Key-lock type mini-sternotomy: an alternative approach for adult cardiac operations.

An alternative technique for minimally invasive aortic valve replacement and atrial septal defect repair is described. After a 5-cm skin incision, a key-lock type sternotomy is made. Excellent exposure of the right atrium and aortic valve was achieved. The configuration of the mini-sternotomy (or the lock) limits the movement of the sternal surfaces (or the key) on the lateral and craniocaudal directions.

Successful treatment of central venous catheter induced superior vena cava syndrome with ultrasound accelerated catheter-directed thrombolysis.

Superior vena cava (SVC) syndrome results from obstruction of flow through the vessel either by external compression or thrombosis. External compression by intrathoracic neoplasms is the most common etiology, especially lung cancer and lymphoma. Thrombosis is becoming increasingly common due to the use of indwelling catheters and implantable central venous access devices. Most patients are unresponsive to anticoagulation alone which appears to be effective only in the mildest cases. However, recent advances in catheter-based interventions have led to the development of a variety of minimally invasive endovascular strategies to remove venous thrombus and accepted as an important first-line treatment given its high overall success rate and low morbidity as compared with medical and surgical treatments. Ultrasound accelerated catheter-directed thrombolysis (UACDT) has been developed to rapidly and completely resolve the existing thrombus. This technique integrates high frequency, low intensity ultrasound (US) with standard CDT in order to accelerate clot dissolution, reducing treatment time and the incidence of thrombolysis-related complications. An US wave enhances drug permeation through thrombus by disaggregating the fibrin matrix, exposing additional plasminogen receptor sites to the thrombolytic agent. The US energy affects thrombus in the entire venous segment, increasing the probability of complete thrombus clearing. We report the case of a 56-year-old man who presented with a 5 days history of SVC syndrome symptoms who had been receiving chemotherapy for colon cancer through a right subclavian vein port catheter. The patient successfully treated with UACDT with EkoSonic(®) Mach4e Endovascular device with an overnight infusion. © 2013 Wiley Periodicals, Inc.

US-accelerated catheter-directed thrombolysis for the treatment of deep venous thrombosis.

PURPOSE: We aimed to evaluate the efficacy and feasibility of ultrasonography (US)-accelerated catheter-directed thrombolysis for the treatment of deep venous thrombosis. MATERIALS AND METHODS: A total of 26 patients with deep venous thrombosis were prospectively selected for thrombolysis. Overall, 80.8% of the occlusions were in the lower extremities, and 19.2% were in the upper extremities. US-accelerated catheter-directed thrombolysis was performed using a recombinant human tissue plasminogen activator (alteplase), which was delivered using the EKOS EkoSonic® Endovascular System (EKOS Corporation, Bothell, Washington, USA). Postprocedure venography was repeated after the treatment, which included angioplasty and stenting if stenosis was present. RESULTS: Thrombolysis was successful in 92.3% (24/26) of the patients, with complete clot lysis in 14 patients and partial clot lysis in nine patients. The mean symptom duration was 54.9±51 days (range, 6-183 days), and the mean thrombolysis infusion time was 25.3±5.3 hours (range, 16-39 hours). Pulmonary embolism was not observed; however, there were three cases of bleeding at the catheter insertion site. In three patients, the underlying lesions were successfully treated with balloon angioplasty and stent insertion. Two patients developed early recurrent thrombosis due to residual venous obstruction. CONCLUSION: US-accelerated thrombolysis was demonstrated to be a safe and efficacious treatment for deep venous thrombosis in this study. The addition of US reduces the total infusion time and increases the incidence of complete lysis with a reduction in bleeding rates. Residual venous obstruction should be treated by angioplasty and stent insertion to prevent early rethrombosis.

Endovenous laser ablation of incompetent perforating veins with 1470 nm, 400 µm radial fiber.

OBJECTIVE: To evaluate the efficacy of endovenous laser ablation (EVLA) of incompetent perforating veins (IPVs) with 1470 nm laser with 400 µm radial fiber. BACKGROUND DATA: EVLA for perforating veins can be performed with insignificant postprocedural morbidity. This allows treatment to be offered to elderly patients with comorbidities that would preclude anesthesia for surgical treatment or subfascial endoscopic perforator surgery (SEPS). METHODS: A total of 24 perforating veins in 16 limbs of 13 patients were treated between July 2010 and December 2011 in our clinic. Follow-up duplex scans were performed at 1 week and 1, 3, 6, and 12 months after the procedure, to determine the treatment outcome. RESULTS: Of the 23 treated IPVs, 20 (86.9%) were occluded on the duplex examination at 12 months. The average energy administrated per perforating vein treated was 174 J (range 105-236 J). Four of five ulcers had healed after 8 weeks in clinical-etiology-anatomy-pathophysiology (CEAP) C6 group. Two patients reported localized paresthesia, which subsided spontaneously, but no deep venous thrombosis or skin burn was observed. All components of the Venous Clinical Severity Score (VCSS) demonstrated significant improvements at each postprocedural visit (p<0.001 for all), except for pigmentation and compression, which exhibited variation throughout the follow-up period. CONCLUSIONS: Especially in the case of liposclerotic or ulcerated skin in the affected region, EVLA of IPVs with 1470 nm diode laser is highly effective and safe, and appears to be feasible. Additionally, repeat treatment can easily be performed should recurrence of IPVs arise.

