Turkish Journal of Thoracic and Cardiovascular Surgery - 2000; 8(3)

CORONARY ARTERY SURGERY IN PATIENTS WITH END STAGE RENAL DISEASE RECEIVING HEMODIALYSIS TREATMENT

2000-07-01

As a result of the innovations in the field of hemodialysis technology, life expectancy of the patients with chronic renal insufficency gets longer; so that the number of those patients coming to the cardiovascular surgery clinics with coronary artery disease complaints increase. Along with this, after the cardiac operations have become to be done more succesfully and widespreadly, also the patients with high risk began to be treated more succesfully. The main cause of mortality in chronic renal insufficency patients on hemodialysis treatment is cardiovascular diseases. In this group of patients, risk of myocardial ischemia and infarction is increased when compared with the normal population. In Ko�uyolu Heart Education and Research Hospital, coronary revascularisation operations were applied on twelwe patients complaining from chest pain during the course of their hemodialysis therapies with serious lesions determined by the tests thereafter. As a result of these operations; it can be said that in this group of patients, if suitable, the coronary artery bypass operation should be done without using the cardiopulmonary bypass technique, with the technique of the beating heart. However, if patient is not suitable for the this procedure, the classical cardiopulmonary bypass also can be used with low morbidity and mortality.

EARLY AND MID-TERM RESULTS OF AORTIC VALVE REPLACEMENT WITH MEDTRONIC FREESTYLE STENTLESS BIOPROSTHESIS

2000-07-01

Background: To evaluate the early and mid-term results of aortic valve replacements (AVR) in an older patient group with a stentless valve "Medtronic Freestyle" which is pretreated with an anti-mineralizing agent, alpha-amino-oleic acid. Methods: AVR was performed with Medtronic Freestyle bioprosthesis to 40 patients with a mean age of 61.6 � 6.5 years (55-71).Thirteen (35%) of the patients were female. Mean preoperative functional capacity according to NYHA was 2.9. Five patients had diabetes and 3 patients were hypertensive. Mean preoperative systolic aortic gradient was 78 � 29 mmHg in cases that were operated for aortic stenosis. Mean cross-clamp duration and cardiopulmonary bypass time were 79 � 12 minutes, and 110 � 27 minutes respectively. Results: One patient died in the early postoperative period (2.5%). Total follow-up of the patients those were discharged were 60.1 years. Mean follow-up was 18.9 � 12.3 months. Two late deaths occurred during the follow up due to non-cardiac causes. Actuarial survival rate for 12 months was calculated to be 94.9% and 92.2% for 18 months. Left ventricular mass index decreased significantly (p =0.02). During the follow-up, no valve related complications such as thromboemboli, prosthetic valve endocarditis or paravalvular leak were observed. Structural valve dysfunction was not seen and no reoperations were needed. Conclusion: Even though long term durabilities need to be proven, stentless bioprosthesis with their superior hemodynamic performance, advantages for the regression of left ventricular hypertrophy and with minimal valve related complications in the mid term follow-up, are better choices compared to other valves in the elderly.

COMPARISON OF ST. JUDE MEDICAL AND CARBOMEDICS PROSTHESES ON CHANGE IN LEFT VENTRICULAR MASS FOLLOWING SMALL SIZE AORTIC VALVE REPLACEMENT

