Multiple Imaging Modalities Including Three-Dimensional Echocardiography in Left Ventricular Pseudoaneurysm After Mitral Valve Replacement.

Left ventricular pseudoaneurysm (LVPA) after mitral valve replacement (MVR) is a rare condition. The diagnosis of LVPA may be difficult, and for accurate diagnosis, two-dimensional (2D) transthoracic echocardiography (TTE) should be used in combination with other imaging modalities such as multiple detector computed tomography (MDCT) and three-dimensional (3D) TTE. Herein is presented a late type of post-MVR pseudoaneurysm in a 72-year-old female who was admitted to the authors' emergency department with complaints of dyspnea. She had undergone MVR five years previously. A diagnosis was made via 2D TTE, supported by 3D TTE and contrast-enhanced CT. Although aneurysmectomy was performed the patient died due to cardiogenic shock. To the authors' knowledge, the present case report provides the most intense investigation, evaluation and assessment of LVPA performed to date, using different imaging modalities and surgical findings. Movie 1(a) Two-dimensional TTE, four-chamber view. Movie 1(b) Two-dimensional TTE, short-axis view. Movie 2(a) Live/real-time 3D TTE, en face view of the LVPA imaged from the lateral side. Movie 2(b) Live/real time 3D TTE, en face view of the LVPA (arrow) imaged from the left ventricular side.

A Late Sequela of the David Procedure: Left Main Coronary Artery Compression and Myocardial Infarction due to Pseudoaneurysm Formation.

Valve-sparing root replacement (the David procedure) is a valuable alternative to conventional aortic root replacement with a composite graft, especially in patients whose aortic valve leaflets have not been altered. However, reintervention rates are higher than are those associated with composite graft implantation. In this report, we present the case of a patient who had undergone valve-sparing root replacement 2 years earlier and was admitted to our hospital with myocardial infarction and cardiogenic shock secondary to coronary ostial button dissection, aortic pseudoaneurysm formation, and severe left main coronary artery compression. To our knowledge, this case is exceedingly rare. Rather than attempt local reconstruction of the mouth of the pseudoaneurysm, we excised the lesion, the aortic valve, and the graft, and we successfully implanted a composite aortic graft with a mechanical aortic valve.

Unusual complication of aortic dissections: intimo-intimal intussusception.

Angiography with a pre-diagnosis of acute coronary syndrome was performed in a 76-year-old female patient presenting to another hospital with symptoms of chest pain and syncope. Upon determination of type III aortic dissection, the patient was referred to our clinic. On CT angiography, the ascending aortic diameter was 57 mm and no dissection flap was observed. There was a filling defect suggestive of intimo-intimal intussusception at the level of the aortic arch, occlusion of the left arteria carotid communis, and a double-channel aorta extending from the left subclavian artery to the iliac artery. On transoesophageal echocardiography, the ascending aorta was seen to be larger than normal and no dissection flap was observed. There were findings suggestive of haematoma and intimo-intimal intussusception at the proximal part of the aortic arch. The dissection flap causing occlusion in the vascular structures was resected. Supracoronary graft replacement of the ascending aorta was performed. Transoesophageal echocardiography is an invasive investigative method with high sensitivity and specificity for the diagnosis of intimo-intimal intussusception.

Computed tomography evaluation of different chest tube sites for residual pleural volumes after coronary artery bypass surgery.

BACKGROUND AND OBJECTIVES: We investigated the efficacy of pleural drainage with the use of different chest tube methods in patients after coronary artery bypass graft (CABG) surgery. DESIGN AND SETTING: Prospective randomized study of 60 patients undergoing elective on-pump single CABG surgery. PATIENTS AND METHODS: The left internal mammary arterial grafts were harvested from all patients. The patients were separated into three groups: In one group (IC6, n=20), pleural tubes were inserted through the sixth intercostal space at the midaxillary line; in the second group (SX-r, n=20), rigid straight pleural tubes were inserted from the mediastinum through the subxiphoid area; and in the third group (SX-s, n=20), soft curved drainage tubes were inserted from the mediastinum through the subxiphoid area. The residual pleural effusion was examined by multislice CT scans within 8 hours of removal of the drainage tubes. Pain was evaluated according to standard methods. RESULTS: The groups did not differ with respect to volume of residual pleural effusion (P >.05). The IC6 group had a higher mean pain score than the other two groups (P <.05), whose mean pain scores did not differ significantly from each other (P >.05). IC6 group patients had a higher requirement for analgesics. The rate of atelectasis was higher in group IC6 (P <.05). CONCLUSION: CT scans revealed that different chest tube insertion sites have the same efficiency for draining of pleural effusion, although drainage tubes inserted through the thoracic cage may result in more severe pain.

