Does Sternal Cable System Prevent Sternal Complications after Revision Sternal Surgery?

OBJECTIVE: To determine the efficacy of a sternal wire system in secondary sternal dehiscence after repeat closure of the sternum, following surgical revision after open heart surgery. STUDY DESIGN: Case-control study. PLACE AND DURATION OF STUDY: Department of Cardiovascular Surgery, Zonguldak Bülent Ecevit University, Zonguldak, Turkey; and Turkey Yuksek Ihtisas Training and Research Hospital, Turkey, from January 2015 to May 2019. METHODOLOGY: Patients, who underwent open heart surgery with median sternotomy, were included in this retrospective study. The patients were divided into two groups, according to the sternal closure material. The time of the sternal reconstruction surgery, because of sternal dehiscence, fracture, broken sternal wire(s) or cable(s) after the first revision surgery, was noted for each patient. RESULTS: A total of 389 patients were identified. Group 1 included 72 (50%) patients whose sternums were closed with a sternal cable system; and Group 2 included 72 (50%) patients whose sternums were closed with conventional steel wires after propensity matching. The duration of cardiopulmonary bypass, number of intra-aortic balloon pumps used, and number of extracorporeal membrane oxygenators used were significantly higher in Group 1 (p = 0.007, p = 0.034, and p = 0.028, respectively). The number of emergency operations was significantly higher in Group 2 (p = 0.021). There was no significant difference in terms of secondary sternal dehiscence between the groups (p = 0.366). CONCLUSION: Application of the sternal wire system in revisional open heart surgery is not more effective than conventional steel wire at preventing secondary sternal dehiscence. Key Words: Sternal dehiscence, Sternal cable, Sternal wire, Open heart surgery, Postoperative revision.

Elective Endovascular Repair of Abdominal Aortic Aneurysms with Modular and Unibody Type Endografts.

BACKGROUND: In this study, we aimed to evaluate the performance of modular and unibody endografts for the endovascular repair of abdominal aortic aneurysm (AAA). METHODS: Between January 2012 and December 2017, 130 elective infrarenal abdominal aortic aneurysms treated in an endovascular manner were retrospectively evaluated. Sixty-six patients with the modular type (Medtronic EndurantTM II and Lifetech AnkuraTM AAA) and 64 patients with the unibody type (Endologix AFX®) were compared with regards to early and postoperative one-year results. RESULTS: There was one in-hospital mortality (0.8%) in the modular group. There was no difference in postoperative first-year mortality rate between the two groups (p = 0.678). Loco-regional anesthesia was used more often in the unibody group [34 patients (53.1%)] and the use of general anesthesia was higher in the modular group [56 patients (84.8%)] (p < 0.001). While the duration of the procedure was shorter in the unibody group (p < 0.001), no statistically significant difference was found in the duration of fluoroscopy (p = 0.813) and the amount of contrast agent used (p = 0.553). The follow-up period in the intensive care unit was shorter in the modular group (p < 0.001). Moreover, the five-year survival rate was similar between the groups (84.8% in the modular group and 78.4% in the unibody group, log-rank p = 0.703). CONCLUSIONS: The results obtained in our study show that modular and unibody grafts are effective and reliable, although there are some negligible differences in the early period.

Incidentally Detected Sternal Foramen during an Urgent Surgical Revascularization: A Case Report.

The sternal foramen is an anatomical variation at the lower third of the sternum which carries the risk of life-threatening complications such as pneumothorax. It is usually asymptomatic and can be misinterpreted as an acquired lesion. The sternum is close to the mediastinal structures; the sternal foramen, thus, leaves the lung, heart, and great vessels unprotected during invasive procedures. A 61-year-old male patient was admitted to our emergency department with sudden-onset chest pain. Acute coronary syndrome was diagnosed by the cardiology department. Coronary angiography confirmed the diagnosis of coronary artery disease, and the patient underwent urgent coronary artery bypass grafting. During the exploration, sternotomy was performed with a proper incision. Two sternal images were obtained via the median incision, and a sternal foramen was detected intraoperatively. To the best of our knowledge, this is the first case of sternotomy to undergo open-heart surgery for coronary heart disease and to be diagnosed with the sternal foramen intraoperatively. It is of vital importance that surgeons and interventionists recognize the sternal foramen, which leaves the mediastinal structures unprotected, and take early precautions.

