The evaluation of 13 patients with intrathoracic extrapulmonary hydatidosis.

Cases of intrathoracic extrapulmonary hydatid cysts are very rare. We identified 13 patients with intrathoracic extrapulmonary hydatid cysts in our clinic over 12 years. Four patients had extrapulmonary cysts only; nine patients had both intrapulmonary and extrapulmonary cysts. Cysts were identified in the pleural space, extrapleural region, diaphragm and chest wall. Thoracotomy was used in all patients, and extrapulmonary lesions were removed by cyst extirpation from surrounding tissue or by pericystectomy. In one patient with chest wall involvement, partial rib resections were performed because of rib destruction. In two patients with liver cysts passing through the diaphragm to the thorax, the diaphragm was cut, cysts on the liver roof were removed and then the diaphragm was repaired. There was no mortality, morbidity, or disease recurrence during the post-operative period in any of the 13 patients. We conclude that these rare cases give a new insight into hydatid cyst pathophysiology.

Reperfusion strategy after regional ischaemia: comparative study of reperfusion conditions and compositions.

We investigated the effects of pressure, temperature and additives on aortic root reperfusion success. Cardiopulmonary bypass and heart arrest were initiated in mongrel dogs and sudden uncontrolled normothermic (group 1), pressure controlled substrate enriched normothermic (group 2a), pressure controlled unmodified normothermic (group 2b) and pressure controlled unmodified tepid (group 3) reperfusion compared. In group 1, the first cardiac rhythm was ventricular fibrillation, but dogs in the other groups showed spontaneous sinus rhythm. Recovery times were significantly longer and cardiac output levels significantly decreased in group 1 compared with the other groups. Prolonged lactate production and oxygen uptake failure were observed in group 1 compared with the other groups; oxidative stress markers and microscopic studies confirmed significant tissue injury in group 1. All parameters were similar between groups 2a, 2b and 3, indicating that low reperfusion pressure in the first 2 min is the most effective component of reperfusion.

Reperfusion strategy after regional ischaemia: simulation of emergency revascularization and effects of integrated cardioplegia on myocardial resuscitation.

We induced ischaemia in the left anterior descending artery of 16 dogs while the heart was beating, followed by cardiopulmonary bypass (CPB), aortic cross clamping and blood cardioplegia. Half of the dogs received integrated blood cardioplegia and sudden uncontrolled reperfusion (group A) while the others received the same cardioplegia followed by pressure-controlled tepid initial reperfusion (group B). The effects on myocardial cell metabolism, oxidative stress and ultrastructure were recorded. The recovery period was significantly longer and cardiac output levels after CPB significantly lower in group A compared with group B. Group A showed a failure to uptake and utilize oxygen during the recovery period and significant lipid peroxidation. Marked tissue oedema was seen in group A but mitochondrial and organelle integrity was almost normal in both groups. We conclude that integrated cardioplegia could partially resuscitate the myocardium in this model, and pressure controlled reperfusion during the first 2 min is needed as an adjunct procedure.

Clinical experience of surgical therapy in 207 patients with thoracic hydatidosis over a 12-year-period.

PRINCIPLES: Hydatid disease is the most severe helminthic zoonosis, with a major medical, social, and economic impact in Turkey. The aim of this study was to evaluate retrospectively 207 patients diagnosed with hydatid cyst and treated surgically in our department between January 1990 and December 2001. METHODS: Hundred and ninety three patients were male and 14 female. They ranged in age from 19 to 72 years (mean 25.3 years). The most common presenting symptoms were cough, expectoration and chest pain. The surgical approach was thoracotomy in 198 patients, bilateral staged thoracotomies in 5 patients, median sternotomy in one patient and video-assisted thoracic surgery in 3 patients. RESULTS: Hundred and thirty eight of the 265 intrapulmonary cystic lesions were found in the right lung and 127 in the left lung. Intrathoracic extrapulmonary cystic lesions were detected in 13 patients. 38 patients also had cystic lesions in the liver. Conservative surgical procedures were adopted except for small wedge resections in 8 patients, segmentectomy in 4 patients and lobectomy in one. Operative and postoperative mortality was nil. Albendazole treatment was given to patients who had multiple intrathoracic cysts or additional hepatic cysts after 1994. CONCLUSIONS: Our preferred surgical techniques for removal of cysts were conservative surgical procedures such as enucleation of cysts or removal by cystotomy. Radical procedures such as pneumonectomy, lobectomy and segmentectomy should be avoided as far as possible.