2000-07-01

Background: The purpose of this study was to evaluate the hemodynamic performance of St. Jude and CarboMedics aortic valve prosthesis in patients with small 19-mm and 21-mm diameter aortic annulus. Methods: >Postoperative hemodynamics were assessed in four groups. A (19 mm CarboMedics) valve was used in eighteen patients Group 1, a 21 mm CarboMedics valve was used in twelve patients Group 2, a (19 mm St. Jude) valve was used in seventeen patients Group 3, and a (21 mm- St. Jude) valve was used in fifteen patients Group 4. Preoperative, postoperative 1. month, 6. month and 12. month echocardiography was performed and left ventricular mass and left ventricular mass index were measured. Results: Postoperative left ventricular mass and left ventricular mass index were decreased in Group 1 and Group 3. Results were not statisticaly significantly (p > 0.05). Postoperative left ventricular mass and left ventricular mass index were decreased in Group 2 and Group 4. Results was not statisticaly significantly (p > 0.05). Conclusion: Group 2 and 4 provides a better hemodynamics and clinical performance than Group 1 and 3. It is concluded that, compared with 19 and 21 mm CarboMedics valves, the 19 and 21 mm St. Jude valves showed a significantly better hemodynamics and clinical performance. We believe that, the results were not statisticaliy significanty because of the small number of patients included in this study.

RESULTS OF CORONARY REOPERATIONS AND ANALYSIS OF RISK FACTORS

M�nevver Y�KSEL, Fatih �SLAMO�LU, Y�ksel ATAY, Tahir YA�DI, Suat B�KET — 2000-07-01

Background: Purposes of this study were to evaluate the performance of our coronary reoperations and to determine the risk factors affecting mortality and morbidity according to preoperative, perioperative, and postoperative early and mid-term follow-up results. Methods: A retrospective analysis of preoperative, perioperative, and postoperative early and mid-term follow-up data of 40 patients who underwent reoperative coronary artery bypass grafting via moderately hypothemic cardiopulmonary bypass in the Cardiovascular Surgery Department of Ege University between 1994 and 1999, was performed. Follow-up data after the discharge of these patients were obtained via monthly periodical examinations in first 6 months, and after then via telephone interviews. Results: As two occured in perioperative, and one in postoperative periods overall mortality was 3 (7.5%) patients. Cardiac problems were observed in 12 of overall 16 complicated patients. The improvement in functional capacity of surviving 37 patients was perfect in 31 � 19.36 months of follow-up. Preoperative factors associated with increased in-hospital mortality and morbidity were diabetes, hypertension, hypercholesterolemia, ejection fraction (LVEF) of < %50, and previous myocardial infarction (MI). Besides these factors, obesity, chronic obstructive pulmonary disease (COPD), female sex, and older age were also associated with increased morbidity. Conclusions: The mortality and morbidity rates of our coronary reoperations were low as well as postoperative symptomatic improvement and survival rates were satisfactory. Hypercholesterolemia, hypertension, diabetes, obesity, female sex, COPD, older age, previous MI, and low LVEF were appeared as significant risk factors in coronary reoperations.

THE EFFECT OF RENAL DOSE DOPAMINE USE ON RENAL TUBULAR FUNCTION

2000-07-01

Background: In patients with normal heart and kidney functions following routine coronary artery surgery was to investigate the effect of �renal dose� dopamine on renal tubular function. Methods: Forty patients were prospectively randomised into two equal groups. The patients in Group 1 (n = 20) received dopamine infusion at renal dose ( 2.5 � 4.0 �g/kg per min ) starting from induction of anaesthesia for 48 hours, whereas the other group (Group 2, n = 20 paents) served as untreated controls. Daily measurements were made of weight�adjusted urine output (ml/kg), fluid balance (input/output), serum creatinine, blood urea and urinary retinol binding protein (RBP). Results: The two groups matched in term of age, time and temperature on cardiopulmonary bypass, number of grafts performed and perioperative haemodynamic status. No differences were detected in the weight-adjusted urine output, fluid balance, serum creatinine and blood urea between the groups. The patients treated with dopamine (Group 1) had much greater urinary excreation of RBP over the same period (1120 � 10 mg / m.mol Cr and 390 � 20 mg / m.mol Cr versus 290 � 5 mg / m.mol Cr and 40 � 3 mg / m.mol Cr in group 2; p = 0.03) than those in Group 2. Conclusion: Dopamine given at renal-dose does not protect renal tubular function in patients with normal heart and kidney functions undergoing coronary surgery. On the contrary, it increases the severity of renal tubular injury during the early postoperative period. We do not recommend the use of dopamine for routine renal prophlaxis in this patients.