Aberrant right subclavian artery (arteria lusoria) aneurysm with a Kommerell's diverticulum.

The treatment options for aberrant right subclavian artery vary depending on the presence of Kommerell's diverticulum. Because there is a tendency not to report mortalities of these rare cases in the literature, it is hard to reach a conclusion on treatments from the limited data on post-interventional results in these patients. We report our experience with a 67-year old patient with an aberrant right subclavian aneurysm with Kommerell's diverticulum, diagnosed by chance.

As opções de tratamento para artéria subclávia direita aberrante variam dependendo da presença de divertículo de Kommerell. Como há uma tendência a não relatar mortalidade nos raros casos descritos na literatura, é difícil chegar a uma conclusão sobre tratamentos tendo em vista os dados limitados sobre resultados pós-intervenção nesses pacientes. Relatamos aqui nossa experiência com um paciente de 67 anos de idade com aneurisma de artéria subclávia aberrante direita com divertículo de Kommerell diagnosticado ao acaso.

Aberrant right subclavian artery (arteria lusoria) aneurysm with a Kommerell's diverticulum / Aneurisma de artéria subclávia direita aberrante (artéria lusória) com divertículo de Kommerell

The treatment options for aberrant right subclavian artery vary depending on the presence of Kommerell's diverticulum. Because there is a tendency not to report mortalities of these rare cases in the literature, it is hard to reach a conclusion on treatments from the limited data on post-interventional results in these patients. We report our experience with a 67-year old patient with an aberrant right subclavian aneurysm with Kommerell's diverticulum, diagnosed by chance

As opções de tratamento para artéria subclávia direita aberrante variam dependendo da presença de divertículo de Kommerell. Como há uma tendência a não relatar mortalidade nos raros casos descritos na literatura, é difícil chegar a uma conclusão sobre tratamentos tendo em vista os dados limitados sobre resultados pós-intervenção nesses pacientes. Relatamos aqui nossa experiência com um paciente de 67 anos de idade com aneurisma de artéria subclávia aberrante direita com divertículo de Kommerell diagnosticado ao acaso

Epicardial anthracosis in a patient undergoing coronary artery bypass graft surgery.

Anthracosis is an occupational disease which is caused by long-term inhalation of coal and rock dust. We present a case of epicardial anthracosis in a patient who underwent coronary artery bypass graft surgery for coronary artery disease. This is the first case of anthracosis related to the heart in the literature to the best of our knowledge. This case report emphasizes the systemic dissemination of inorganic particles such as carbon in the human body.

Off-pump Coronary Artery Bypass Grafting in Moyamoya Disease: a Case Report.

Moyamoya disease is a rare, idiopathic, progressive, occlusive disease of the internal carotid artery characterized by the development of collateral vasculature in the brain base. In patients with accompanying coronary artery disease, cardiopulmonary bypass posses a potential risk for perioperative cerebral ischemic complication. Herein, we report a 53-year-old male case of Moyamoya disease and coronary artery disease who was treated with off-pump coronary artery bypass grafting.

Off-pump coronary artery bypass grafting in moyamoya disease: a case report

Abstract Moyamoya disease is a rare, idiopathic, progressive, occlusive disease of the internal carotid artery characterized by the development of collateral vasculature in the brain base. In patients with accompanying coronary artery disease, cardiopulmonary bypass posses a potential risk for perioperative cerebral ischemic complication. Herein, we report a 53-year-old male case of Moyamoya disease and coronary artery disease who was treated with off-pump coronary artery bypass grafting.

Aneurysm rupture from blunt abdominal trauma after endovascular repair.

We present a case of aneurysm rupture from severe blunt abdominal trauma due to fight in a patient who had endovascular aneurysm repair. The patient presented to the emergency service with computed tomography evidence of an endoleak and a large retroperitoneal hematoma. The contrast abdominal computed tomography demonstrated a type Ib endoleak, increase in the aneurysm diameter and hematoma in the retroperitoneum. The patient has been taken under interventional procedure for endovascular aneurysm repair revision under urgent condition. Type Ib endoleak was treated by placement of a covered iliac extension limb, but a second leakage from graft body was found in control computed tomography images and open surgical conversion was necessary. Operative findings included a type III endoleak from graft body, defect on fabric. It was seen that the aneurysm sac anterior and posterior parts were ruptured. Upon reviewing the literature, we found that it was an interesting case as the first rupture case which had been developed after severe blunt abdominal trauma during the follow-up period of a patient on which endovascular aneurysm repair procedure had been performed and progressed in this manner.

