Coronary artery bypass surgery in a patient with a functional single lung.

Destroyed lung and pneumonectomy are associated with anatomic and physiologic changes that may interfere with the conduct of subsequent open heart surgery. Here we report a case of an autopneumonectomized patient who required open heart surgery. The preoperative, intraoperative and postoperative management of this patient was unique. Open heart procedures on patients with a single lung can be performed with acceptable operative mortality and morbidity.

Conduction disturbances in coronary artery bypass surgery.

BACKGROUND: Conduction disturbances are very common after coronary artery bypass grafting (18-45%). Long cross-clamp time, method of cardioplegia, depth of hypothermia, and patient age are some of the risk factors. We planned this study to ascertain the effect of crystalloid or tepid blood cardioplegia (CP) on conduction disturbances. METHODS: One hundred patients were randomly divided into two groups. The first group received tepid blood CP and the second received cold crystalloid CP. St. Thomas II CP was used as CCP and the same CP was mixed with blood with a ratio of 4:1 in the tepid CP group. In both groups as an initial bolus, a 10 to 15 ml/kg CP was infused with a pressure of 75 mmHg. Additionally, 400 ml of CP were given every 20 min during the cross clamping period in addition to infusion of 50-100 ml of CP after each distal anastomosis. Blood samples for CK, CK-MB, LDH and Troponin T measurements were obtained at induction, before bypass, after cross clamping, before de-clamping, after de-clamping and after bypass. Postoperative ECGs were analyzed by a cardiologist. RESULTS: There were no deaths in both groups but the mean hospitalization was 8.4 +/- 1.7 days in group I, and 14.4 +/- 3.1 days in group II (P=0.004). Although there were significant rises in CK, CK-MB, LDH and Troponin T levels in both groups after CPB or de-clamping, the difference in increment between the two groups was not significant. Twelve patients in group II (24%) developed new fascicular blocks, four of these caused hemodynamic instability and needed inotropic treatment but only one was discharged with LAHB. Four patients in group I (8%) also developed new conduction disturbances within the first hour, but all completely resolved. Incidence of conduction disturbances was significantly increased in the crystalloid CP group (P=0.019). CONCLUSION: There were no significant differences in cardiac enzyme measurements between cold crystalloid and tepid blood CP, but crystalloid CP caused more fascicular blocks. We conclude that myocardial protection was equal in both cardioplegia methods whereas conduction disturbances have been assumed to be caused by cold injury to the conduction tissues.

Comparative study of microfibrillar collagen hemostat (Colgel) and oxidized cellulose (Surgicel) in high transfusion-risk cardiac surgery.

OBJECTIVE: The effects of microfibrillar collagen hemostat (Colgel) and oxidized cellulose (Surgicel) on bleeding and allogeneic transfusions were compared in cardiac operations with a predicted high risk of bleeding. METHODS: Between August 1999 and November 2001, 71 patients undergoing elective, high risk of bleeding operations were studied after giving informed consent. The procedures included repeat cardiac operations (aorta-coronary bypass operations or valvular operations), ascending aortic aneurysm repair necessitating deep hypothermic circulatory arrest, and ascending aortic grafting without deep hypothermic circulatory arrest. Subjects were excluded if they had recent (<5 days) acetylsalicylic acid ingestion, thrombolytic therapy, or anticoagulant therapy (heparin <4 hours preoperatively or warfarin <3 days preoperatively). Consenting subjects were randomized to receive either Colgel or Surgicel. RESULTS: Chest tube drainage in the first 24 hours was 373 +/- 143 mL in the Colgel group and 571 +/- 144 mL in the Surgicel group (P =.01). Total postoperative chest tube drainage was 423 +/- 154 mL (range, 280-1100 mL) in the Colgel group and 677 +/- 128 mL (range, 285-1350 mL) in the Surgicel group (P =.01). In addition, chest tube drainage was compared between the 2 groups every 3 hours after operation. Blood loss in the first 3 postoperative hours was significantly less in the Colgel group (132 +/- 41 vs 228 +/- 57 mL, P <.001). In the following 3-hour interval, this significant difference persisted (67 +/- 24 vs 121 +/- 49 mL, P <.001). CONCLUSIONS: In conclusion, the easy application, low cost, and significant blood-loss reduction effect of microfibrillar collagen powder renders this agent attractive for cardiac operations associated with high risk of bleeding.

Primary benign schwannoma of the heart.

We report herein a case of a 61-year-old woman who was found to have a mass adjacent to the left atrium. The tumor was resected giving least damage to the left atrium on cardiopulmonary bypass with a subsequent histological diagnosis of a schwannoma. Neurogenic tumors comprise 10% to 34% of mediastinal tumors. Nerve sheath tumors are more common in adults than in children, and these are equally malignant in children and adults. Nerve sheath tumors of the heart are extremely rare. Although there are many malignant cardiac neurilemomas reported, only a few cases of benign schwannomas have been reported. We describe a rare primary benign schwannoma of the left atrium.

Antiarrhythmic effect of magnesium sulfate after open heart surgery: effect of blood levels.