[Clinical approach to trauma-related internal iliac artery pseudoaneurysms (two connected cases)]. / Travmaya bagli internal iliak arter pseudoanevrizmalarindaki klinik yaklasimimiz (iki olgu nedeniyle).

Penetrating injuries to abdomen and especially deep gluteal injuries causes vascular and non vascular injuries which necessitates emergency surgery. Surgical management of the penetrating injuries is very difficult, especially exploration of the gluteal region is very difficult. Management of the injury of iliac artery branches is extremely difficult. Two cases with penetrating injury to the gluteal region in 1998 and 2000 one was operated on urgently and the other was operated on electively. Coil embolization was tried to be performed for elective case but intervention was unsuccessful. In both cases internal iliac artery was ligated and aneurysm was repaired. There were no complications in postoperative period. In postoperative angiographic controls, aneurysm in the internal iliac artery was regressed and there were no vascular complications at this region such as hematoma. Penetrating injuries at gluteal region causes injury to the internal iliac artery branches which seriously necessitates emergency management, internal iliac artery ligation and repair.

Efficacy of topically applied glutamate-aspartate and pentoxifylline solutions in decreasing myocardial damage during open-heart surgery in rats.

During open-heart surgery, the period between cross-clamping and maintenance of homogeneous diastolic arrest is often accompanied by significant ischaemic-hypoxic injury. The topical application of glutamate-aspartate or pentoxifylline may reduce energy demands during this period and thus prevent myocardial damage. Fifty rats were divided into five groups. In group A (control) the pericardial cavity was opened, all inlet and outlet vasculature cross-clamped, and the heart excised after 60 s. In groups B-E, the pericardial cavity was opened, all inlet and outlet vasculature cross-clamped for 60 s (groups B and D) or 90 s (groups C and E), and the pericardial cavity filled with glutamate-aspartate solution (groups B and C) or pentoxifylline solution (groups D and E) for 2 min. Following clamping, blood was withdrawn from the right atrium for biochemical analysis, and the heart excised for histological analysis. Histopathological and biochemical analysis showed a significant reduction in ischaemic-hypoxic cardiac injury in rats treated with topically applied glutamate-aspartate or pentoxifylline.

Surgical approach to military vascular injuries.

PURPOSE OF THIS STUDY: Vascular injuries caused by high-velocity military missiles are associated with bone fracture, soft-tissue, nerve and tendon injuries. In this study we will discuss the surgical strategy and results of vascular injuries, which require a different approach from primary and elective surgical procedure. BASIC METHODS: Surgical interventions were performed in 116 patients. Vascular lesions were localized on the lower extremity in 53, upper extremity in 55, and nine were in other regions. Vascular injuries were concomitant with bone fracture in 46 and nerve injuries in 36 patients. Vascular repair was performed after orthopedic stabilization in vessels with an ischemic period of less than 4 hours. PRINCIPAL FINDINGS: Fasciotomy was performed after vascular repair in the 22 cases that had arrived after 8 hours. Amputation was required in two cases. There was one mortality. CONCLUSIONS: The best results are obtained when a multidisciplinary and emergency approach are used by the team of vascular, orthopedic, plastic and neurosurgeons who are experienced in military injuries.

Left ventricular endoaneurysmorrhaphy: effect on left ventricular size, shape and function.

Left ventricular (LV) endoaneurysmorrhaphy is a relatively new surgical procedure with excellent results. Forty-five patients underwent surgical repair of LV aneurysm with LV endoaneurysmorrhaphy from 1991 to 1995. The main indication for operation was angina pectoris (71%). Concomitant myocardial revascularization was performed in 97% of the patients. The operative mortality rate was 2.2%. Pharmacologic inotropic support was required in 31% and mechanical support in 15%. Mean echocardiographic ejection fraction improved from 29.6% preoperatively to 48.3% postoperatively (p <0.001). LV end-diastolic volumes were 195 +/- 63 and 118 +/- 44 ml before and after surgery (p <0.01). Intraoperative transesophageal echocardiography revealed normal or near-normal LV shape in all cases. The mean follow-up was 34.0 +/- 9.2 months (16-50 months) and 1 patient died 9 months postoperatively. We conclude that endoaneurysmorrhaphy improves LV geometry and function in patients with LV aneurysms and can be performed with low surgical risk even in patients with large aneurysms and severely depressed LV function. ........

Long-term prevention of atrial fibrillation after coronary artery surgery.