Risk Factors for Survival following Open Surgical Repair of Ruptured Abdominal Aortic Aneurysms: A 13-Year Experience.

BACKGROUND: Surgical treatment of a ruptured abdominal aorta aneurysm (RAAA) continues to present a significant challenge to surgeons. There are some patient factors such as age and gender that cannot be changed, and comorbid conditions can be optimized but not eliminated. The purpose of this study was to identify the risk factors affecting high mortality after the surgical repair of an RAAA. METHODS: Data on 121 patients who underwent surgical repair for RAAAs between January 1997 and June 2011 in our institution were collected retrospectively. All the patients had been diagnosed by computed tomography (CT) scans, and intraoperative extra-luminal blood was visualized intraoperatively. Variables studied comprised demographic data; preoperative, operative, and postoperative data; and the causes of mortality. Multivariate regression analysis was used to determine the predictors of mortality. RESULTS: One hundred eight (89.2%) patients were male and 13 (10.7%) were female at an average age of 68.9 ± 10.5 years. Totally, 121 patients underwent surgery for RAAAs. Fifty-four patients had aortic tube grafts, 32 aortobiiliac grafts, 20 aortobifemoral grafts, 1 aortoiliac graft, and 1 aortofemoral graft for the replacement of the RAAAs. Seven patients had only surgical exploration. Operative mortality was 41.3% (50 patients). The factors associated with mortality were preoperative shock, free blood, positive inotropic agent, hematocrit value, and need for blood and plasma. In the multivariate analysis, preoperative shock and positive inotropic agents were found to be significant as the predictors of death (OR: 19.8, 95%CI: 3.2-122.8 and OR: 8.6, 95% CI: 2.9-26.3, respectively). CONCLUSION: This study revealed that the preoperative clinical findings affected the mortality associated with RAAAs.

Comparison of two different skin preparation strategies for open cardiac surgery.

INTRODUCTION: Surgical site infection (SSI) is a serious complication after cardiac surgery; skin preparation is an important step in the prevention of wound contamination with skin flora. In this study, two different skin preparation strategies (standard povidine iodine cleaning plus plain adhesive drape and microbial sealant (InteguSeal, Kimberly-Clark Health Care, Roswell, GA, USA) were compared in cardiac surgery patients. METHODOLOGY: This prospective study included 96 cardiac surgery patients randomized to either a standard plain adhesive drape (28 patients, control group) or a microbial sealant (68 patients, study group). Bacterial isolates were obtained from the wounds in the operating room before the skin incision and after the surgical procedure had ended. RESULTS: Microorganisms were isolated from 38 patients (39.6%) in the study population. Twenty-seven of these patients were from the microbial sealant group and 11 were from the plain adhesive drape group. No postoperative wound infection was encountered in either group. No statistically significant differences between the two groups regarding the number of patients with microorganism isolation (p = 0.974) or postoperative leukocyte counts and neutrophil granulocyte percentages were observed. CONCLUSIONS: Regarding SSI after cardiac surgery, microbial sealant is equivalent to the standard skin preparation strategy applied with povidine iodine cleaning and a plain adhesive drape.

Cause of a rare acute renal insufficiency: rupture aortocaval fistula.

INTRODUCTION: Abdominal aortic aneurysms can be complicated by some conditions and aortocaval fistula is one of them. Aortocaval fistula is an unusual entity. CASE REPORT: A male patient was admitted to the hospital for abdominal pain and leg oedema of three days duration. In addition, severe anuria was also noted. We determined a fistula from the right lateral wall of aneurysm to the distal of vena cava inferior. The aortocaval fistula was closed with pledged-reinforced 4/0 polypropylene suture in the aneurysmal wall. At the postoperative 10th day, he was discharged with normal renal function. DISCUSSION: After a long-term untreated fistula, right-sided heart failure, acute renal and hepatic insufficiency, deep vein thrombosis and pulmonary thrombo-embolism can be seen in these patients. Increased venous pressure should be the reason for decreased arterial flow results in renal insufficiency. Emergency intervention in these patients saves the patient's life as well as prevents irreversible organ failure.

