vs. 13.15 ±15.87 HITS/5 min, p = 0.001). There was a significant correlation between microbubbles and HITS counts after peak exercise (r = 0.55, p < 0.001). CONCLUSIONS: In our study, we found that the microbubbles were increasing as the heart rate increased and more HITS were propelled to the cerebral circulation. As previously shown, HITS can alter cognitive functions. Therefore heart rate control is essential in mechanical heart valve patients to protect neurocognitive functions.

Comparison of inhaled nitric oxide and aerosolized iloprost in pulmonary hypertension in children with congenital heart surgery.

BACKGROUND: Pulmonary arterial hypertension is of importance in congenital cardiac surgery as being a significant cause of morbidity and mortality. Although therapy options are limited, inhaled nitric oxide (NO) is used as a standard therapy. The present study aimed to compare inhaled NO and aerosolized iloprost in children with secondary pulmonary hypertension who underwent congenital cardiac surgery. METHODS: Sixteen children included in the study were randomized into either inhaled NO or aerosolized iloprost group. For both groups, the observation period terminated at 72 h after cardiopulmonary bypass. RESULTS: There was no significant difference between the groups in terms of mean age, weight, cross clamp time, pump time, and extubation time. No significant change was observed in the arterial tension and central venous pressure of both groups before the operation, 30 min after the pump, 45 min after the pump, and after extubation, whereas an increase was observed in the heart rate and cardiac output, and a decrease was observed in the pulmonary artery pressure. The mean values at the above-mentioned time points showed no difference between the groups. No serious adverse event and mortality was detected. CONCLUSIONS: Both inhaled NO and aerosolized iloprost were found to be effective and comparable in the management of pulmonary hypertension.

Successful transcatheter closure of a Fontan fenestration with a bioabsorbable Biostar occluder.

We report the successful closure of an extracardiac Fontan fenestration with a bio-absorbable device, which may be refenestrated by a transcatheter route when needed, in a 10-year-old boy. The patient presented with cyanosis two years after an extracardiac Fontan operation. Echocardiography revealed a moderate shunt from the Fontan circulation into the systemic circulation with a mean pressure gradient of 3-4 mmHg. Treadmill testing revealed a significant decrease in oxygen saturation (down to the low 50's from a baseline level of 80-85%). Cardiac catheterization revealed normal pressure in the Fontan circuit. A temporary balloon occlusion test showed that the defect was suitable for permanent occlusion. The fenestration was then occluded by a bio-absorbable Biostar (NMT medical, Boston, USA) atrial septal occluder device. The oxygen saturation on room air increased up to 95% after closure.

Intermediate-term results after surgery for anomalous origin of the left coronary artery from the pulmonary artery.

PURPOSE: Anomalous origin of the left coronary artery from the pulmonary artery is optimally treated by creating a dual coronary system. Our aim was to review the results of operations performed in these patients and determine the intermediate-term outcomes for left ventricular function and mitral regurgitation. METHODS: Between July 2004 and January 2009 seven patients (5 boys, 2 girls) aged between 4 months and 12 years (median, 4.5 years) were operated for anomalous origin of the left coronary artery from the pulmonary artery. The surgical correction was either performed by direct implantation (58%) or restoration of a composite tunnel (42%). Simultaneous mitral annuloplasty was performed in one patient with severe mitral regurgitation and simultaneous total correction of tetralogy of Fallot was performed in another. RESULTS: There was no hospital or late deaths. Postoperative echocardiograms demonstrated a significant improvement in the left ventricular ejection fraction (52% ± 6% versus 39% ± 8%, P = 0.02) and mitral regurgitation (11% mild versus 48% moderate, P = 0.02) compared to those obtained preoperatively. CONCLUSION: Direct re implantation of the left coronary artery to the aorta and restoration of a composite tunnel from aortic and pulmonary artery walls are equally effective techniques with an acceptable operative mortality, excellent cardiac recovery, and intermediate survival.

Repair of left main coronary ostial stenosis using autologous aortic tissue.

BACKGROUND: Patch angioplasty is one of the several surgical options for patients with left main coronary ostial stenosis. It restores native antegrade blood flow in the left main coronary artery (LMCA) and does not leave the patient with graft-dependent retrograde perfusion. Various direct techniques have been described for left coronary ostioplasty. Herein, we described the use of autologous aortic tissue in the surgical treatment of left main coronary ostioplasty, and reported the short- and long-term outcomes of the patients. METHODS: Between January 2003 and December 2010, 11 patients (nine males and two females) underwent surgical patch angioplasty for LMCA ostial stenosis using autologous aortic tissue as the patch material. RESULTS: All patients survived the operation, and there were no significant postoperative complications. The follow-up period was 44.09 ± 30.26 months (range, 1-94 months), and no deaths or restenoses were observed during follow-up. CONCLUSIONS: The use of autologous aortic tissue as an onlay patch for reconstruction of left main coronary ostial stenosis is safe and free of major complications. This tissue is a reasonable material for treating selected types of LCMA patients.