THE EFFECT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE ON MORTALITY AND MORBIDITY IN PATIENTS UNDERGOING CORONARY BYPASS SURGERY

2000-07-01

Background: To evaluate the effect of chronic obstructive pulmonary disease on patients undergoing coronary bypass surgery. Methods: Forty patients who were undergone CABG in our department were enrolled, 20 patients with chromic obstructive pulmonary disease (Group 1) and 20 patients without pulmonary disease preoperatively as a control group (Group 2). Comparison of the groups was made with regard to postoperative reintubation, prolonged intubation (longer than 48 hours), atrial fibrillation, using of intraaortic balloon pump, mediastinitis, wound infection, pneumonia, steroid and bronchodilator use, elevation of diaphragm, ventricular fibrillation, trakeotomy, low cardiac output, length of intensive care unit and hospital stay. Results: After operation, patients in Group 1 had a longer intensive care unit (5.90 � 2.68 versus 2.3 � 1.8, days p = 0.003) and hospital stay (15.85 � 3.28 versus 7.97 � 1.86 days, p = 0.003). More patients in Group 1 required prolonged intubation (4 versus 0, p = 0.106) and reintubation (4 versus 0, p = 0.106). More patients in group 1 had arrhythmias (5 versus 0, p=0.106), using intraaortic balloon pump (2 versus 0, p = 0.487), mediastinitis (1 versus 0, p = 0.487), pneumonia (2 versus 0, p = 0.487), tracheotomy (2 versus 0, p = 0.487), low cardiac output (4 versus 0, p = 0.106) steroid and bronchodilator use (4 versus 1, p = 0.342). Two patients in group 1 died, whereas no patient in Group 2 died (p = 0.487). Conclusions: Nowadays, as a result of improvements in open heart surgery and intensive care unit, coronary bypass surgery in patients with chronic obstructive pulmonary disease can be performed with acceptable mortality and morbidity.

THE USE OF MATHEMATICAL SOLUTION IN ANALYSIS OF MORPHOMETRIC CHARACTERISTICS OF AORTIC VALVE AND LEFT VENTRICULAR OUTFLOW TRACT

2000-07-01

Valva semilunaris sinistra and the aortic root complete to left ventricle morphologically and form to left ventricular outflow tract physiologically. This study was designed to investigate the relationship of diameters and geometric features of human aortic valve and root in static state. The morphological effects of geometry and dimensions of the aortic valve and root were examined using of 18 adult hearts from fixed male cadavers who had expired due to noncardiac causes. The aortic valve measurements were performed on the free edge of the leaflets and the annullar edge from tomographic cross-sectional views obtained from magnetic resonance imaging (MRI). Morphological assessement of the aortic root was done with cross-sectioned sequentially for measurements at four levels: at the ventriculoarterial junction (annulus), at the sinuses of Valsalva (sinus), at the sinotubular junction, and at 1 cm above the sinotubular junction. Mathematical relationship and comparisons were made by level setting using Euclidean radiation and a computerized morphometric analysis programming among the values from four different aortic root levels. The diameters of the annulus and the sinus level were represented by a value of one, and all other values were represented by a fraction (percentage) of these values. Statistical analysis among the variation of the diameters at the four levels of aortic root was achieved using ANOVA test (one-way analysis of variance). The free edge of left coronary cusp was the shortest among three leaflets (p < 0.05). Our data obtained from mathematical modelling showed that the aortic root was the narrowest at the sinotubular junctional level, and the widest at the sinus level (p < 0.05). The mean thickness of the aortic root wall was variable within each MRI cross-section. The aortic wall was thicker at the commissural level than at the sinus level. The analysis of our mathematical data implied that the production of the design to aortic root anatomy and geometry by 3-dimentional geometrical solution could resemble the surgical anatomy and could be adapted to the aortic root replacement and the procedures of the aortic valve preservation.