Early type II endoleak repair after endovascular therapy in Behcet's disease.

Vascular complications of Behçet's disease include occlusion of vessels and arterial aneurysm formation, which is prone to rupture. Early type II endoleak repair following an endovascular stent-graft procedure for a ruptured descending aortic aneurysm in a 31-year-old man with Behçet's disease is described. Endovascular stent-grafts provide an important alternative in complicated cases, but the possibility of endoleak should be born in mind.

Does on-pump normothermic beating-heart valve surgery with low tidal volume ventilation protect the lungs?

BACKGROUND: Postoperative pulmonary dysfunction following cardiopulmonary bypass (CPB) usually develops secondary to the inflammatory process with contact activation, hypothermia, operative trauma, general anesthesia, atelectasis, pain, and pulmonary ischemia/reperfusion due to cross-clamping. The aim of the present study was to evaluate the effects of an on-pump, normothermic, and beating-heart technique and of low-volume ventilation on lung injury. METHODS: We compared the results for 20 patients who underwent operations with an on-pump, normothermic, and beating-heart technique of mitral valve surgery with low-volume ventilation (group 1) with the results for 23 patients who underwent their operations with an on-pump, hypothermic cardiac-arrest technique (group 2). In both groups, blood samples were collected from the right superior pulmonary vein, and inflammation and oxidative stress markers (malondialdehyde, lactic acid, platelet-activating factor, and myeloperoxidase) were studied. RESULTS: Malondialdehyde, myeloperoxidase, and lactate values were significantly lower in group 1 than in group 2 just before the termination of CPB (P < .05). We observed no differences between the 2 groups with regard to values for platelet-activating factor. CONCLUSIONS: Inflammation and oxidative stress markers were lower in the group of patients who underwent beating-heart valve surgery with low-volume ventilation. These results reflect less of an ischemic insult and lower inflammation compared with the results for the patients who underwent conventional operations.

Beating heart versus conventional mitral valve surgery.

OBJECTIVES: The present study aimed to compare the results of beating heart technique and conventional mitral valve surgery (MVS). METHODS: Three hundred and nineteen patients who underwent MVS between April 2005 and December 2006 were enrolled in the study. While 125 patients underwent beating heart MVS (group 1), the conventional approach was used for 194 patients (group 2). Of those patients who underwent beating heart MVS, 75 underwent MVS without cross-clamping the aorta. Coronary sinus retroperfusion was used during surgery in the remaining 50 patients. The right anterolateral thoracotomy was performed in nine out of the 29 patients requiring re-operation, while resternotomy was performed in 20. RESULTS: No significant differences were shown between the groups in the preoperative period in terms of the Parsonnet mortality score, Ontario mortality score, and length of intensive care stay. However, there were significant differences with respect to EuroSCORE risk score, EuroSCORE mortality, and Parsonnet risk score, and length of hospital stay according to Ontario risk scoring. It was established that the patients in group 1 had a shorter length of hospital stay [group 1: six days (range, 4-37 days); group 2: 10 days (range, 4-62 days)]. Group 1 was observed to have shorter time periods when the groups were compared regarding operative time [group 1: 130 min (range, 100-270 min); group 2: 240 min (range, 100-360 min)], cross-clamping (XCL) time [group 1: 27.5 min (range, 3-99 min); group 2: 60.5 min (range, 30-163 min)], and cardiopulmonary bypass time [group 1: 57 min (range, 22-150 min); group 2: 90 min (range, 39-388 min)]. There were also significant differences in favor of group 1 in terms of postoperative need for inotropic support [group 1: 26 patients (16%); group 2: 68 patients (35%)]. Although there were no statistically significant differences in the groups in terms of mortality rates according to the Parsonnet scoring system, with the exception of the moderate risk group, it was noted that the mortality rates in the beating heart group were lower. CONCLUSIONS: This study concluded that beating heart MVS can be performed successfully, particularly for patients at higher risk which will lead to increased morbidity and mortality in postoperative period.

