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.

Open heart surgery in patients with end-stage renal failure: fifteen-year experience.

OBJECTIVE: Risk factors and results of cardiac surgery with cardiopulmonary bypass (CPB) in hemodialysis-dependent renal failure patients at our center were evaluated. METHODS: Out of 16,425 patients undergoing open heart surgery with CPB at our center between January 1991 and April 2006, 91 (0.6%) experienced hemodialysis-dependent end-stage renal failure. Preoperative, operative, and postoperative findings of two groups of patients were evaluated: those with normal renal function (control group) and those with chronic renal failure undergoing regular hemodialysis (HDRF group). Survival analyses of the hemodialysis group of patients were performed. RESULTS: In the hemodialysis group, 54 (59.3%) patients underwent coronary artery surgery, 31 (34.1%) patients had valve surgery, four (4.4%) patients had aortic surgery, and two others (2.2%) experienced concomitant coronary and peripheral artery surgery. CPB and aortic cross-clamping (ACC) times were longer in the HDRF group (p=0.000 and 0.002, respectively). There was no significant difference between the two groups with regard to either reoperations, infections, pulmonary and gastrointestinal system complications, or cerebrovascular event parameters (p=0.167, 0.341, 1.000, 1.000, and 1.000, respectively). There was no difference between groups in the postoperative development of low cardiac output (p=0.398). The early mortality rate was 7.7% (seven patients) in the HDRF group and 4.8% (780 patients) in the controls (p=0.211). The actuarial survival rates in HDRF survivors at one, two, three, four, five, and ten years were overall 86%, 80%, 68.1%, 45.4%, 20%, and 6.8%, respectively. CONCLUSIONS: Open heart surgery in hemodialysis patients is associated with a higher incidence of risks, but can be performed with acceptable operative complications and mortality with an effective hemodialysis program.

What to expect after tricuspid valve replacement? Long-term results.

OBJECTIVE: Current knowledge in long-term results of tricuspid valve replacement is limited. Present study reviews our experience from a consecutive series. METHODS: Forty-two patients (16 male, 26 female; mean age: 33+/-15) underwent tricuspid valve replacement between March 1987 and December 2004. The etiology was rheumatic in 64%, Ebstein's anomaly in 31%, and endocarditis in 5%. Nineteen patients were in New York Heart Association (NYHA) Class III functional capacity (45%), and 13 in class IV (31%). Twenty patients (48%) underwent isolated tricuspid valve replacement. The remaining underwent combined (mitral and/or aortic) valve replacements. Tricuspid replacement device was mechanical in 31% and bioimplant in 69%. RESULTS: Hospital mortality was 26%. Rheumatic etiology, reoperation and elevated pulmonary artery pressure were associated with higher early mortality. The patients with decreased functional capacity (NYHA Class III/IV), congestive symptoms and rheumatic origin were more prone to low cardiac output development. The Kaplan-Meier survivals were 37% at 10 years and 30% at 15 years. The 10-year event-free survival was 31%. Elevated pulmonary artery pressure and rheumatic etiology unfavorably affected the long-term results. The average functional capacity in survivors improved significantly after operation. CONCLUSIONS: Any tricuspid disease not amenable to repair thus necessitating replacement is an unfortunate situation since both the short and long-term results of valve replacement are suboptimal in regard to those of left-sided valve replacements, probably due to different structural and geometrical characteristics of right ventricle and the low-pressure venous system hemodynamics. Etiology, clinical presentation and pulmonary vascular hemodynamics are major determinants of the outcome.

[Effects of combined mitral valve replacement and radiofrequency atrial ablation in chronic atrial fibrillation]. / Kronik atriyal fibrilasyonda mekanik mitral kapak replasmani ile birlikte radyofrekans atriyal ablasyonun etkinligi.