BACKGROUND: Arrhythmias following cardiac surgery is still a difficult complication to treat. Magnesium sulfate is an effective antiarrhythmic agent with negligible side effects. In this study, effects of magnesium sulfate as a first line antiarrhythmic agent was compared with results of two different well-accepted antiarrhythmic agents. METHODS: One hundred patients with arrhythmia were prospectively randomized to a study and a control group. Lidocaine and amiodarone were accepted as standard antiarrhythmic agents. Patients in study group were received magnesium sulfate routinely as a first line antiarrhythmic agent. Unresponsive arrhythmias were treated with standard antiarrhythmic agents. Control group patients received only standard antiarrhythmics. RESULTS: Magnesium sulfate alone was effective in 56% of the study group whereas 74% of the control group were responsive to standard antiarrhythmics (P=n.s.). In study group, a subgroup analysis according to blood levels of Mg2+ revealed that magnesium sulfate was more effective in patients with low Mg2+ levels (63% for low Mg2+ levels, 55% for normal Mg2+ levels, 36% for high Mg2+ levels) and ventricular arrhythmias (60% for ventricular and 40% for supraventricular arrhythmias), without statistical significance. CONCLUSIONS: Magnesium sulfate is an effective and safe antiarrhythmic agent for arrhythmias developed after open-heart surgery. Its antiarrhythmic effect may relate to its pharmacological properties and unrelated to normalization of the circulating magnesium concentrations. We recommend its use as a first line antiarrhythmic agent without routine measurement of blood levels.

Coronary endarterectomy with off-pump coronary artery bypass surgery.

BACKGROUND: The aim of this study is to review our experience in coronary artery endarterectomy performed without cardiopulmonary bypass. METHODS: Between May 1998 and June 2000 off-pump coronary endarterectomy was performed on 11 patients who had unstable angina pectoris. The mean ejection fraction (EF) was 26.3 +/- 4.4, and all of the patients were New York Heart Association (NYHA) III or IV. Off-pump open left anterior descending (LAD) endarterectomy was performed on 7 patients, and closed endarterectomy of the right coronary artery (RCA) was done on the remaining 4. RESULTS: There were no deaths. None of the procedures was converted to on-pump operation; all the endarterectomies and bypasses were performed on the beating heart. All patients were completely revascularized, the left internal mammary artery was bypassed to the LAD in all operations, and all other grafts were of saphenous vein. At the end of the first year all bypasses to the endarterectomized arteries were patent. The overall patency rate was 95.6%. The mean postoperative EF was 34.7 +/- 9.1, which was significantly higher than the preoperative one (p < 0.05). At the end of the first year 9 patients were NYHA I or II and all were angina free in Canadian Cardiovascular Society class 0 or I. CONCLUSIONS: Endarterectomy without cardiopulmonary bypass can be performed in patients with severe left ventricular dysfunction who are expected to benefit from the complete revascularization.

Acute pulmonary hypertensive crisis after TAPVC repair treated with atrial septectomy with inflow occlusion. Total anomalous pulmonary venous connection.

Acute pulmonary hypertensive crisis is a fatal complication after obstructive TAPVC repair. An atrial septectomy or enlargement of a small ASD could be a lifesaving procedure in order to maintain cardiac output in severe cases. This procedure can be accomplished with inflow occlusion in patients with critical condition.

The effect of preoperative digitalis and atenolol combination on postoperative atrial fibrillation incidence.

PURPOSE: The most frequent arrhythmia after coronary artery bypass surgery is atrial fibrillation (AF). The prevention and treatment of this type of arrhythmia is subobtimal. Digitalis, beta-blockers, diltiazem and amiodarone are the preferred drugs for the treatment. This study was designed to compare the effects of preoperatively started digitalis and atenolol in combination and separately, on the incidence of AF that occurs within 7 days following the operation. MATERIALS AND METHOD: One-hundred and sixty patients who had similar demographic properties were randomly grouped as group I, that preoperatively received combined drug therapy (n=40), group II preoperatively used digitalis (n=40), group III atenolol (n=40), and group IV was the control group (n=40). RESULTS: Postoperative AF incidence was 25, 15,4, and 17,9% in groups IV, III, and II, respectively, whereas it was 5% in group I which was lower than all other groups, but the difference was only significant between groups I and IV (P=0.012). CONCLUSION: The combined use of atenolol and digitalis preoperatively was considered as an efficient treatment for lowering the incidence of AF following coronary artery bypass surgery.

Prolonged pleural effusion following Fontan operation: effective pleurodesis with talc slurry.

Prolonged pleural effusions following a Fontan operation are a difficult problem. Although fenestrations and embolizations of systemic-pulmonary artery collaterals were suggested to treat and to decrease the risk of this complication, talc slurry pleurodesis may successfully augment and accelerate the beneficial effects of those techniques against the resistant effusions.

Off-pump coronary artery bypass surgery in the left ventricular dysfunction.

OBJECTIVE: The purpose of this study is to report our experience in off-pump coronary artery surgery in patients who have left ventricular dysfunction. METHODS: Off-pump coronary artery surgery was performed to 48 patients who were chosen randomly among 265 patients having two or more coronary artery disease and whose ejection fraction (EF) was less than 30%. In these patients fractioned shortening (FS) was evaluated by echocardiography, EF with multiple gated acquisition (MUGA) and ischaemic regions with myocardial perfusion scintigraphy both pre- and postoperatively. Coronary artery angiography was done to all patients at the end of the 1st year and patients were evaluated according to New York Heart Association (NYHA) classification. RESULTS: There were three deaths. The clinical situations of 41 of 45 patients (91.1%) improved after the operation. These four patients who didn't improve in NYHA status were the ones in whom complete revascularization couldn't be done. The FS and EF values were significantly increased at the 1st month, and 1st year. The constant perfusion defects and irreversible damaged areas changed into dynamic myocardial tissue in the 1st year scintigraphies. DISCUSSION: Off-pump CABG can be done with an acceptable mortality and clinic results in patients who have ventricular dysfunction.