The oldest patient in literature of spontaneous true giant superficial temporal artery aneurysm.

Background: Superficial temporal artery (STA) aneurysms are very rare compared to vascular aneurysms of other regions. They are divided into two as true and pseudo. Pseudoaneurysm were much more common and often depend on an etiological factor but spontaneous true aneurysms are extremely uncommon and the etiologic causes are not clear yet. Case presentation: We present a 91-year-old female patient who consulted to us with swelling in front of the ear; there was no history of previous surgery or any trauma. The patient had a pulsatile mass in the preauricular region, which started 4 years ago and growed faster for the last 2 months. Conclusion: There was a mass consistent with a saccular type aneurysm whose continuity was observed with the temporal artery in imaging studies. The mass was excised under general anesthesia. The patient whose pathological examination was a true STA aneurysm was discussed in the light of the literature.

Usefulness of live/real time three/four-dimensional transesophageal echocardiography in the percutaneous closure of an iatrogenic aorto-right ventricular fistula.

The development of an aorto-right ventricular fistula is a rare complication of cardiac surgery. The most common treatment is surgical closure of the fistula, but percutaneous closure of the fistula has become an attractive alternative option. We present a case of successful utilization of live/real time three/four-dimensional transoesophageal echocardiography (3/4DTEE) to select the correct device size for percutaneous closure of an adult patient presenting with an aorto-right ventricular (AO-RV) fistula following aortic valve replacement. To the best of our knowledge, this is the first case in which 3/4DTEE was used to select the device size and guide percutaneous closure of an iatrogenic AO-RV fistula.

Comparison of minimally invasive direct coronary artery bypass and off-pump coronary artery bypass in single-vessel disease.

BACKGROUND: Off-pump coronary surgery is an established method of less invasive cardiac surgery. We compared our early results in patents with I-vessel disease who underwent surgery with full sternotomy with off-pump coronary artery bypass (OPCAB) or a left anterior minithoracotomy with minimally invasive direct coronary artery bypass grafting (MIDCAB) without cardiopulmonary bypass. METHODS: From July 2003 to June 2006, 54 patients with single-vessel disease of the left anterior descending artery who underwent surgery performed by the same surgical team were included in this prospective study. Of these patients, 27 underwent MIDCAB through an anterolateral minithoracotomy, and 27 had OPCAB through a full sternotomy. Patients were selected for the surgical groups on the basis of general condition, anatomical aspects, type of coronary lesions, comorbidities, and patient preferences. Demographic, operative, and postoperative data were collected prospectively. RESULTS: Demographic data, Canadian Cardiovascular Society Classification, and comorbidities were identical for both groups. There were no cases of operative mortality, early graft insufficiency, myocardial infarction, cerebrovascular accident, or conversion to cardiopulmonary bypass in either group. Durations of mechanical ventilation and total hospital stay were shorter in the MIDCAB group, 6.8+/-3.0 hours vs 8.3+/-1.6 hours and 4.5+/-0.7 days vs 5.2+/-1.4 days (P= .03 and P= .03), respectively. Atrial fibrillation was seen in 2 patients in each group; all were returned to sinus rhythm by medical therapy. CONCLUSION: Although MIDCAB grafting is a challenging technique, it may be safely performed on selected patients with low postoperative mortality and morbidity.

Sternal wound complications in bilateral internal thoracic artery grafting: a comparison of the off-pump technique and conventional cardiopulmonary bypass.

BACKGROUND: Sternal wound complication is a major concern in bilateral internal thoracic artery grafting. The purpose of this study was to assess whether avoiding cardiopulmonary bypass has beneficial effects with fewer wound complications in patients receiving bilateral internal thoracic artery grafting. METHODS: Retrospective review was performed using prospectively gathered data of 69 patients who had undergone elective coronary artery bypass grafting and received conventional pedicled bilateral internal thoracic artery grafting from December 2002 through April 2004 by the same surgical team. The patients were divided into 2 groups: those who underwent coronary artery bypass grafting without cardiopulmonary bypass (off-pump group, n = 41), and those who underwent coronary artery bypass grafting with cardiopulmonary bypass (CPB group, n = 28). Chart review and 3-month follow-up were obtained for all patients. These 2 groups were compared for sternal wound complications and preoperative, intraoperative, and postoperative variables. RESULTS: Deep sternal wound infection (SWI) was seen in 1 patient (2.4%), superficial SWI in 2 patients (4.8%), and sternal dehiscence in 1 patient (2.4%) in the off-pump group. Deep SWI was seen in no patients, superficial SWI in 2 patients (7.1%) and sternal dehiscence in 2 patients (7.1%) in the CPB group. No statistically significant difference in the frequency of occurrence of sternal complications was detected between the 2 study groups. CONCLUSIONS: The results suggest that the avoidance of CPB has no beneficial effect on the number of sternal wound complications in patients receiving bilateral internal thoracic artery grafting. However, further prospective, randomized studies on large patient groups are required to assess this finding.