Left anterior descending artery revascularization in low-risk patients: early outcomes after off-pump versus on-pump surgery.

BACKGROUND AND AIM OF THE STUDY: This study aimed to compare the early outcomes of off-pump and on-pump myocardial revascularization in patients with stenosis in the left anterior descending artery (alone or with diagonal artery disease). METHODS: We retrospectively reviewed the medical records of 300 patients: 150 who underwent on-pump coronary artery bypass and 150 who underwent off-pump coronary artery bypass grafting. There were no significant differences between the 2 groups with respect to medical data and operative findings. On-pump and off-pump groups were compared in terms of mortality and morbidity within 30 days of the operation. RESULTS: Hospital mortality was 3.3% (5 patients) in the on-pump group and 2.6% (4 patients) in the off-pump group. Five patients (3.3%) in the on-pump group experienced myocardial infarction; 3 died of cardiogenic shock. Four patients (2.6%) in the off-pump group experienced myocardial infarction, and 2 of these patients died. Two patients (1.3%) in the on-pump group and 2 patients (1.3%) in the off-pump group experienced stroke; 1 patient in each group died. One patient (0.6%) in the on-pump group had mediastinitis and died of sepsis. CONCLUSIONS: Among low-risk patients (defined according to EuroSCORE criteria) who underwent left anterior descending coronary artery bypass, the results obtained with the on-pump and off-pump methods showed no significant differences with respect to morbidity or mortality.

Leiomyosarcoma protruding into the left ventricle during diastole: report of a case.

Cardiac leiomyosarcoma is a rare tumor with poor survival prospects. Surgery prolongs survival, but the tumor often recurs early after surgery. The diagnosis is often made by transthoracic echocardiography. Magnetic resonance imaging and computed tomography are required to characterize the location and extent of cardiac masses. In this report, we present a patient with a leiomyosarcoma that was resected completely. The tumor was located in the left atrium, mimicked a myxoma, and protruded into the left ventricle during diastole.

Sternal wrapping for the prevention of sternal morbidity in elderly osteoporotic patients undergoing median sternotomy.

Osteoporosis, a major risk factor for sternum-related morbidity after median sternotomy, is quite prevalent among the elderly. In this prospective study, we investigated the potential of sternal protection by use of the "sternal wrapping method" in elderly osteoporotic patients who were undergoing median sternotomy.For this study, we chose 100 elderly osteoporotic patients who were scheduled to undergo median sternotomy. During surgery, we wrapped the sternal edges with polyvinyl chloride tubing in 50 patients (group 1) and omitted the sternal wrapping in the remaining 50 patients (group 2). We then compared the groups with regard to postoperative pain, bleeding, early and late sternum-related morbidity, sternal fractures, and duration of hospitalization.Sternal wrapping was associated with fewer sternal fractures, less chest pain, and shorter hospital stays. Overall sternal morbidity was significantly less common among patients with sternal wrapping (4% vs. 20%, P = 0.03); however, the difference in individual rates for early and late dehiscence or deep sternal infection did not reach statistical significance.Sternal wrapping using polyvinyl chloride tubes provides mechanical protection and, apparently, less postoperative chest pain and shorter hospitalizations. Probably, it reduces sternum-related complications, particularly in high-risk patients. Its benefits, however, should be confirmed in larger studies.

Sternal dehiscence in patients with moderate and severe chronic obstructive pulmonary disease undergoing cardiac surgery: the value of supportive thorax vests.

