Coronary artery bypass grafting and concomitant descending aorta-to-bifemoral artery bypass via sternotomy.

INTRODUCTION: We evaluated a new approach of combined coronary and aorto-bifemoral artery bypass grafting performed through median sternotomy using the descending aorta as the inflow source. MATERIALS AND METHODS: Four patients with advanced coronary and aorto-iliac disease were operated on in the same session. Following the coronary artery bypass grafting (CABG), we performed a proximal anastomosis of a bifurcated Dacron graft to the descending aorta through the posterior pericardium. The limbs of the graft were passed through the diaphragm into the retroperitoneal space. They were then passed through tunnels in the groins, and distal anastomoses in the groins were performed. RESULTS: The postoperative course was uneventful in all four patients. In the second year, follow-up multi-slice computerised tomographies (CT) and magnetic resonance angiographies were done and all grafts were patent. DISCUSSION: We believe this technique is a reliable alternative procedure to consider in CABG patients who are not suitable candidates for standard aorto-femoral operations. It has a reasonable rate of morbidity and perfect patency.

Posterior pericardial annuloplasty in ischemic mitral regurgitation.

BACKGROUND: Ischemic mitral regurgitation (IMR) is an important risk factor in coronary artery bypass grafting (CABG) operations. The decision to perform concomitant mitral annuloplasty along with the CABG depends on the surgeon's choice. The aim of this study was to evaluate the results of posterior annuloplasty procedures with autologous pericardium performed in patients with midadvanced and advanced functional ischemic mitral regurgitation. METHODS: Study participants were 36 patients with IMR (mean age 59 +/- 10 years) who underwent posterior pericardial annuloplasty and CABG operations between 2002 and 2007. Preoperative and postoperative (mean follow-up 18 +/- 1 months) MR grade, left atrium diameter, left ventricle end systolic diameter, left ventricle end diastolic diameter, left ventricle ejection fraction, and mitral valve gradients were measured with transthoracic echocardiography. RESULTS: There was one late mortality (2, 8%) but none of the patients required reoperation for residual MR. We did not observe thromboembolism, bleeding, or infective endocarditis. The mean MR grade decreased from 3.4 +/- 0.5 to 0.5 +/- 0.6 (P < .01), left atrium diameter decreased from 45.3 +/- 5.5 mm to 43.2 +/- 3.8 mm (P < .01), left ventricle end diastolic diameter decreased from 53.2 +/- 5.6 mm to 50.9 +/- 5.5 mm (P < .01), and left ventricle end systolic diameter decreased from 39.7 +/- 5.8 mm to 34.6 +/- 6.5 mm (P < .01), whereas mean left ventricle ejection fraction increased from 37.9% +/- 6.1% to 43.7% +/- 7.3% (P < .01). In the late postoperative term, the functional capacity of the patients increased from mean New York Heart Association class 2.6 +/- 0.9 to 1.1 +/- 0.5. We did not observe any gradient in the mitral valve preoperatively in any patient, but in the follow-up, the mean gradient increased to 1.3 +/- 2.1 mmHg (P < .01). CONCLUSION: Posterior pericardial annuloplasty with CABG in the treatment of IMR provides efficient mitral repair and significant decrease in the left atrium and left ventricle diameters, and provides a significant increase in left ventricular function. These results show IMR to be as effective as the other annuloplasty techniques. IMR is performed with autologous material and therefore does not entail any risk of complications from prosthetic material and is highly cost-effective.

A new technique to avoid the intraoperative complications of septal myectomy in patients with obstructive hypertrophic cardiomyopathy.

Although transaortic septal myectomy in obstructive hypertrophic cardiomyopathy (OHC) is accepted as a safe procedure, it may end up with serious peroperative complications. We developed a practical method to avoid this unfavorable outcome by using a 20-cc syringe body. We believe this apparatus will provide safe and effective septal myectomy procedures without additional cost.