THE PROTECTIVE ROLE OF PENTOXIFYLLINE IN THE PERIPHERAL SYSTEM DURING EXTRACORPOREAL CIRCULATION

2000-07-01

Pentoxifilin inhibits 5�nucleotidase, so that it decreases losing of ATP. Therefore Ptx may avoid cell damage that occurs after ischemic period during open heart surgery. In this study, the patients who have got different diagnosis (ASD, VSD, coronary disease, and valve disease), and were operated with open heart technique were divided into two subgroups which were study group (n = 25) and control group (n = 10). We added Ptx (500 mg/lt) in the prime solution in the study group. Tumor necrosis factor alpha (TNF-a), interleukin-6 (IL-6), Interleukin-8 (IL-8) were studied in the blood that was sampled from right atrium before and after extracorporeal circulation in the both groups. Alanin aminotransferaz, aspartate aminotransferaz, blood urea nitrogen, creatinine, bilirubin, alchalen phosphotase, lactic dehidrogenase, creatine phosphokinase were also studied. We also compared preoperatively and postoperatively hemodinamic data, daily drenage, coagulation-bleeding time in the both groups. We used nonparametric Wicoxon test to evaluate the results. Results of TNF-a, IL-6, IL-8 were meaningful statistically (p < 0.005). The other parameters also expressive (p < 0.05). There was no difference in hemodynamic data, daily drenage, coagulation-bleeding time between both groups. We suggest that PTX has got the important protecting role on the peripheral organs during extracorporeal circulation.

A NEW CONCEPT IN CARDIAC SURGERY: UNIFOCALIZATION

Cevahir HABERAL, * Emin T�REL�, * Enver DAYIO�LU, * Ertan ONURSAL — 2000-07-01

Pulmonary atresia with ventricular septal defect (VSD) hawing major aortopulmonary collateral arteries is a rare congenital cardiac disease. These cases differ from type IV Truncus arteriosus for having central pulmonary arteries and from pseudotruncus for having MAPCA�s and they are classified as ��VSD+PA+MAPCA�� in new surgical concept. Seven ��VSD+PA+MAPCA�� cases were admitted to the department of Thoracic and Cardiovascular Surgery, Istanbul Medical Faculty, University of Istanbul. Six cases had hypoplastic confluent pulmonary arteries and 2 cases had no native pulmonary artery. Out of 21 MAPCA�s, only 1 MAPCA had a communication with the native pulmonary artery. Five cases had right arcus aorta. Patients had average 3 MAPCA�s, ranging between 2, 6. Two cases had right unifocalization through right thoracotomy, 2 cases had left unifokalization through left thoracotomy, 2 cases had bilateral unifokalization through median sternotomy and 2 cases were considered to be inoperable. MAPCA�s were unifocalized using polytetrafluoroethylene graft in 1 case and in 7cases, MAPCA�s were unifocalized with direct anastomosis. There was no mortality. Although unifocalization for VSD+PA+MAPCA cases are limited today, we think that staged surgical repairs are suitable for these cases.

NEO-PULMONARY ARTERY STENOSIS AFTER ARTERIAL SWITCH OPERATION

2000-07-01

The surgical approach of the transposition of the great arteries is the anatomical correction by arterial switch operation. The most common cause of reoperation after this procedure is neo-pulmonary stenosis. The factors influencing the neopulmonary artery stenosis rates seem coronary arterial pattern, operation time, relationship of the great vessels and surgical technique. The reported rate of neopulmonary stenosis ranged between 5% and 20% in literature. In our department 40 patients ith D-TGA underwent arterial switch operation between 1997 and 2000. In 30 patients we referred echocardiography evulation in early and late postoperative periods to search neo-pulmonary stenosis. In 1 patient we determined modarate degree transpulmonary gradient (20 mmHg ). The echocardiographic evulation of the remaning patients revealed unsignificant gradient (< 15 mmHg). 6 months after the operations we performed second echocardiographic evaluation and determined 2 severe (> 30 mmHg), two modarate (20 mmHg) pulmonary stenosis. Other patients had insignificant pulmonary gradients. This complication is more common in our first 15 cases. We didn�t measure a sigwasnificant gradient in the last 15 cases. The patient with severe gradient was reoperated and we have been following him routinely. The other patient was died before the planned reoperation. We are believed that the neo-pulmonary stenosis after arterial switch operation is related to surgical technique and experience.