OBJECTIVE: The aim of the study is to find out the efficacy of radiofrequency catheter atrial ablation (RF) simultaneously done with mitral valve replacement (MVR) surgery in patients having rheumatic mitral valve disease with chronic atrial fibrillation and to evaluate the short-term postoperative results. METHODS: Seventeen patients underwent MVR surgery, and intraoperative RF procedures were done simultaneously with MVR to eight of these patients, whereas remaining nine of them were assigned to control group. Patients were assessed preoperatively, at time of discharge, and 1st, 6th and 12th months controls. Atrial and ventricular functions were evaluated with echocardiography, serum atrial natriuretic peptide (ANP) levels were investigated and electrocardiograms were recorded in all patients. RESULTS: Demographically there were no significant differences between two groups. Radiofrequency ablation group had longer aortic cross-clamping and cardiopulmonary bypass times. Sinus rhythm was established in seven patients of RF group at postoperative 12th month. However, all patients of this group experienced sinus rhythm at postoperative sixth month whereas 'atrial kick' was detected in five of them. Significantly increased ejection fraction, decreased pulmonary artery pressure and decreased left atrial diameter were observed in RF group compared to control group. Serum ANP levels were found to be significantly decreased as compared to preoperative periods in both groups. CONCLUSION: Although RF ablation has higher costs, this technique is efficient and useful to restore the sinus rhythm and to recover the atrial functions back in patients having rheumatic mitral valve disease.

An unusual combination: aortic arch coarctation associated with Dandy-Walker variant.

We report on a 29-year-old woman with aortic arch coarctation with cerebral anomalies including posterior fossa cyst, hydrocephalus, cerebellar vermis hypoplasia and multiple congenital anomalies including hirsutism, hipotelorism, shortened philtrum, unregulated teeth and short alveolar crest, rotated auricles, short and webbed neck, hypopigmentation on the scalp, bilateral clinodactyly, bilateral hallux valgus, brachydactyly on the left foot 3rd finger, hemangioma on the sacrum. An extra-anatomical bypass was made by grafting from the ascending to the distal descending aorta. Some of these features are consistent with the diagnosis of the other clinical syndromes except genetical expression, no chromosomal deletions in our patient with normal familial pedigree, however, cerebral anomalies are consistent with the Dandy-Walker variant. To the best of our knowledge, literature contains no other report of the association of aortic coarctation, Dandy-Walker variant with these clinical features. These previously undescribed combinations, however, raise the possibility of a newly recognized disorder.

Acute renal failure following open heart surgery: risk factors and prognosis.

BACKGROUND: Acute renal failure (ARF) development after cardiac surgery carries high mortality and morbidity. METHODS: Out of 14437 consecutive patients undergoing open-heart surgery between January 1991 and May 2001, 168 (1.16%) developed postoperative ARF mandating hemodialysis. Possible perioperative risk factors, and the prognosis of this dreadful, often fatal complication were investigated. RESULTS: The mortality rate in this group was 79.7% (134 patients). The risk factors associated with postoperative ARF were advanced age (p=0.000), diabetes mellitus (p=0.000), hypertension (p=0.000), high preoperative serum creatinine levels (p=0.004), impaired left ventricular function (p= 0.002), urgent operation (p=0.000) or reoperation (p=0.007), prolonged cardiopulmonary bypass (CPB) (p =0.000) and aortic cross-clamp (ACC) (p =0.000) periods, level of hypothermia (p =0.000), concomitant procedures (p =0.000), low cardiac output state (p =0.000), re-exploration for bleeding or pericardial tamponade (p =0.000), and deep sternal or systemic infection (p = 0.000). Of those who could be discharged from hospital, renal functions were restored in 21 patients (12.5%); however, eight patients (4.7%) became hemodialysis dependent. The mean follow-up period was 5.7+/-3.2 years (range: 4 months to 13 years; a total of 195 patient-years), and 10-year survival was 58.6+/-10.2% in the discharged patients. CONCLUSIONS: ARF development after cardiac surgery often results in high morbidity and mortality. Recognizing risk factors permits the timely institution of proper treatment, which is the key to reducing untoward outcomes.

Repair of the aortic arch with left unilateral selective cerebral perfusion.

A 67-year-old woman who presented with chest and back pain was diagnosed with an aneurysm of the ascending aorta. Coronary angiography and aortography were performed via the right brachial artery, which was complicated by axillary artery dissection. At surgery, despite our clinical experience of using the right upper brachial artery for arterial cannulation, right femoral artery cannulation was performed to establish cardiopulmonary bypass (CPB) as the dissection was extending to the brachiocephalic artery. The aortic crossclamp was placed on the arch of the aorta just after the origin of the brachiocephalic artery so that cerebral perfusion was performed via the left common carotid and left vertebral and basilar arteries through the left subclavian artery. No neurologic event was observed during the intensive care unit stay and follow-up period. To the best of our knowledge, the literature contains no other report of the use of only the left carotid and subclavian arteries to perfuse cerebral structures during CPB.