UNLABELLED: We researched the necessity of quinidine fumarate or acebutolol prophylaxis in patients in whom atrial fibrillation occurred in the postdischarge period and returned to sinus rhythm after coronary artery surgery. DESIGN: Prospective review. PATIENTS: Since 1992, 60 patients were chosen in whom atrial fibrillation occurred in early postoperative period. There were no significant differences between them and they were separated into 3 groups. In group I (20 patients) we did not give any drug, in group II (20 patients) quinidine fumarate was given and in group III (20 patients) acebutolol was given and patients were controlled for 90 days. RESULT: Atrial fibrillation occurred in one patient in group I, (5%), two in group II (10%) and two in group III (10%), (p < 0.05). Different from the other groups, atrial fibrillation was asymptomatic with low ventricular response in group III. CONCLUSIONS: There were no significant differences among three groups statistically, so we suggested that long-term prevention of atrial fibrillation with quinidine fumarate or acebutolol was not necessary after coronary artery surgery.

Aneurysms of the sinus of Valsalva.

OBJECTIVE: To evaluate the properties of the coexistent cardiac anomalies associated with the aneurysm of sinus of Valsalva (ASV) and examine the long-term surgical results after operation. PATIENTS: From 1980 to 1994, nine patients (median age 22 years) underwent surgical correction of ASV. Aneurysms originated from the right (n = 5), noncoronary (n = 3) and left coronary sinus (n = 1) and entered into right ventricle (n = 5), right atrium (n = 3). In one patient, ASV originated from the left coronary sinus and unruptured. Coexistent cardiac lesions were aortic valve insufficiency (n = 4), ventricular septal defect (n = 5), patent foramen ovale (n = 1), right ventricular outflow tract obstruction (n = 1) and coronary artery anomaly (n = 2). All patients were symptomatic (sudden onset of symptoms in 3, gradual onset in 6). INTERVENTIONS: Ruptured ASVs were repaired by double approach in which both the involved chamber and the aortic root. Concomitant aortic surgery was performed in four patients (2 replacement, 2 valvuloplasty). VSDs were closed by patch in 4 and by direct suture in 1. RESULTS: The incidence of coexisting coronary artery anomaly was 22.2%. There was no hospital and late mortality. The mean follow-up period was 6.8 years (range 1 to 14 years). There were no reoperation for leaks of VSD, recurrence of aneurysm and aortic regurgitation. Eight patients were found to be in New York Heart Association class I, one patient in class II. CONCLUSION: The risk of the recurrent fistula or VSD is prevented by double approach technique, and also this approach reduces the incidence of late aortic insufficiency. Routinely preoperative coronary angiography must be performed for determine of coronary anomaly.

Aneurysm of the membranous septum in adult patients with perimembranous ventricular septal defect.

OBJECTIVE: The aneurysm of the membranous septum (AMS) has often been considered as benign in the minds of many previous investigators. We have analyzed the complications with AMS in adult patients. METHODS: Fifty-one cases (20%) of AMS in 254 adult patients with perimembranous ventricular septal defect (VSD) are described. The diagnosis of AMS was based on angiographic criteria. Thirty-nine (76.5%) of the 51 patients with AMS were aged between 20 and 29 years. All patients but one with AMS had a pulmonary-to-systemic flow (Qp/Qs) of less than 2.3 (range 1-2.1, mean 1.4). In a patient who had a ruptured aneurysm, the Qp/Qs was 2.7. There were six main complications affected by AMS and/or VSD; aortic valve prolapse in 24 patients (47%), aortic regurgitation in 15 (29.4%), tricuspid insufficiency in nine (17.6%), right ventricular outflow tract obstruction in two (4%), and rupture of the aneurysm in one patient (2%). Seven patients (13.7%) had prior bacterial endocarditis. All patients underwent surgery. Aneurysm and VSD were closed by direct suture in nine and with a patch in 42 patients. Aortic valve repair was performed in 13 patients in whom regurgitation was mild to moderate, and replacement was required in two patients with severe aortic regurgitation. RESULTS: There were no early or late deaths. Residual communication and recurrence of the aneurysm was noted three and seven years postoperatively in two patients where VSD had been closed by direct suture. CONCLUSIONS: According to present data, aneurysm formation functionally reduces the VSD size, but it has the potential consequence of promoting tricuspid insufficiency, aortic valve prolapse, right ventricular outflow tract obstruction, rupture and bacterial endocarditis. Therefore, we recommend that AMS should be resected completely and the defect produced closed with a patch in order to prevent further enlargement and consequent complications even if there are no cardiac symptoms.