EARLY AND MIDTERM RESULTS OF CRYOLIFE-ROSS PULMONARY XENOGRAFTS IN 34 CONSECUTIVE PATIENTS

2000-07-01

Newly used pulmonary xenogrefts seem to be good alternatives for homogreft conduits, although in the literature there are only a few studies for early and late results of these xenogrefts. In Ba�kent University Hospital, from January 1999 to October 2000, 34 patients underwent open heart surgery for Cryolife-Ross xenogreft valved conduit implantation. The mean age and weight of the patients were 8.0 � 6.6 years old (4 months - 28 years old), and 22.7 � 15.3 kg (4.4-54 kg), respectively. The diagnoses were corrected transposition of great arteries in 4 patients, double outlet right ventricle in 5 patients, tetralogy of Fallot in 5 patients, transposition of great arteries in 9 patients, truncus arteriosus in 2 patients, pulmonary atresia in 5 patients, abscence of pulmonary valve in 2 patients, and Shone complex in 1 patient. The last patient had ventricular septal defect with vegetations in the pulmonary artery at the previous pulmonary banding site. The mean aortic cross clamp time was 105.0 � 37.0 min (range, 34 to 196 min), and the mean cardiopulmonary bypass time was 163.1 � 70.1 min (range 62 to 390 min). In 6 patients circulatory arrest was used. In the early postoperative period 6 patients died; 3 of them had pulmonary atresia, 2 patients had truncus arteriosus, and one patient had Shone complex. In the intermediate postoperative period one patient who had double outlet right ventricle repair died because of Brusella endocarditis. In congenital heart surgery, the use of valved conduits permits repair of complex congenital heart malformations but conduit dysfunction brings the necessity to replace them for a certain period of time. There was early dysfunction among these 34 patients and they hawe been followed for the long term results.

THE COMPARISON OF ANALGESIC EFFECTIVINESS OF BOLUS AND CONTINUOUS INFUSION VIA EPIDURAL CATHETER AND PARENTERAL SYSTEMIC ANALGESIA AFTER CORRECTION OF PECTUS DEFORMITIES

2000-07-01

54 patients were operated for pectus deformity at GATA (G�lhane Military Medical Academy) and were divided into three groups from the point of used pain control method. In the first group (n = 15), 20 cc 0.25% bupivacaine was injected to the pericondrium and the subcutaneous tissue, and additionly an epidural catheter was inserted. Initially, 4 cc 0.25% bupivacaine + 1 cc 0.05% fentanil + 5 cc 0.9% physiologic serum was given via epidural catheter and as needed additionly dose was given in a bolus manner. In the second group (n = 18), 1-2 mg/kg/h 0.25% bupivacaine + 1-2 mcg/kg/h 0.05% fentanil was given as continuous infusion via epidural catheter. In the third group (n = 21), metamizol sodium (intravenously) and diclofenac sodium (intramuscularly) was used. All patients were evaluated by verbal analog pain scala. In the point of analgesia effectiveness, an excellent analgesia was determined in the second group. In the third group the worse analgesia control was maintained. We needed more additional analgesia dose in this group. In conclusion, local bupivacaine application intraoperatively and continuous epidural bupivacaine + fentanil infusion method is the most safe and effective method in postoperative pain control.