Revascularization of left anterior descending (LAD) artery with in situ left internal thoracic artery (LITA) and coronary-coronary free LITA grafts: 12-year patency.

BACKGROUND: We aim to present a patient with coronary-coronary bypass grafting (CCBG), left anterior descending-left anterior descending (LAD-LAD) coronary artery bypass with left internal thoracic artery (LITA), and provide the 12-year follow-up angiogram to confirm the longest reported patency. METHODS AND RESULTS: A 57-year-old man with three vessel disease where LAD had multiple lesions was operated on. LITA with pedicle was grafted in situ onto the proximal LAD, and the distal residual segment was used as a free LITA graft to bypass the distal stenosis. The postoperative course was uneventful. The patient has been recently readmitted to our clinic with atypical chest pain. In angiography, all of the bypasses, including the free LITA graft, were patent. CONCLUSIONS: We used free LITA graft to bypass the distal lesions of LAD in selected patients as a valid alternative to sequential bypass grafting. To the best of our knowledge, this is the only angiographic view of a CCBG in LAD with LITA graft confirming the long-term patency.

The effects of internal thoracic artery preparation with intact pleura on respiratory function and patients' early outcomes.

OBJECTIVE: Postoperative respiratory functions, arterial blood gases, blood loss and clinical outcome following coronary artery bypass surgery (CABG) were assessed in a prospective randomized single-blind (patient- blind) clinical study comparing two different techniques of internal thoracic artery (ITA) harvesting. METHODS: Fifty-four patients admitted for CABG were allocated into two groups according to 'random numbers' technique. In a Group 1 (n=26) ITA was prepared keeping the pleura intact and in a Group 2 (n=28) pleura was opened. Both groups were compared in terms of postoperative respiratory functions, arterial blood gases, bleeding and clinical outcomes using ANOVA for repeated measurements analysis. RESULTS: Analysis of spirometric and partial oxygen pressure data showed that postoperative reductions in forced expiratory volume (0.17+/-0.18 lt vs. 0.28+/-0.14 lt, p=0.016), forced vital capacity (0.18+/-0.19 lt vs. 0.28+/-0.13 lt, p=0.037) and arterial oxygen measurements (-0.03+/-0.22 mmHg vs. 0.15+/-0.4 mmHg, p=0.023) were less pronounced in patients of Group 1 as compared with patients of Group 2. The increase in intrapulmonary shunts (Qs/Qt ratio) after the operation was more pronounced in Group 2 patients than in Group 1 patients (p<0.01) and the mean values of Qs/Qt ratio 24 hours after the operation were higher in group 2 as compared to Group 1 patients(0.100+/-0.063 vs. 0.054+/-0.048, p=0.001). Radiological evaluation revealed that costophrenic angle obliteration after operation more often occurred in Group 2 (14/28 patients) than in Group 1 (0/26 patients) (p<0.0001). Cardiothoracic index increased significantly after operation only in group 2 patients (p=0.001). Postoperative blood loss within 24 hours was significantly lower in Group 1 compared to Group 2 (656+/-179 ml vs. 907+/-257 ml, p=0.001). There was no significant difference between groups in the ICU stay duration (p=0.186), whereas the hospital stay was significantly longer in group 2 patients than in Group 1 patients (8.8+/-2.0 days vs. 7.6+/-2.0 days, p=0.039). CONCLUSION: According to our results, preserving pleural integrity has positive effects on the respiratory functions and patients' clinical outcomes following CABG operations.

Pulmonary effects of noninvasive ventilation combined with the recruitment maneuver after cardiac surgery.