Asymmetric dimethylarginine levels in Buerger's disease.

BACKGROUND: Endothelial dysfunction may play a major role in both peripheral arterial disease (PAD) and Buerger's disease (BD). Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of endothelial nitric oxide synthase and increased ADMA levels impair vascular homeostasis. We aimed to determine the plasma levels of ADMA and evaluate the relationship of ADMA levels with smoking and clinical severity of the disease in patients with BD and to compare these results with those of patients with PAD and healthy individuals. METHODS: In our center, 45 patients undergoing peripheral arterial surgery, 28 patients being followed up for BD, and 24 healthy individuals without vascular or cardiac disease, were enrolled in the study. Intra- and intergroup analysis was performed to evaluate the relationship of ADMA levels with smoking behaviors and clinical disease severity according to Fontaine classification. RESULTS: ADMA levels were 1.26 ± 0.76 mmol/L, 0.87 ± 0.27 mmol/L, and 1.07 ± 0.88 mmol/L in patients with PAD, in patients with BD, and in the control group, respectively. ADMA levels were significantly higher in patients with PAD than those in control patients (p = 0.003) and the levels observed in patients with BD were significantly lower than those in control patients (p = 0.001). Smokers with PAD had higher ADMA levels than smokers with BD (p = 0.03). ADMA levels were higher in patients with Fontaine stage III and IV disease than those with Fontaine stage II diseases, for patients with PAD as well as those with BD. CONCLUSION: The lower ADMA levels observed in patients with BD might be related to the degradation of ADMA by dimethylarginine dimethylaminohydrolase in response to ischemia and could act as a defensive mechanism during the acute or quiescent phases. In patients with BD experiencing severe clinical conditions or with a longer time course for the disease, higher ADMA levels may suggest a poor prognosis.

Simultaneous operation in a patient with coronary heart disease, abnormal orifice of coronary arteries, morgagni hernia, atrial septal defect, and pericardial and pleural agenesis.

A 68-year-old male patient with acute coronary syndrome was referred to our center. He also received a diagnosis of diaphragmatic hernia after a clinical examination. The patient underwent a simultaneous aorta coronary bypass operation and repair of the congenital diaphragm hernia. During the operation, the patient was observed to have an atrial septal defect. Our handling of the case is discussed in light of the literature.

Safety of coronary artery bypass grafting in patients with bilateral total carotid occlusions.

The presence of bilateral carotid artery occlusions in patients that require coronary artery bypass surgery is rare. Here, we report the successful coronary revascularization of two patients with cardiopulmonary bypass under moderate hypothermia. Routine preoperative carotid artery duplex sonographies revealed bilateral total internal carotid occlusions. However, no neurological deficits or abnormalities were found on clinical examination or brain computed tomography, respectively. The vertebral blood flows of both patients were also found to be highly increased. Following successful surgery, the postoperative courses were uneventful and patients were discharged from the hospital on the seventh postoperative day.

Is the aortic valve pathology type different for early and late mortality in concomitant aortic valve replacement and coronary artery bypass surgery?

We assessed the effects of aortic valve pathology type on the long-term outcomes of patients who underwent concomitant aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) surgery. We retrospectively reviewed 150 patients who underwent AVR-CABG at our institution between January 1997 and December 2006. We divided patients into aortic stenosis (AS), aortic regurgitation (AR), and mixed-type groups consisting of 98 (65.3%), 20 (13.3%) and 32 (21.3%) patients, respectively. The AS group had more female patients, a higher mean angina class, older mean patient age, increased history of previous myocardial infarction (MI), and smaller valve size compared to other groups. No significant differences were observed among groups in the operative mortality for five or ten-year survival rates. Significant early mortality risk factors included cross-clamp and cardiopulmonary bypass (CBP) time, number of blood transfusion units, chronic obstructive pulmonary disease (COPD), intra-aortic balloon pump (IABP), inotropic drugs, and pacemaker use. Significant late mortality risk factors included intensive care unit (ICU) stay, IABP, stroke, and dialysis. The aortic valve pathology type in patients undergoing concomitant AVR-CABG does not adversely affect survival.