PULMONARY HYDATID DISEASE AND SURGICAL THERAPY

Maruf �ANLI, B�lent TUN��ZG�R, Levent ELBEYL� — 2000-07-01

Background: We reviewed 60 hydatid cyst cases with results of operation whom most of them were operated by cystotomy and capitonnage technique. Methods: Sixty patients with hydatid cyst were operated in our clinic between January 1998 and February 2000. Diagnosis was made by clinical manifestations, chest x-ray and thorax CT. After the operation we treated the patient by 10 mg/kg/day albendazole for out 6 weeks if there were no contraindications. Results: In five patients the hydatid cysts were bilateral, in eleven patients the cysts were multiple and in three patients the cysts were at hepatic dome localization. Fifty-five patients underwent cystotomy and capitonnage, two patients underwent lobectomy. Three patients which the cysts were at hepatic dome localization underwent cystotomy via transdiafragmatically. There were no early or late mortalities. Three patients had postoperative complication. There were no recurrences in these cases for two years. Conclusion: We concluded that the procedure of cystotomy and capitonnage without resection is an efficient therapy in the pulmonary hydatid cyst cases.

CORRELATION OF CHANGES IN FEV1 AND LUNG PERFUSION SCINTIGRAPHY AFTER THORACOTOMY

Ak�n Eraslan BALCI, Nesimi EREN, * Tansel Ansal BALCI — 2000-07-01

In this prospective study performed for explaining the operative profit with objective criteria rather than clinical observations and relation between pulmonary function tests and lung perfusion scans, 72 patiens whose mean age 37.52 years were evaluated. Pulmoner scans and pulmonary function tests were performed both preoperatively - and postoperatively. Both FEV1 and scans increased after thoracotomy and increasing were correlated each other. In conclusion, if operation causes improvement in FEV1 then one can expect increasing in lung perfusion.

THE ANALYSIS OF THE 55 CASES OPERATED ON FOR ESOPHAGUS CARCINOMA

2000-07-01

Esophagus cancer treatment is difficult to do because of its multicentricity, early lymphatic invasion and late symptoms. We have presented here 55 operated esophagus carcinoma cases between 1990 and 2000 and observed them retrospectively. Preoperatively we have taken routine biochemical and hemathological tests and have done esophagogastric passage graphy with barium and chest tomography, abdominal ultrasonography and rigid esophagoscopy to the all patients. Postoperatively, we tested the patients for morbidity, mortality and survey. Sixteen patients were women (%16) and 39 patients were men (%70). The youngest patient was 18 years old boy and the elder was 76 year old man (average age 52 � 1 years). Most frequent symptom was dysphagia (%95) and weight loss (%30). Histopathologically, 49 cases (%90) were squmous cell, 6 cases (%10) were adenocarcinoma. The carcinoma localization was at the middle 1 / 3 rd in the %45, lower 1 / 3 rd in the %38, upper 1 / 3 rd in the %7 and at the cardia in the %10 of patients. We did laparotomy + right thoracotomy + distal esopahogectomy + esophagogastrostomy in the 20 patients and in the other 18 patients left thoracophrenolaparotomy + distal esophagectomy + proximal gastrectomy + esophagogastrostomy. And we did laparotomy + total esopahagectomy + total laryngectomy + radical neck dissection + oropharyngogastrostomy. We used the stomach for the replacement in almost every patient. Only in the one case we did laparotomy + right thoracotomy + esophagojejunostomy because of his prior operation for peptic ulcus. Only one case died from myocard infarction in the 7th postoperative day. We have determined fistulae in the 2 patient. Average survey was found to be 15 months.