OBJECTIVE: Sternal dehiscence after open surgery is a major cause of morbidity and mortality, and chronic obstructive pulmonary disease is a significant risk factor. Therefore, we aimed to determine whether moderate and severe chronic obstructive pulmonary disease had an effect on the development of sternal dehiscence and whether the use of the Robicsek technique for sternal closure along with sternal support vest postoperatively would reduce the incidence of sternal dehiscence in patients with moderate/severe chronic obstructive pulmonary disease undergoing cardiac surgery. METHODS: Two studies were performed. In study 1, 842 patients undergoing cardiac surgery and figure-of-8 wire closure were retrospectively evaluated in 2 groups: group 1a (328 patients with chronic obstructive pulmonary disease) and group 1b (514 patients without chronic obstructive pulmonary disease). In study 2, 221 patients with moderate and severe COPD who were scheduled for open surgery were prospectively enrolled. The Robicsek technique was used for sternal closure. The postoperative thorax support vest was used in 100 patients (group 2a), and no additional procedure was applied in 121 patients (group 2b). RESULTS: In study 1, the dehiscence rate was significantly higher in group 1a (7.9%) than in group 1b (1.2%; P < .001), and mortality rates in patients with dehiscence were 53.8% and 33.3%, respectively. In study 2, the dehiscence rate was significantly lower in group 2a (1%) than in group 2b (11.5%; P = .002). None of the patients with dehiscence in group 2a died, and 35.7% of patients died in group 2b. CONCLUSIONS: The Robicsek technique for sternal closure and the use of a thorax support vest postoperatively are highly effective in preventing sternal dehiscence after cardiac surgery in patients with moderate and severe chronic obstructive pulmonary disease.

Cardiac reoperation in a patient who previously underwent omentoplasty for postoperative mediastinitis: a case report.

Sternal infection has become a rare but challenging problem with significant mortality and morbidity rates since the introduction of sternotomy. Reported rates of mediastinal and sternal infection range from 0.4% to 5%. The ideal reconstruction after sternal debridement is still controversial. Different methods, such as debridement and open packing with continuous antibiotic irrigation, or sternectomy with omental or muscle transposition have been proposed. In this study, we present the cardiac reoperation of a 52 year old man with corrected transposition of great arteries (c-TGA) who had undergone a previous omentoplasty for postoperative mediastinitis.

Anaesthetic and post-operative management of a modified Norwood operation for hypoplastic left heart syndrome: a retrospective series of 11 cases.

OBJECTIVE: This study aimed to describe the pre-operative and operative findings, as well as the post-operative haemodynamics of patients operated on for hypoplastic left heart. The findings of patients who survived or did not survive were also compared to anticipate the risk factors for mortality. METHODS: We retrospectively reviewed the anaesthetic and intensive care records of 11 (seven male and four female) patients who underwent a modified Norwood operation as neonates. There were eight patients who survived, while three did not survive after the operation. Haemodynamics, oxygenation, and medications of patients were recorded for the pre-operative and post-operative conditions for 2 days, and compared between groups of patients who survived and those who did not. RESULTS: The normalised modified Blalock-Taussig shunt area was 3.28, 0.57 square millimetres per kilogram (mean, standard deviation) for the group of patients who survived and 3.55, 1.4 square millimetres per kilogram for the group of patients who did not survive (p = 0.51). The group of patients who survived had a significantly larger normalised aortic annulus area (3.3, 0.89 square millimetres per kilogram versus 1.68, 0.21 square millimetres per kilogram, p = 0.01), lower median age (5.57 (3-8) days versus 46.67 (4-90) days, p = 0.02), and lower weight (2.95, 0.46 kilograms versus 3.85, 0.56 kilograms, p = 0.03) than the group of patients who did not survive. Furthermore, the group of patients who did not survive had a significantly worse pre-operative condition, lower systemic venous and arterial oxygen saturation, and need for a high dose of drugs in the pre-operative and post-operative periods (p was less than 0.05 for each variable). CONCLUSION: The pre-operative, operative, and post-operative findings may be related to mortality early after the modified Norwood operation for hypoplastic left heart syndrome.

Mitral regurgitation secondary to anterior leaflet rupture during percutaneous balloon valvuloplasty: case report.

Rheumatoid heart disease and the mitral stenosis secondary to it in the long term are still important cardiovascular problems in developing countries. Percutaneous balloon mitral valvuloplasty is a valid treatment option with low complication rates for relieving the signs and symptoms of selected patients with mitral valve stenosis. In this report, we describe subacute mitral regurgitation secondary to anterior leaflet rupture following percutaneous balloon mitral valvuloplasty and the management strategy in a 54-year-old female patient. Such a complication is rare in experienced hands in the current era.

Mitral valve repair in a patient with thrombocytopenia-absent radius syndrome: case report.

Thrombocyte level and functions are vital factors during cardiac surgery. Thrombocytopenia-absent radius syndrome (TAR) is a rare genetic disorder consisting of skeletal abnormalities and thrombocytopenia. In this report, we present the management strategy for a 23-year-old female patient with TAR syndrome who underwent mitral valve repair.