An approach to cultural adaptation and validation: the Intermittent Claudication Questionnaire.

The objective of this study was to perform a cultural adaptation and define the validity of the Turkish version of the Intermittent Claudication Questionnaire (ICQ) in order to provide a practical instrument for the evaluation of the impact of intermittent claudication (IC) on patients' quality of life and response to therapy. A standard 'forward-backward' translation method was used to translate the questionnaire into Turkish. Reliability was assessed by internal consistency of the questionnaire reporting Cronbach's alpha coefficient, test-retest reliability that was assessed with the intraclass correlation between instrument scores over time and with the Spearman-Brown coefficient as a variant of split-half reliability. Validity was examined by correlation of the ICQ with the scores of the SF-36 and its eight domains. Eighty-four patients (mean age, 60.7 +/- 7.3 years; male, 57%) were given the ICQ and a final completion rate of 98.8% (83 patients) was reached. The mean total ICQ score was 39.1 +/- 21.8 (SD) (0-100) for the first application of the questionnaire. Thirty patients out of the eligible 83 completed the questionnaire at two time points with a 1-day interval. For the retest, the total ICQ score was 40.6 +/- 26.1 (4.7-97.2). The total SF-36 score of all the study patients was 33.8 +/- 20.7 (3.0-81.0). Cronbach's alpha was 0.95; the Spearman-Brown coefficient was 0.92; and the intraclass correlation coefficient for the two measurements was 0.91. For the total score and for the scores of domains except the emotional role domain, the correlations were high and all the correlations were statistically significant. In conclusion, the Turkish version of the ICQ, which is a disease-specific, self-administered, and practical instrument, is reliable and valid. We recommend its use to assess the effect of IC on the quality of life of patients in clinical trials and in daily clinical practice.

Perioperative type I aortic dissection during conventional coronary artery bypass surgery: risk factors and management.

OBJECTIVES: Perioperative iatrogenic type I aortic dissection (PIAD) is a rare but potentially fatal complication of conventional coronary artery bypass surgery (CCABG). Prompt recognition and repair of PIAD may significantly improve outcomes. METHODS: We reviewed the hospital records of patients with PIAD occurring as a complication of CCABG at Siyami Ersek Thoracic and Cardiovascular Surgery Center from January 2001 through June 2007. During this period, 10,130 CCABG were performed and 21 patients (0.20%) with PIAD were identified. We compared variables for these 21 patients with 603 patients without PIAD (control group). RESULTS: PIAD occurred intraoperatively in 19 patients (90%) and during the early postoperative period (first 6 hours) in 2 patients (10%) who underwent CCABG. Dissections were noticed after removal of the aortic crossclamp in 11 patients, during aortic cannulation in 3 patients, and after removal of the partial-occlusion clamp in 5 patients. Patients with and without PIAD differed significantly in regard to sex (P = .05), history of hypertension (P = .001), and history of severe concomitant peripheral arterial disease (PAD) (P = .001). The diameter of the aorta was significantly wider in patients with PIAD. (3.83 +/- 0.9 vs 2.93 +/- 0.46 cm, P = .019). The occurrence of high cardiopulmonary bypass (CPB) pressure (>==120 mmHg) was significantly higher in the PIAD patients than the non-PIAD patients (28.6% vs 3.3%, P = .0001). Seven PIAD patients (33.3%) died preoperatively and 3 (14.2%) died postoperatively. CONCLUSION: PIAD is frequently fatal. Risk factors for PIAD during or after CCABG include female sex, history of PAD and hypertension, increased aortic diameter, and high CPB pressure.

Simultaneous open-heart surgery and pectus deformity correction.