Dexmedetomidine in cardiac surgery patients who fail extubation and present with a delirium state.

BACKGROUND: We evaluated the use of dexmedetomidine to facilitate the weaning of delirious postoperative patients from mechanical ventilation. METHODS: We included 72 consecutive patients who underwent elective cardiac surgery in this prospective observational study. Each patient had failed at least 1 trial of continuous positive airway pressure (CPAP) and had agitation. Patients were assessed with the Richmond Agitation-Sedation Scale (RASS) and the Confusion Assessment Method for the Intensive Care Unit (CAMICU) 12 to 18 hours after their admission to the ICU. Midazolam and fentanyl were then given to all patients according to the sedation protocol. At 36 hours in the ICU, patients who had agitation and an inability to wean were randomly divided into 2 groups: group M, 34 patients who continued to follow the routine sedative protocol; and group D, 38 patients who were given dexmedetomidine. Arterial blood gas measurements, hemodynamic parameters, and time to extubation were recorded. Statistical analysis was performed with GraphPad InStat (version 2.02 for DOS). RESULTS: All patients tested positive in the CAM-ICU assessment, and all had a delirium diagnosis. The 38 patients in group D tolerated a spontaneous breathing trial with CPAP and were extubated after a mean (±SD) of 49.619 ± 6.96 hours. The 2 groups had significantly different extubation times (58.389 ± 3.958 hours versus 49.619 ± 6.96 hours). The 2 groups had significantly different RASS scores at 48 and 60 hours and significantly different heart rates and PO2 values at 12 and 24 hours. The 2 groups showed no significant differences with regard to hemodynamic parameters. CONCLUSIONS: Dexmedetomidine may help to eliminate the emergence of agitation and can be a good treatment choice for the delirium state after cardiac surgery.

Right coronary artery with high takeoff.

Anomalous origin of the right coronary artery is an extremely rare anomaly. We describe the case of a patient whose right coronary artery was arising from the ascending aorta with high takeoff. We diagnosed the anomaly incidentally during the operation. After transverse aortotomy for aortic valve replacement, we recognized the transection of the right coronary artery. The right coronary artery ostium was located approximately 5 cm above the right sinus of Valsalva. It was showing a complete transmural course. We repaired the right coronary artery by bypassing it with a saphenous vein graft.

A case of prosthetic mitral valve Brucella endocarditis complicated with torsades de pointes.

Brucella endocarditis is a zoonosis transmitted by contaminated dairy products. Endocarditis is a rare complication of brucellosis and mainly the aortic valve is infected. We present the case of a female patient with prosthetic mitral valve endocarditis associated with QT prolongation and torsades de pointes. Transesophageal echocardiography revealed vegetation on both anterior and posterior mitral annulus. She was seropositive with Brucella agglutination titers of up to 1/320. The QT interval was markedly prolonged upon admission (QTc 530 ms). She experienced torsades de pointes several times. She underwent reoperation under an appropriate antibiotic regimen. She continued on triple antibiotic therapy for 12 months. She is now well and free of symptoms.

Role of physiological state 'normothermia' in internal thoracic artery spasm after harvesting.

OBJECTIVE: Vasospasm is often faced after the operative preparation of internal thoracic artery. Different vasodilating pharmacological agents are being used to eliminate this problem. During the preparation of internal thoracic artery, normal, local, and systemic temperatures are lost. We aimed to find out the effect of this decrease in temperature on the free flow of internal thoracic artery. METHODS: We investigated the effects of normal saline solution at 20 degrees C (group I), papaverine at 20 degrees C (group II) and normal saline solution at 37 degrees C (group III). Each group contained 20 patients undergoing coronary bypass. Free flow of the left internal thoracic artery was measured after mobilization. After approximately 18 min the graft had been sprayed with one of the agents, and the second free flow was measured (t-interval was 18.2+/-2.1 for group I, 18.3+/-1.8 for group II, and 17.5+/-1.9 for group III). RESULTS: Normal saline solution at 20 degrees C did not cause a significant change. Topical papaverine at 20 degrees C increased the flow from 42.1+/-10.7 ml/min to 77.5+/-17.9 ml/min (p < 0.0001). A significant increase also occurred with normal saline solution at 37 degrees C from 41+/-11.9 ml/min to 75.3+/-18.9 ml/min (p < 0.0001). CONCLUSIONS: After harvesting the graft, regaining physiological normothermic state is enough for vasodilatation. Even using one of the most potent vasodilating agent papaverine at 20 degrees C is not superior to normothermia.

[Thoracic aortic transection following blunt trauma: two case reports]. / Künt travma sonrasi olusan torakal aortik transeksiyon: iki olgu sunumu.

Acute aortic transection after blunt trauma is a clinical situation, with a high mortality. When the other system injuries are predominant, the diagnosis could be possible only if it would be considered. These type of cases are usually die. The survivors are generally the cases of whom be diagnosed incidentally. Two cases who were admitted to our clinic due to falling down (suicide attempt) were diagnosed as aortic transection and were immediately operated. End to end graft interpositions were performed by using left atrio-femoral bypass in one patient and femoro-femoral bypass in the other. Systemic examinations of all the patients who are referred to the hospital after blunt trauma should be done completely and the physician should be alert for possible aortic transection or dissection.