BACKGROUND: The aim of our study was to evaluate the pulmonary effects of noninvasive ventilation (NIV) with or without recruitment maneuver (RM) after open heart surgery. METHODS: One-hundred patients undergoing coronary artery bypass surgery were randomized into four groups after the operation: 1) RM with sustained inflation during mechanical ventilation postoperatively (RM group, n = 25); 2) RM combined with NIV applied for 1/2-h periods every 6 h in the first postoperative day after tracheal extubation (RM-NIV group, n = 25); 3) NIV after tracheal extubation (NIV group, n = 25); and 4) a control group consisting of patients receiving neither RM nor NIV (control group, n = 25). Pulmonary function tests, oxygenation index, and atelectasis on chest radiograph were evaluated and compared among the groups. RESULTS: RM provided higher arterial oxygen levels during mechanical ventilation and after tracheal extubation compared to other interventions. Oxygenation was better in the RM-NIV and NIV groups than in the control group (P = 0.02 and P = 0.008, respectively) at the end of the study. The postoperative atelectasis score of the control group (median: 1) was higher than those of the RM (1; P = 0.03), RM-NIV (0; P < 0.01) and NIV (0; P < 0.01) groups. Pulmonary function of the NIV groups on postoperative day 2 was better than in the other groups, whereas the tests were similar among the groups on postoperative day 7. CONCLUSIONS: NIV associated with RM provided better oxygenation both during and after the mechanical ventilation period. NIV either alone or in combination with RM provided lower atelectasis scores and better early pulmonary function tests compared to the control group, without a significant difference regarding the duration of mechanical ventilation, intensive care unit stay, and the length of hospitalization. NIV combined with RM is recommended after open heart surgery to prevent postoperative atelectasis and hypoxemia.

Inflammatory aneurysm of arcus aorta with massive hemoptysis.

A 72-year-old woman was admitted to the intensive care unit with a diagnosis of acute coronary syndrome. An aneurysm in the aortic arch was detected in the radiologic investigations. The aortic arch was replaced with a Dacron graft with the patient under total circulatory arrest. A pathology evaluation revealed an inflammatory aneurysm. To date, a few cases of inflammatory aneurysms of the aortic arch have been reported. Unlike the previously reported cases, the aneurysm in our case unexpectedly presented with massive hemoptysis.

A novel approach to surgical treatment of diseased intracavitary coronary arteries and ventriculotomy closure.

Inadvertent opening of the right ventricle may occur during dissection of an intracavitary artery. Two patients with stenotic intracavitary left anterior descending arteries were operated on. A right ventriculotomy was performed in the operation. The anastomosis was performed to this intracavitary segment of the artery. The ventriculotomy was closed with a pericardium. There were no ischemic changes or aneurysmal formation in the postoperative follow-ups. This technique may be preferable in the closure of right ventriculotomy without compromise of coronary flow or anastomosis.

A late pseudoaneurysm caused by thermal injury in the descending aorta: report of a case.

Pseudoaneurysm is a pulsating hematoma that occurs after an injury to all layers of the arterial wall. Traumas due to gunshot injuries may sometimes damage the arteries indirectly with the thermal energy causing deterioration in the arterial wall and rarely induce pseudoaneurysm formation. Pseudoaneurysm caused by the chest traumas in the adults have already been defined in the literature, however, pseudoaneurysms due to penetrating traumas in pediatric patients are very uncommon. We present a case of late pseudoaneurysm in the descending aorta of a six-year-old child caused by discharge of a hand gun.

Right coronary system grafts: alone or together with left system grafts--angiographic results.

PURPOSE: The aim of this study is to compare the long-term graft patency between patients who had sequential or individual right posterior descending artery (RPDA) anastomosis. MATERIALS AND METHODS: Two hundred and forty-two patients underwent coronary artery bypass grafting (CABG) between June 1994 and December 2003. They were examined retrospectively with respect to coronary angiograghic data. [Group 1] Individually right system grafts in RPDA position (n=139). [Group 2] RPDA anastomosis sequentially with left system (n=103). Patency rates for posterior descending arteries in each group were separately calculated for each vessel quality category. RESULTS: The mean interval from operation to angiography was 50.6+/-48.9 months in group 1 vs 57.5+/-39.2 months in group 2 respectively. The overall patency rate was 66.2% (92/139) in group 1 and 78.6% (81/103) in group 2 (p=0.04). When the RPDA has good run-off capacity, the patency rate was 69.1% in group 1 and 85.2% in group 2. CONCLUSION: When the RPDA has good run-off capacity, snake grafts show excellent results and right and left coronary systems could be anastomosed sequentially.