Post-traumatic tricuspid insufficiency: a case report.

Post-traumatic tricuspid insufficiency is a rare complication of chest trauma. An 18-year-old male patient was injured in a bicycle accident from his abdominal and anterior chest wall. The tear on the inferior diaphragmatic surface of the heart was repaired with primary sutures by the attending surgeon. Eighteen years later, he was admitted to the hospital with severe tricuspid regurgitation (3+/4+). During the operation, the valve was determined unsuitable for repair and was replaced with a bioprosthesis. The hemodynamic aberrations relevant to an isolated tricuspid valve injury are very often well-tolerated. Reconstructive surgery may be possible in the early period. In the late cases, repair is sometimes not feasible due to degeneration of the valvular apparatus. Replacement with a biological prosthesis may give the best long-term results in longstanding cases.

Treatment of mechanical aortic valve thrombosis: fibrinolytic treatment versus surgical intervention: result of eight cases.

OBJECTIVE: : Thrombosis of mechanical heart valve prosthesis is a rare fatal complication after heart valve replacement. Although surgical intervention is the suggested treatment in many series, fibrinolytic treatment offers a good alternative. We describe eight cases with mechanical aortic valve thrombosis and compare their results after fibrinolytic treatment or redo aortic valve replacement. METHODS: : Between February 2008 and March 2009, eight patients with previous mechanical prosthetic aortic valve replacement history were admitted to our center with mechanical aortic valve thrombosis. Four patients were operated, and the remaining four patients received low-dose fibrinolytic treatment. All patients' data were collected prospectively. RESULTS: : Two of the four operated patients died. In the fibrinolytic group, all patients totally recovered, and there was no mortality or morbidity during the follow-up period. CONCLUSIONS: : We thought that fibrinolytic treatment is a feasible and effective method for thrombosed mechanical aortic valve. However, much more populated patient groups are needed for the vigorous inference.

Primary cardiac myxomas: clinical experience and surgical results in 67 patients.

BACKGROUND: Primary cardiac tumors are rarely seen and have an incidence of 0.3% of all open-cardiac operations. Among those, myxoma is the most common cardiac tumor. There are only a few reports of such tumors from Turkey. METHODS AND RESULTS: We report our experience with 67 patients with primary cardiac myxoma operated on at our institute between December 1990 and October 2006. The study group comprised 22.38% males and 77.61% females with a mean age of 46.29 (+/-18.29) years. The predominant symptoms were dyspnea and palpitation. In addition, 3 patients presented with peripheral embolism with impending limb ischemia that necessitated emergency embolectomy. Echocardiography was generally enough for the demonstration of the myxomas. Two sporadic myxomas (%2.98) and one familial myxomas (1.49%) presented with recurrence. There were three (4.47%) hospital mortalities. Two patients (2.27%), with preoperative decompensation, died after tumor resection, from progressive low cardiac output. One patient, with preoperative massive pulmonary embolus, died two days after operation, from right ventricle insufficient. CONCLUSION: In conclusion, we herein summarized surgical results with primary cardiac myxomas. Surgical excision of primary cardiac myxomas tends to show excellent results after surgical excision.

Residual postmyocardial infarction ventricular septal defect repair through right atrium with right thoracotomy on beating heart technique.

BACKGROUND AND AIM: The incidence of residual opening after repair of postmyocardial infarction ventricular septal defect (VSD) was reported to be 10% to 25%. Redo surgery with remedial sternotomy is more complex than primary surgery and is consequently associated with higher mortality and morbidity due to the myocardial and patent coronary grafts injury during pericardial dissection. METHODS: A 59-year-old female patient had coronary artery bypass grafting and closure of post myocardial infarction ventricular septal defect with patch 10 months earlier in a different cardiac center. She was admitted to the hospital for severe congestive heart failure. RESULTS: She was operated because of the residual opening after repair of post myocardial infarction ventricular septal defect. Post myocardial infarction ventricular septal defect closure was performed through the right atrium by on-pump beating heart technique via the right thoracotomy. CONCLUSIONS: Closure of post myocardial infarction ventricular septal defect with this technique offers an alternative and safe approach to repair of the residual VSD when the coronary bypass grafts are patent.