Treatment of Brucella endocarditis: 15 years of clinical and surgical experience.

BACKGROUND: Brucella endocarditis is a life-threatening complication of human brucellosis. In this study, our aim was to evaluate the effects of combined medical and surgical treatment in the midterm to long term. METHODS: We retrospectively analyzed 13 patients (mean age 44 +/- 18 years; 8 males) who were operated on from January 1993 to June 2009. Duke criteria were used for the diagnosis of endocarditis. The primary endpoint was defined as the overall mortality and readmission to the hospital during early and late follow-up periods. The other collected data included baseline and follow-up clinical findings, along with echocardiographic and laboratory measurements. RESULTS: No patients died in the early period (up to 1 month) and 2 patients (15.3%) died during the late follow-up period. Aortic valve disease was observed in 11 of 13 patients (85%). The most commonly performed procedure was aortic valve replacement (10 of 13 patients; 77%) during a mean follow-up period of 95 +/- 60 months (range, 10 to 184; median, 74). CONCLUSIONS: For Brucella endocarditis, perioperative antibiotic therapy combined with surgical treatment (prosthetic valve replacement) has satisfactory results and increases the quality of life in the long-term follow-up.

Elective shunt use for easy resection of a carotid body tumor.

Carotid body tumor resection has the potential hazards of hemorrhage, cranial nerve palsy, and cerebrovascular accident. The control of intraoperative bleeding during manipulation of the tumor is a critical issue for safe resection. In the presented case with a carotid body tumor, the Shamblin II, a carotid shunt with a dual balloon was used electively. The aim of shunt use was partial isolation of the tumor from carotid arterial circulation in a short time only. Shunt use may facilitate safe and easy resection.

Surgical treatment of post-infarction left ventricular pseudoaneurysm: a two-decade experience.

Herein, we present a retrospective analysis of our experience with acquired pseudoaneurysms of the left ventricle over a 20-year period.From February 1985 through September 2004, 14 patients underwent operation for left ventricular pseudoaneurysm in our clinic. All pseudoaneurysms (12 chronic, 2 acute) were caused by myocardial infarction. The mean interval between myocardial infarction and diagnosis of pseudoaneurysm was 7 months (range, 1-11 mo). The pseudoaneurysm was located in the inferior or posterolateral wall in 11 of 14 patients (78.6%). In all patients, the pseudoaneurysm was resected and the ventricular wall defect was closed with direct suture (6 patients) or a patch (8 patients). Most patients had 3-vessel coronary artery disease. Coronary artery bypass grafting was performed in all patients. Five patients died (postoperative mortality rate, 35.7%) after repair of a pseudoaneurysm (post-infarction, 2 patients; chronic, 3 patients). Two patients died during follow-up (median, 42 mo), due to cancer in 1 patient and sudden death in the other. Although repair of left ventricular pseudoaneurysm is still a surgical challenge, it can be performed with acceptable results in most patients. Surgical repair is warranted particularly in cases of large or expanding pseudoaneurysms because of the propensity for fatal rupture.

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.

Pedicled right internal mammary artery for reoperative off-pump revascularization of left anterior descending coronary artery.

In situ right internal mammary artery is the graft of choice in reoperative off-pump coronary artery bypass grafting, as well as in primary on-pump coronary artery bypass grafting, unless the vessel has been used previously. However, there are not enough data about postoperative angiographic findings of the in situ right internal mammary artery in reoperative coronary artery bypass grafting with the off-pump technique. From September 1993 through January 2004, we reviewed the postoperative course and the graft patency of 12 selected patients who underwent off-pump coronary artery bypass grafting reoperation only for revascularization of the left anterior descending artery, by means of a pedicled right internal mammary artery graft. All patients were evaluated clinically and by postoperative coronary angiography. There were no early or late deaths during the mean follow-up period of 33.08 +/- 30.05 months (range, 1-77 months). The mean interval from the 1st operation to the 2nd operation was 74.1 +/- 57.01 months (range, 4.5-171 months). Postoperative coronary angiograms of all patients showed a 100% patency rate for both in situ grafts and composite grafts. We suggest that use of the in situ right internal mammary artery in off-pump coronary artery bypass grafting is a safe and reliable option for revascularizing the left anterior descending artery, especially in reoperation.

Double-patch repair of postinfarction ventricular septal defect.

We report 4 consecutive cases in which the double-patch technique was used to repair an inferior postinfarction ventricular septal rupture. The ventricular septal perforation was closed directly by stitching, with the same sutures, 2 autologous pericardial patches onto both sides of the affected septum, through only a left ventriculotomy. Complete closure of the defect was accomplished, and no residual shunt was observed in any patient. This technique appears to be useful in selected cases, such as ventricular septal perforation with myocardial infarction in the subacute or chronic phase, especially in instances of inferoposterior infarction. Further experience is needed to verify its safety and efficacy.

Surgical treatment of aortobronchial and aortoesophageal fistulae due to thoracic aortic aneurysm.

We present a review of our single-institution experience, over 19 years, with aortobronchial and aortoesophageal fistulae due to descending thoracic aortic aneurysm. We conducted a retrospective chart review of 10 cases involving surgery for aortobronchial and aortoesophageal fistulae in our clinic from February 1985 through October 2004. Pathologic or predisposing conditions associated with aortobronchial fistula were descending thoracic aortic aneurysm (n=8), previous aortic surgery (n=1), and concomitant aortoesophageal fistula (n=1). Three patients presented emergently with aortobronchial fistula (n=2) and aortoesophageal fistula (n=1). Ages of the 10 patients ranged from 42 to 74 years (median, 63 years). The median cross-clamp time was 34 minutes (range, 27-41 min). Repairs, in 9 patients, involved an inlay of prosthetic tube graft using the clamp-and-sew technique, and in 1 patient repair involved patch aortoplasty. The operative mortality rate was 20%:1 patient had acute concomitant aortoesophageal and aortobronchial fistulae, and another had chronic aortobronchial fistula. There was no embolic stroke or paraplegia. During follow-up (median, 2.5 years), there were no deaths or postoperative morbidity We conclude that repair of aortobronchial and aortoesophageal fistulae using the clamp-and-sew technique can be performed with acceptable operative mortality and long-term results. However, the mortality rate continues to be highly significant in patients with acute bleeding aortobronchial fistula or with aortoesophageal fistula, despite rapid surgical intervention.