An alternative reinforced closure technique with external Kirschner wires in sternal dehiscence.

OBJECTIVE: We present an alternative closure technique that is effective in length stabilization of the dehisced sternum, technically easy, and less time consuming. METHODS: Between June 2000 and June 2003, 850 patients underwent open heart surgery in the participating clinics. In all of the patients, the sternotomies were primarily closed with No. 5 steel wires in a figure 8 manner or with single sutures. Eleven patients with sterile sternal dehiscence underwent operations with Kirschner wires. RESULTS: During the postoperative period, no complications related to the implants were observed in any of the patients in the early and late follow-ups. CONCLUSION: With this technique, the fragile sternum is easily and effectively stabilized by reinforcing with suprasternal Kirschner wires without applying complicated manipulations.

The pulmonary and hemodynamic effects of two different recruitment maneuvers after cardiac surgery.

BACKGROUND: The aim of our study was to evaluate the pulmonary and hemodynamic effects of two different recruitment maneuvers after open heart surgery. METHODS: Sixty patients undergoing coronary artery bypass surgery were randomized into three groups after operation: recruitment maneuver with continuous positive airway pressure (CPAP) (CPAP-40 group, n = 20), recruitment by positive end-expiratory pressure (PEEP) (PEEP-20 group, n = 20), and 5 cm H2O PEEP (PEEP-5 group, n = 20). In the CPAP-40 group, 40 cm H2O peak inspiratory pressure was applied for 30 s, then PEEP was reduced to 20 cm H2O and ventilation was continued with baseline variables with PEEP decreased until the best Pao2 was achieved. In the PEEP-20 group, 20 cm H2O PEEP was set for 2 min, tidal volume was adjusted to achieve a peak inspiratory airway pressure of 40 cm H2O during the maneuver, then PEEP was decreased until the best Pao2 had been achieved. In the PEEP-5 group, 5 cm H2O PEEP was applied postoperatively. RESULTS: The mean arterial blood pressure of the CPAP-40 group was lower than that of the PEEP-20 (P < 0.01) and PEEP-5 groups (P < 0.01) during the interventions. Oxygenation was higher in both recruitment groups than in the PEEP-5 group during the mechanical ventilation period. There was no significant difference among the groups beyond that period. The atelectasis score of the PEEP-5 group (1.3 +/- 0.9) on postoperative day 1 was higher than that of the CPAP-40 (0.65 +/- 0.6; P = 0.01) and PEEP-20 (0.65 +/- 0.5; P = 0.01) groups. CONCLUSIONS: The recruitment techniques with postmaneuver PEEP increased oxygenation and decreased atelectasis equally, whereas PEEP-20 provided more stable hemodynamic conditions than the CPAP maneuver.

St. Jude Medical and CarboMedics mechanical heart valves in the aortic position: comparison of long-term results.

We designed this study to compare long-term results of St. Jude Medical and CarboMedics mechanical heart valves in the aortic position. We retrospectively analyzed the results of 174 consecutive patients who received either a St. Jude (n=80) or a CarboMedics (n=94) mechanical aortic valve from March 1992 through October 2004. The follow-up rate was 97.7%. The mean follow-up duration for the St. Jude group was 79.3 +/- 35.0 and for the CarboMedics group, 70.0 +/- 34.3 months. The cumulative follow-up was 523.8 and 530.1 patient-years, respectively The 30-day mortality rates for the St. Jude and CarboMedics patients were 1.3% and 3.2%, respectively. The actuarial survival rate for the St. Jude group at 138.0 +/- 4.7 months was 75.9% +/- 0.1% and for the CarboMedics group at 130.8 +/- 4.8 months was 69.8% +/- 0.1% (P=NS). There was no structural valve deterioration in either group. Freedom from thromboembolic events was 87.7% for the St. Jude group and 83.0% for the CarboMedics group (P=NS). Freedom from bleeding events for the St. Jude group was 93.6% and for the CarboMedics group, 89.7% (P=NS). The results obtained from this study indicate that standard St. Jude Medical and CarboMedics aortic valve prostheses offer similar excellent clinical performance. Definitive judgment must await trials that are extensive, randomized, and prospective.