Missed arterial injuries in military patients.

BACKGROUND: Military vascular injuries frequently result from fragment wounds while civilian vascular injuries usually are caused by gunshot wounds. The natural history of untreated major injuries by small low velocity fragments is not well known. This study evaluated the nature of these wounds. METHODS: From 1990 to 1995, 40 patients with a delayed diagnosis of an arterial injury in the extremity, abdomen, or neck were treated. The median delay between injury and diagnosis was 60 days. All patients had been seen at other military hospitals immediately after trauma. RESULTS: During initial hospitalization, immediate exploration had been performed in 23 patients and arteriogram in 3 patients. According to analysis of the records of patients, none of them had hard signs of vascular injury at the time of initial evaluation after trauma. Complications of missed arterial injuries included the following: false aneurysm, 21 (52.5%); arteriovenous fistula, 14 (35%); and occlusion, 5 (12.5%). The superficial femoral artery (n = 11) was the most commonly injured vessel. The remaining arteries included the following: carotid, 2; vertebral, 1; subclavian, 5; axillary, 2; brachial, 3; radial or ulnar, 2; internal iliac, 2; common femoral, 1; profunda femoris, 2; popliteal, 1; tibioperoneal, 8. Thirty-eight patients had penetrating wounds (21 fragments, 9 gunshot, 3 shotgun, 5 stab wounds), and only 2 patients had blunt trauma. All patients underwent surgery. There were no deaths and no loss of extremity, but 10 patients had fair results and only 4 patients required later reoperation. CONCLUSION: Traumatic arterial injuries that particularly are caused by low-velocity small fragment wounds can result in serious delayed complications months or even years after the injury. Patients with penetrating injuries must be closely monitored, and arteriography is recommended to evaluate the conditions of patients with potential vascular injury even when overt clinical signs or symptoms of vascular injury are absent.

Postoperative use of aprotinin in cardiac operations: an alternative to its prophylactic use.

BACKGROUND: Aprotinin reduces blood loss after cardiopulmonary bypass. Although there can be little doubt about the efficacy of aprotinin, its safety has been questioned recently and is still under investigation. Because of the potential for complications and the high cost, a selective strategy limiting drug delivery to patients with established postoperative bleeding will be more reasonable. METHODS: In a prospective, randomized, double-blind trial we studied the effect of postoperative low-dose (2 million kallikrein inactivator units) aprotinin on blood loss and transfusion requirements in patients undergoing cardiopulmonary bypass. Fifty-seven patients were randomly assigned to two groups: aprotinin or placebo. RESULTS: The two groups were comparable in all demographic and surgical variables. Postoperative chest tube drainage was significantly less in the aprotinin group than in the placebo group (410 ml vs 696 ml, p < 0.01). The use of homologous blood products was significantly less in the aprotinin group than in the placebo group (0.4 +/- 0.5 unit vs 1.7 +/- 0.9 unit for packed red blood cells and 0.8 +/- 1.3 unit vs 2.3 +/- 1.6 unit for fresh frozen plasma). CONCLUSIONS: Our results suggest that postoperative aprotinin reduces blood loss and transfusion requirements and provides the opportunity to restrict its use selectively to patients with excessive postoperative bleeding.

Late posterior cardiac tamponade after open heart surgery.

OBJECTIVE: Late cardiac tamponade after open heart surgery is a relatively uncommon, but potentially serious complication. We retrospectively analyzed 14 patients who had posterior cardiac tamponade 13 to 210 days after open heart surgery. PATIENTS: Between May 1988 and July 1995, 3150 adult patients underwent open heart surgery at the Gülhane Military Medical Academy. In 35 of 3150 patients (1.11%) late pericardial effusions developed, and in 14 (0.44% of 3150 consecutive open heart surgery performed on adult patients in our center) of these patients had posterior tamponade. There were moderate symptoms including fatigue, malaise, and dyspnea on exertion in all patients. The diagnosis was made by echocardiography in 13 patients, and by tomographic scanning in 1 patient. Analysis of these 14 patients revealed that all of them had hemodynamic criteria consistent with tamponade physiology on right heart catheterization with Swan-Ganz catheters. RESULTS: Echocardiography guid pericardiocentesis through the left anterior axillary line was effective in decompressing of posterior cardiac tamponade in 10 of 14 patients. Three patients required operative surgical drainage after unsuccessful pericardiocentesis through subxiphoid area. Two patients who underwent surgical drainage died, and in one patient surgical pericardiotomy had complete evacuation of posterior pericardial fluid with major complication. CONCLUSIONS: 2-D echocardiography guid pericardiocentesis through left anterior axillary line was found to be a useful, safe, and simple technique. It can be used as an alternative treatment to surgical pericardiotomy for posterior cardiac tamponade after open heart surgery.