PURPOSE: Pectus deformities and cardiac problems sometimes require simultaneous surgery. We report our experience of performing this surgery and review the relevant literature. METHODS: We performed simultaneous pectus deformity correction and open-heart surgery in six patients between 1999 and 2006. The pectus deformities were pectus carinatum in one patient and pectus excavatum in five patients. The cardiac problems were coronary artery disease in one patient, an atrioseptal defect (ASD) with a ventricular septal defect (VSD) in one, a VSD in one, mitral valve insufficiency with left atrial dilatation in one, and an ascending aortic aneurysm with aortic valve insufficiency caused by Marfan's syndrome in two. We corrected the pectus deformities using the modified Ravitch's sternoplasty in all patients. First, while the patient was supine, we resected the costal cartilage; then, after completing the cardiac surgery, the sternum was closed and the additional time required for the pectus operation was calculated for each patient. Patients were examined 1, 4, and 6 months postoperatively. RESULTS: The average operation time was 102 min, and there were no major complications. The pectus bars were removed 4-6 months postoperatively. Good cardiac and cosmetic results were achieved in all patients, who were followed up for 5 years. CONCLUSIONS: Concomitant pectus deformity correction and open-heart surgery can be performed safely, eliminating the risks of a second operation in a staged procedure.

Cardiac papillary fibroelastoma as a reason of transient ischemic attack for a young patient.

Cardiac papillary fibroelastoma is a rare primary cardiac tumor. It occurs mainly in the endothelium of cardiac valves. Although cardiac papillary fibroelastomas are benign tumors, they have potential life threatening complications such as sudden death, stroke, and myocardial infarction. A young man who presented two syncope attacks referred to our hospital for cardiac examination. A mass was found attached to the anterior mitral leaflet, detected by transthoracic echocardiography. We planned an urgent surgery for the patient. During operation, we found out the cauliflower shaped mass on the atrial side of the anterior mitral leaflet. We excised the tumor completely without damage to the mitral valve. We confirmed the diagnosis histopathologically. Intracardiac tumors must be excised urgently due to severe complications. It's so important to protect native valve leaflets during the excision of papillary fibroelastoma with low rates of recurrence.

A comparison of the acute hemodynamic effects of inhaled nitroglycerin and iloprost in patients with pulmonary hypertension undergoing mitral valve surgery.

BACKGROUND: Since the presence of pulmonary hypertension (PHT) affects the prognosis of the patients, it is important to manage and evaluate PHT. The aim of this study was to compare the hemodynamic effects of inhaled nitroglycerin and iloprost during early postoperative period, in patients with PHT undergoing mitral valve replacement surgery. MATERIALS AND METHODS: One hundred patients with PHT (mean pulmonary artery pressure (MPAP) >25 mmHg at rest), were randomized to receive either inhalation of nitroglycerin (group I; n=50) or iloprost (group II; n=50) in the postoperative period. In both groups, baseline hemodynamic parameters were recorded before the treatment (T(0)). Then, patients in group I received 20 microg.kg(-1) nitroglycerin and those in group II received 2.5 microg.kg(-1) iloprost. The same parameters were recorded immediately after the end of the treatment (T(1)). RESULTS: In both study groups MPAP and pulmonary vascular resistance (PVR) were found to be significantly lower at T(1) when compared to that of T(0) period (p<0.05). MPAP and PVR were significantly lower and mean arterial pressure (MAP) was significantly higher in group II when compared to group I at T(1) period (p<0.05). In addition to decreases in PVR and MPAP, iloprost also increased cardiac output (CO)(4.9+/-1.3 vs 5.1+/-0.9, p<0.05) and stroke volume (SV)(48+/-13 vs 56+/-13, p<0.05). CONCLUSION: Inhaled iloprost and nitroglycerin, both effectively reduce MPAP and PVR without affecting MAP, systemic vascular resistance (SVR) and CO. However, iloprost seems to be a more powerful pulmonary vasodilator, therefore we suggest iloprost inhalation in patients with severe PHT.

[The effects of insulin given prior to release of cross-clamp on coronary sinus lactate levels in coronary artery surgery]. / Koroner arter cerrahisinde kros-klemp alinmadan önce yapilan insülinin koroner sinüs laktat seviyeleri üzerine etkileri.