Arch-first technique via clamshell incision: successful surgical reoperation for aortic arch dissection.

We report a case of successful reoperation for aortic arch dissection with use of the "arch-first" technique in a patient who had Marfan syndrome. Extracorporeal circulation was initiated via right subclavian artery cannulation, and the chest was entered through a clamshell incision for the best exposure. When the patient was cooled to 18 degrees C, the perfusion was stopped. After the 1st aortic arch anastomosis to a 30-mm Dacron graft, cerebral perfusion was reestablished via the right subclavian artery. The aortic repair was then completed. The cerebral ischemic time was 18 minutes, the aortic cross-clamp time was 69 minutes, and the total extracorporeal circulation time was 334 minutes. The patient was discharged from the hospital on postoperative day 10 with no neurologic impairment. The arch-first technique shortens the duration of brain ischemia. When combined with a clamshell incision, the technique is particularly helpful for reoperation of the aortic arch and thoracic aorta.

Effect of cardiac resynchronization therapy on left atrial appendage function and pulmonary venous flow pattern.

BACKGROUND: Previous studies have shown improvement in left ventricular function and development of the reverse remodeling in the left ventricle and left atrium after cardiac resynchronization therapy (CRT). The aim of this study was to investigate the effect of CRT on left atrial appendage (LAA) function and pulmonary venous flow pattern. METHODS: Eighteen patients with systolic heart failure and complete left bundle branch block underwent implantation of biventricular pacemaker devices. In order to follow changes in LAA, transthoracic and transesophageal echocardiographic examinations were performed 1 week before and repeated 1 and 6 months after pacemaker implantation. RESULTS: CRT resulted in significant clinical improvement and decrease in NYHA functional class in 17 patients (94%). Maximum and minimum areas of left atrial appendage (LAAAmax and LAAAmin) decreased, with a concomitant increase in LAA ejection fraction. [LAAAmax: from 4.6+/-2 to 4.2+/-1.8 cm2 at the first (P < 0.001) and to 4.0+/-1.8 cm2 at the sixth month (P < 0.001); LAAAmin: from 2.7+/-1.3 to 2.3+/-1.2 cm2 at the first (P < 0.001) and to 2.2+/-1.2 cm2 at the sixth month (P < 0.001) and LAA ejection fraction: from 41+/-12% to 46+/-10% at the first (P = 0.007) and to 47+/-8% at the sixth month (P = 0.003)]. LAA active emptying and filling flow and pulmonary venous systolic velocities also increased after CRT. The appendage active emptying velocity correlated significantly with left ventricular ejection fraction (r = 0.50, P = 0.002), LAA ejection fraction (r = 0.51, P = 0.002), left atrial maximal volume, LAVmax (r = -0.44, P = 0.007), left atrial minimal volume, LAVmin (r = -0.50, P = 0.002) and pulmonary vein systolic flow velocity (r = 0.33, P = 0.05). CONCLUSION: Treatment of heart failure by CRT results with marked improvements in LAA function and increases pulmonary venous systolic velocity.

Postinfarction ventricular septal rupture: surgical intervention and risk factors influencing hospital mortality.

