Surgical management of coronary malperfusion due to type a aortic dissection.

BACKGROUND: Acute aortic dissection coexisting with coronary malperfusion is a relatively rare but fatal condition. Surgical treatment of these patients is to perform early coronary revascularization concomitant with aortic repair. We review our surgical results of a selected group of 14 patients with type A acute aortic dissection and coronary artery dissection. METHODS: Between January 1993 and March 2005, 14 patients (10.2%) from a total of 136 consecutive patients with acute type A aortic dissection concomitant coronary dissection were treated by performing aortic repair and coronary artery bypass grafting. There were 11 men and 3 women (mean age, 56.7 +/- 8.4 years). The right coronary artery was involved in eight patients, the left in two patients, and both coronary arteries in four patients. At admission, nine patients had Q waves (64.2%), inferior in seven (50%) and anterior or lateral in two (14.2%). RESULTS: Hospital mortality rate was 21.4% (3 of 14 patients). Of these, two patients could not be weaned from cardiopulmonary bypass, and one patient died of multiorgan failure in the intensive care unit. CONCLUSIONS: Since acute type A aortic dissection with coronary involvement is associated with high mortality rate, immediate coronary artery bypass grafting and aortic repair is a safe and reliable approach to these challenging group of patients.

Combined coronary artery bypass grafting and lung surgery.

Combined coronary bypass and lung surgery was performed in 3 patients. Through a median sternotomy or a left thoracotomy, bypass grafting was performed on beating heart or under cardiopulmonary bypass, followed by the lung operation. The lung lesion was diagnosed as carcinoma in 2 patients and hydatid cyst in 1 patient. With few exceptions, beating heart coronary bypass through a median sternotomy can be performed in a combined operation.

[Surgical treatment of iatrogenic cardiac traumas induced by heart catheterization]. / Kalp kateterizasyonuna bagli iyatrojenik kardiyak travmalarda cerrahi tedavi.

BACKGROUND: A retrospective evaluation was made on iatrogenic cardiac traumas requiring surgical treatment, that were induced by cardiac catheterizations and interventions performed within a 17-year period. METHODS: A total of 64,911 patients underwent cardiac catheterizations and interventions from 1985 to 2002. Complications of iatrogenic cardiac traumas induced by these interventions were examined together with the surgical treatment performed within 24 hours after catheterization. RESULTS: Iatrogenic cardiac trauma requiring prompt surgical intervention was documented in 20 patients (6 females, 14 males; mean age 51 years; range 31 to 69 years). These were due to coronary angiography/balloon angioplasty-stenting in 14 (70%), percutaneous mitral balloon valvuloplasty in four (20%), and to heart catheterization in two patients (10%). Acute cardiac tamponade was detected in 10 patients (50%) resulting from perforations to the cardiac chambers in six, coronary arteries in two, and major vessels in two patients. Surgical interventions included coronary artery by-pass in 14, mitral valve surgery in four, and repair of major vessels in two patients. Perioperative mortality occurred in two patients. Six patients developed complications contributing to morbidity, including perioperative myocardial infarction (3 patients), infection (2 patients), and prolonged intubation (1 patient). CONCLUSION: In case of major cardiac complications induced during cardiac catheterizations, early diagnosis and prompt surgical intervention are of vital importance regardless of considerably high risks.

Long-term comparison of aortic arch replacement with or without elephant trunk procedure via retrograde cerebral perfusion for aortic arch dissection.

OBJECTIVE: The aim of this study is to investigate the effects of the duration of retrograde cerebral perfusion (RCP) in patients with aortic arch dissection. METHODS: Between 1993 and December 2000, 56 patients were operated on for aortic arch dissection. Elephant trunk procedure was performed in 28 patients (Group A) and semiarcus replacement in 28 patients (Group B). Type I dissection (P=0.003), chronic ethiology (P=0.006), medial degeneration (P<0.001), and preoperative hemodynamic instability (P=0.004) were observed significantly more in Group A. In both groups RCP was used for cerebral protection. RESULTS: Hospital mortality was higher in Group A than Group B (32.1% versus 7.1%; P=0.015). Late mortality was observed only in Group A (10.5%; P=0.049). Actuarial survival was 55.1+/-11.55% in Group A and 91.67+/-5.64% in Group B at 5 yr (P=0.0113), while cumulative survival for all patients was 78.38+/-5.77% at 5 yr. RCP time was longer in Group A (62.7+/-16.8 versus 34.2+/-19.5 min; P<0.001). Forward stepwise logistic regression analysis showed that chronic obstructive pulmonary disease (P=0.014) and renal insufficiency (P=0.004) were significantly predictors for hospital mortality, whereas elephant trunk (P=0.052) and RCP (>60 min) (P=0.175) did not increase early mortality. Only hemodynamic instability was significantly (P=0.006) predictors for late mortality. CONCLUSIONS: Preoperative severity of dissection, hemodynamic instability or organ dysfunctions impair early or late outcome. Elephant trunk technique with increased RCP time do not increase early or late mortality. To shorten RCP time (<60-65 min) can improve surgical results.