OBJECTIVE: The aim of this study is to evaluate the effects of single dose insulin, given prior to reperfusion, in patients undergoing coronary artery bypass surgery (CABG). METHODS: One hundred and twenty patients were prospectively randomized to be given either insulin (Group 1;n=60), or saline (Group 2;n= 60). Blood samples were taken 15 minutes before the reperfusion and insulin was given (0.3 IU/kg) to the patients in Group 1. Arterial and coronary sinus blood samples were taken, after the release of aortic cross-clamp (0. min), and 5th -10th -15th minutes of reperfusion. Arterial and coronary sinus lactate and glucose levels, postoperative insulin, inotropic and intraaortic balloon pump requirements; need for defibrillation and postoperative dysrhythmia, creatine kinase- MB (CPK-MB) levels, and length of stay in intensive care unit (ICU) and hospital were compared. RESULTS: In Group 1, arterial lactate levels were found to be lower at 0.min, coronary sinus lactate levels were found to be lower at 0-5-10th minutes of reperfusion compared to Group 2. Similarly, defibrillation, glucose, postoperative insulin and inotrop requirements, postoperative arrhythmia and length of ICU stay were lower in Group 1. The CPK-MB levels and length of hospital stay were similar in all patients. CONCLUSIONS: We conclude that single dose insulin given before the reperfusion period, has positive perioperative effects. Therefore it can be used in patients undergoing CABG surgery to decrease ischemia-reperfusion injury.

A rare case of pulmonary hypertension. As a result of arteriovenous fistula after cardiac surgery.

A 19 year-old woman who underwent corrective surgery for an atrial septal defect (ASD) and ventricular septal defect (VSD) 12 years previously presented with pulmonary hypertension. Cardiac catheterization showed a fistula between the right subclavian artery and vena jugularis interna. In this case, a rare example of secondary pulmonary hypertension due to acquired arteriovenous fistula after cardiac surgery is presented.

Effect of nitroglycerin inhalation on patients with pulmonary hypertension undergoing mitral valve replacement surgery.

BACKGROUND: The aim of this study was to investigate the postoperative hemodynamic effects of nitroglycerin inhalation on patients with pulmonary hypertension undergoing mitral valve replacement surgery. METHODS: Twenty patients who underwent mitral valve replacement surgery were included in the study. In the surgical intensive care unit, at T0 (before the inhalation of nitroglycerin), basal systemic and pulmonary hemodynamics were recorded. Then, 2.5 microg x kg-1 x min-1 nitroglycerin liquid nebulized by a 2-l gas flow of 40% oxygen and air mixture was administered to the patients who were diagnosed as having pulmonary hypertension (mean pulmonary arterial pressures > 25 mmHg). The same parameters were measured at the first (T1), third (T2), and fifth (T3) hours after the beginning of this treatment and 1 h after the end of nitroglycerin inhalation (T4). RESULTS: There were no statistically significant differences at T0, T1, T2, T3, or T4 with respect to heart rate, mean arterial pressure, systemic vascular resistance, cardiac index, mixed venous oxygen saturation, arteriovenous oxygen content difference, or arterial carbon dioxide tension. However, mean pulmonary artery pressure, pulmonary vascular resistance, and intrapulmonary shunt fraction were significantly lower, and the arterial oxygen tension/fraction of inspired oxygen ratio was higher at T1, T2, and T3 when compared to that of T0 and T4. CONCLUSION: The results suggest that nitroglycerin inhalation produces a significant reduction in both mean pulmonary artery pressure and pulmonary vascular resistance in patients after mitral valve operations without reducing mean arterial pressure and systemic vascular resistance. Therefore, it might be a safe and useful therapeutic intervention during the postoperative course.

Limb ischemia due to use of internal thoracic artery in coronary bypass.

Immediately after undergoing coronary bypass grafting using the left internal thoracic artery, a 59-year-old man developed left leg ischemia. Right-to-left femoral artery crossover bypass was performed and the ischemia resolved. A 72-year-old man developed left calf pain 12 days after a similar procedure; peripheral angiography revealed stenosis of the abdominal aorta and distal peripheral arteries, which did not require intervention.