VIDEOTHORACOSCOPY FOR PLEURAL EFFUSION: A REVIEW OF 47 CASES

2000-07-01

Background: In this study, it was aimed to evaluate the diagnostic and treatment values of videothoracoscopy in patients with pleural effusion. Methods: 47 patients underwent video assisted thoracic surgery (VATS) between March 1994 and March 2000 in Thoracic Surgery Center, Atat�rk Chest Diseases Hospital and Department of Thoracic Surgery Atat�rk University Faculty of Medicine. Of the patients 32 were male and 15 were female, the mean age was 48.2 year (range 19 to 74 years). The procedure was performed under general anesthesia and single lung ventilation in 45 patients, and local anesthesia in 2 patients. Results: Of the patients, 40 had benign and 7 had malignant disease. The diagnostic value of the procedure has 97.9%. In patients with malignant disease pleurodesis was performed to obtain cure. No complication occurred in our cases. Conclusions: It was thought that videothoracoscopy is an effective procedure in diagnosis and palliative treatment of pleural effusion.

TREATMENT MODALITIES IN DEEP VENOUS THROMBOSIS

2000-07-01

The ratios of complications and recovery of heparinization applied to the patients diagnosed with deep venous thrombosis, fibrinolytic therapy, trombectomy and pulmoner embolectomy were examined retrospectively by the purpose of presenting the approach of the clinic of cardiovascular surgery of Atat�rk University. In treatment, low-molecule weighted heparin was used in 155 patients (44%), standart heparin was used in 173 patients (50%), fibrinolytic agents were used in 14 patients (4%). Pulmonary embolectomy was applied to 4 patients (1%) and ileofemoral trombectomy to 3 patients (1%). With the results obtained, we concluded that, due to effectiveness and lower bleeding risk and application facility of low molecular weighted heparin, it began to replace standart heparins, and fibrinolytic therapy could be used in early cases because of succesful results, and that thrombectomy could still be applied in suitable cases.

THE ROLE OF THE CHLAMYDIA PNEUMONIAE IN THE DEEP VENOUS THROMBOSIS

2000-07-01

It is thought that Chlamydia pneumoniae (Cp) enfection could participate in the thicking of the wall of venous system. It has also been invastigated whether Cp is a risk factor or not for deep venous trombosis. In this study, Cp IgG, Cp IgM and Cp IgA antibodies were investigated, using microimmunoflouresan in the study group (22 patients with deep venous thrombosis) and control group ( 8 normal population) in the first and thirth mounth. Cp IgG antibodies of the study were two times higher than the control group. Both antibiotherapy and routin anticoagulant therapy quietly removed Cp IgG antibodies in the study group.

STENT IMPLANTATION IN THE DISSECTION OF THE SAPHENOUS VEIN GRAFT

Sinan DA�DELEN, Cevat KIRMA, Bengi YAYMACI, �smet D�NDAR — 2000-07-01

We report a 61 year old male patient with dissection of the saphenous vein graft on coronary angiogram who had undergone two vessels coronary artery bypass graft seven years ago, with left internal mammarial artery to left anterior descending coronary artery and saphenous vein graft to right coronary artery. For the last one and half month, he sustained angina pectoris. Coronary angiogram revealed a dissection of the saphenous vein graft at the mid-portion. His anginal symptoms couldn�t be controlled despite maximal medical theraphy for two weeks. On repeat coronary angiogram, the dissection was found to be persisted and balloon angioplasty was performed for predilatation followed with implantation of a 3,5 mm diameter and 26 mm length Jo stent. Anginal symptoms of the patient rapidly resolved.

RIGHT VENTRICULAR MASS IN NEPHROTIC SYNDROME

Osman BOLCA, Mehmet EREN, Bahad�r DA�DEV�REN, Ayd�n YILDIRIM, Tuna TEZEL — 2000-07-01

A twenty year old male patient presented with complaints of fatigue, palpitation and swelling on his right leg. Two months ago the patient was diagnosed as having nephrtic syndrome. Physical examination revealed swelling, pallor, coolness and decreased pulses on his right leg with 3 + pretibial edema in his both extremities. Echocardiography showed a 3 x 4 cm non-homogenous, immobile, lobulated, irregular mass with defined margins in the right ventricle. Doppler studies showed subacute thrombi the right iliac vein extend up to distal venous tracings, obliteration images caused by thrombi in the right main iliac artery with its internal and external branches and inferior veno cava along with partial venous thrombus in bilateral renal veins. A right ventricular mass can be categorized in to four groups, namely, malignancy, thrombus, vegetation and artifact. Herein the clinic diagnosis of a right ventriculary mass in a patient with nephrotic syndrome was discussed.