Coronary artery aneurysm associated with adult supravalvular aortic stenosis.

Two patients, aged 20 and 21 years, with supravalvular aortic stenosis and aneurysms of the coronary arteries are described. In supravalvular aortic stenosis, dilatation of the sinuses of Valsalva and multiple abnormalities of one or both coronary arteries are common. Aneurysm of coronary artery has not been well recognized as a lesion associated with supravalvular aortic stenosis. The operation in these patients was limited to relief of the supravalvular obstruction.

Repair of the left AV valve in atrioventricular septal defect in adults.

BACKGROUND: This study examined the septal cleft and septal commissure of the left atrioventricular (AV) valve, which are two different anatomical structures. METHODS: We presented 36 cases of adult partial atrioventricular septal defect. A distinction was made between patients based on the anatomy of the anterior leaflet of the left AV valve. The left AV valve appeared to be normal or to have minimal radial openings from the free edge of the anterior leaflet of the left AV valve in 10 patients (28%). There was a septal commissure structure in 8 (22%), and a septal cleft structure in 18 (50%) patients. In the commissure type anatomy, leaflet coaptation was usually adequate and no or mild degree of left AV regurgitation existed preoperatively. Cleft type structure usually was associated with some degree of left AV regurgitation. Attempts were made to close the septal clefts and leave the septal commissures unsutured during the repair of the partial AV septal defects. RESULTS: We have not found any increase of left AV regurgitation in patients with commissures during the follow-up period. Closure of the cleft successfully eliminated regurgitation. Long-term results for septal cleft and septal commissure after repair of partial AV septal defect were excellent with survival of 100% and freedom from reoperation of 100% at mean 6.5 years. CONCLUSIONS: Septal cleft and septal commissure should be considered two different structures. Repairing procedures for left AV valve abnormalities associated with partial AV septal defect should only be done in patients who have cleft type of leaflet structure.

Partially unroofed coronary sinus syndrome with persistent left superior vena cava, absent right superior vena cava and right-sided pericardial defect.

Partially unroofed coronary sinus syndrome with persistent left superior vena cava is a rare congenital anomaly. It frequently produces a right-to-left shunt. We report a case in which a large left-to-right shunt was present, because of the obstruction to left ventricular inflow as a result of the dilated coronary sinus. This abnormality was associated with absent right superior vena cava and a partial pericardial defect on the right side.

Gastrointestinal complications after cardiac surgery.

OBJECTIVE: Gastrointestinal (GI) complications after cardiac surgery with cardiopulmonary bypass (CPB) are uncommon complications with significant morbidity and mortality rates. METHODS: From 1988 to 1995, 36 GI complications were identified in 3158 patients who underwent cardiac surgery (1.14% incidence). The mortality rate was 13.9%. Complications included hemorrhage in the GI tract in 22, perforated ulcer in 3, acute cholecystitis in 3, pancreatitis in 2, mesenteric ischemia in 3, diverticulitis in 1 and liver failure in 2 patients. RESULTS: Clinical risk factors included advanced age, combined coronary artery bypass grafting (CABG)-valve operation, postoperative low cardiac output (LCO), prolonged ventilation time, re-exploration of the chest, sternal infection and a positive history of peptic ulcer. Patients with a prolonged pump time had an increased risk of GI complications (P < 0.001). CONCLUSIONS: Gastrointestinal complications, although of low incidence, carry a significantly high mortality, and the clinician must be alert to institute early appropriate treatment.

Cor triatriatum: report of an unusual variant--triatrial heart. A case report.

Cor triatriatum is a rare cardiac malformation presenting with symptoms and signs of pulmonary venous obstruction. Although diagnosis of this defect has been facilitated by diagnostic procedures such as echocardiography and angiocardiography, it could be missed preoperatively. The authors report a case of cor triatriatum that is unique in having two separate atrial septal defects in each side of the fibromuscular membrane and that was undiagnosed preoperatively with transthoracic echocardiography and cardiac catheterization.