Effect of timing of chest tube removal on development of pericardial effusion following cardiac surgery.

BACKGROUND: There are no standard criteria for the timing of drain removal. The objective of this study was to determine whether the macroscopic appearance of chest tube drainage fluid to serosanguineous may be used as a criteria for drain removal. METHODS: 2,359 patients were assessed retrospectively and 80 randomized patients were followed prospectively who underwent cardiac surgery. In both parts of the study, patients were divided into two groups according to the timing of drain removal. Group I consisted of patients whose chest tubes were removed as soon as the macroscopic appearance of the drainage fluid turned to serosanguineous. Group II consisted of patients whose chest tubes were removed at the second postoperative day when the drainage output declined to less than 50 mL in a five-hour period. In the retrospective part, cases of hemodynamically significant pericardial effusion observed within seven days postoperatively were reviewed. In the prospective part, just before the drain removal, the fluid sample hematocrit obtained from the drain lines and patients' blood hematocrit were measured and recorded. Patients were evaluated with echocardiography for pericardial effusion. RESULTS: No statistically significant difference was detected in the frequency of hemodynamically significant pericardial effusion and incidence or amount of pericardial effusion between the two study groups. The drain hematocrit to blood hematocrit ratios before drain removal showed a significant correlation with pericardial effusion. The strength of correlation between the drain hematocrit to blood hematocrit ratios before drain removal and pericardial effusion was also studied using receiver operating characteristic curve, which suggests that a drain hematocrit to blood hematocrit ratio of < or = 0.3 is strongly predictive that pericardial effusion would be absent or mild between the fifth and seventh postoperative days. CONCLUSIONS: It is safe to remove the chest tubes as soon as the macroscopic appearance of the drainage fluid turns to serosanguineous since this practically indicates cessation of active bleeding.

Endotoxemia in coronary artery bypass surgery: a comparison of the off-pump technique and conventional cardiopulmonary bypass.

OBJECTIVES: The endotoxemia associated with cardiac surgery is thought to be dominantly influenced by the use of cardiopulmonary bypass. The objectives of this study were to assess the relative contribution of cardiopulmonary bypass on endotoxemia apart from cardiac surgical access and to improve our understanding of the potential benefits of off-pump procedures. METHODS: Thirty patients undergoing coronary artery bypass grafting were followed up prospectively. The patients were divided into 2 equal groups: those who underwent bypass grafting through a sternotomy incision without cardiopulmonary bypass (off-pump group) and those who underwent bypass grafting through a sternotomy incision with cardiopulmonary bypass (CPB group). Blood sampling for endotoxin, lactate, and cardiac index measurements were performed during the following time points: (1) after sternotomy; (2) during the coronary occlusion period in the off-pump group and during aortic clamping in the CPB group; (3) after removal of the coronary occlusion sutures in the off-pump group and after removal of the aortic clamp in the CPB group; (4) 30 minutes after the completion of all distal anastomoses in the off-pump group and immediately after weaning from cardiopulmonary bypass in the CPB group; (5) 1 hour postoperatively; and (6) 12 hours postoperatively. RESULTS: Endotoxin and lactate levels were significantly (P <.05) lower in the off-pump group at all sampling time points, except after sternotomy. CONCLUSIONS: In conclusion, this study has shown that endotoxemia during coronary artery bypass surgery seems mainly to be associated with cardiopulmonary bypass procedure. The relatively lower endotoxin levels observed in off-pump surgery might contribute to improved postoperative recovery.