Postinfarction rupture of the interventricular septum is usually fatal without surgical intervention and requires urgent closure. Between 1989 and 2003 twenty consecutive patients (15 male, 5 female), underwent postinfarction ventricular septal rupture (VSR) repair. Mean age of the patients was 62.05 +/- 7.51 years. Fifteen patients were operated within 48 hours after myocardial infarction. Patch reconstruction was performed in all patients. Infarct locations were anterior in 65%, posterior in 35%. Coronary artery surgery was performed in 14 patients (70%). Hospital mortality was 30% (6 patients). Four patients were presented for surgical therapy with frank cardiogenic shock or low cardiac output syndrome. A residual shunt was detected in 4 patients and three of these patients were reoperated. One of them, who has been reoperated on the first day of the postoperative period, did not survive. The statistical analysis of the patients' records demonstrated that time period between MI and surgery, applied additional CABG procedure, the sex of the patients and the site of the rupture are significant factors influencing in-hospital mortality. Preoperative condition, age of the patients and the number of the affected coronary vessels do not have an important effect on the mortality. Postinfarction ventricular septal rupture is a fatal complication of the myocardial infarction and must be treated surgically. The time interval between septal rupture independent from the preoperative haemodynamic condition, the location of the defect and additional myocardial revascularization procedure are the factors influencing the early outcome.

Myocardial ischemia after Cabrol operation.

A 33-year-old woman who had undergone a Cabrol-type aortic root replacement for acute aortic dissection during labor 27 months ago was admitted with chest pain. Electron-beam tomography and coronary angiography showed stenosis at the level of the anastomosis. Urgent coronary revascularization was performed using bilateral internal mammary artery grafts. Although graft occlusion after the Cabrol procedure is an infrequent complication, it should be considered during follow-up.

Postoperative mechanical circulatory support with Biomedicus centrifugal pump.

Despite advances in surgical techniques, myocardial protection, and management protocols, approximately 1% of patients undergoing open heart operations still need mechanical circulatory support for severe cardiac dysfunction. The Biomedicus centrifugal pump, available in most cardiovascular centers, is a highly effective and relatively inexpensive system compared to other more sophisticated devices for the same purpose. Of 10 patients aged 5 to 61 years who were supported for 22 to 168 hours with a Biomedicus centrifugal pump, 7 (70%) were weaned from support, there was one hospital death, and 6 patients were discharged from hospital. Two sudden deaths occurred in the first 8 months after discharge. Four patients (40%) were still alive after follow-up of 11-55 months, with no restriction in their daily activities. The centrifugal pump is a very cost-effective support system with survival rates comparable to those of more sophisticated devices in short-term ventricular assistance.

Effect of cardiac resynchronization therapy on left atrial reverse remodeling and spontaneous echo contrast.

Recent studies revealed reverse remodeling in left ventricle with cardiac resynchronization therapy (CRT). However, effects on left atrial remodeling, left atrial total emptying fraction and left atrial spontaneous echo contrast (SEC) have not been adequately evaluated. The aim of this study was to investigate the long-term changes in SEC, left atrial reverse remodeling, and left atrial total emptying fraction after CRT. Twenty patients with systolic heart failure and complete left bundle-branch block underwent implantation of biventricular pacemaker devices. Transthoracic and transesophageal echocardiography were performed one week before and one and six months after pacemaker implantation. After biventricular pacemaker implantation, significant clinical improvement was observed in all patients. Left atrial maximal and minimal volumes showed a significant progressive decline after CRT (reverse remodeling). Left atrial total emptying ejection fraction (LATEF) was 33 +/- 19% at baseline and increased to 37 +/- 10% and 41 +/- 11% at the 1st and 6th months respectively (p = 0.01 and p = 0.04). SEC was detected in 18 of 20 patients (90%) at the beginning of the study. After six months SEC disappeared in 5 patients and frequency of SEC reduced to 45%. Decrease in the intensity of the SEC was also statistically significant (at the 1st and 6th months; p = 0.001 and p < 0.001 respectively). Long-term CRT results in atrial reverse remodeling, increases LATEF, and reduces both frequency and intensity of atrial SEC.