AN ALTERNATIF PERSPECTIVE FOR GRAFT INFECTION IN INGUINAL AREA: OBTURATOR BYPASS

Cengiz �ZBEK, Ufuk YETK�N, Banu AKDA�, �brahim �ZS�YLER, Tayfun G�KTO�AN — 2000-07-01

When it is impossible to use main femoral artery in various situations specially in case of graft infections in area of femoral bypass through an obturator foramen is an useful alternative. In this study, aorto supragenuar femoral bypass through obturator foramen was practiced by removing infected graft. In this case, the subject was 65 year-old, man mandemanding for graft infection and has already had an operation of aortofemoral bypass. After discharging him as well-being, it was found out that there was no ischemic change and that the graft was open in his angiography taken for the post-operative control on 18th month. Although it is not a widely-used procedure to operate aortofemoral bypass from obturator foramen, it is an essential method to be known by vascular surgeons as an alternative way which saves life and extremity.

A CASE OF TAKAYASHU ARTERITIS ACCOMPLISHED WITH CORONARY-PULMONARY ARTERY FISTULA AND ABNORMALITY OF RENAL ARTERIES

2000-07-01

Takayashu arteritis is a systemic inflamatuary disease which affects aorta and its mains branches with other arteries and thought to be otoimmune in origin. The clinic signs are related to the arteries affected. This manuscript involves a case of Takayashu arteritis which was accomplished with coronary artery-pulmonary artery fistula and abnormality of renal arteries as the first case report in the literature.

SURGICAL APPROACH TO AN ACUTE DISSECTING ANEURYSM OF THE ASCENDING AORTA IN THE PRESENCE OF AORTIC COARCTATION

Yavuz Y�R�KO�LU, Af�in YAVER�, Enver EK�C�, Co�kun �K�ZLER, *G�l�mser HEPER — 2000-07-01

A 20 year-old man was referred to our hospital with severe chest pain and a prelimenary diagnosis of acute dissecting aneurysm of the ascending aorta in the presence of an untreated coarctation of the thoracic aorta. Following stabilization of the patient�s condition a balloon coarctation angioplasty was performed to reduce afterload and hypertension and to facilitate a femoral arterial cannulation for cardiopulmonary bypass. The patient was taken directly to surgery following this procedure and underwent a replacement of the ascending aorta and bicuspid aortic valve. A resection and graft interposition technique with reinforcement of the distal and proximal aortic stumps ("teflon sandwich reinforcement") was utilized with an excellent result. We review the literature and discuss this rare entity, with special emphasis on the surgical approach, choice of arterial cannulation site and surgical technique.

PAPILLAR THYROID CANCER WITH INTRALUMINAL TRACHEAL INVASION

2000-07-01

Thryoid cancer invading the trachea is a rare occurrence that can cause death due to airway bleeding or suffocation. The incidence of tracheal invasion varies between 0,5-6,5% [,]. The patient was 70 years old woman who had undergone subtotal thyroidectomy 4 years ago. She presented with dyspnea and hemoptysis for one year. A nodule of 2 cm invading the trachea in the right thyroid lobe and 18 mm LAP were found and diagnosed as papillary thyroid cancer metastasis. She had left vocal cord paralysis and obliteration of the tracheal lumen between the 2ndand 4th tracheal rings. The lesion was resected along with involved 7 tracheal rings, and the trachea was reconstructed. Lymph node dissection was performed on the right side. She had uncomplicated postoperative course and was discharged on the 15th day for I131 treatment. She has been fallowed for 6 months and found to have normal tracheal lumen and no recurrence.