Turkish Journal of Thoracic and Cardiovascular Surgery - 2002; 10(2)

OUR INFRAPOPLITEAL BYPASS APPLICATIONS

Kaz�m BE��RL�, Kamran KAZIMO�LU, G�k�e ��R�N, Hasan T�Z�N — 2002-04-01

Background: Bypass procedures related to the popliteal, anterior tibial, posterior tibial, peroneal and plantar arteries and tibioperoneal trunk have a great importance in the treatment of infrapopliteal atherosclerotic occlusive diseases. Methods: In our study, 95 cases operated for infrapopliteal atherosclerotic disease between 1990-1999 were examined including follow up and results. The most common inflow site was the common femoral artery (71.13%). Distal anastomoses were performed on infrapopliteal artery in 68.42%, posterior tibial artery in 13.68%, the tibioperoneal trunk in 11.58% and the anterior tibial artery in 6.31% of the cases. The most commonly used graft material was the autogenous saphenous vein. Results: The first and the second year patency rates for below knee popliteal artery bypasses were 88.2% and 80.2%, respectively. It was 76.3% and 67% for anterior tibial artery, 81.3% and 76.6% for tibioperoneal trunk, 78.2% and 62.3% for posterior tibial artery bypasses. For the reversed autogenous saphenous vein group, the first and second year patency rates were 87.5% and 79.4%. For in situ autogenous saphenous vein group it was 83% and 75.6%. These rates were significantly higher compared to the polytetrafluoroethylene used group (59.5% and 50.8%). Conclusions: All infrapopliteal arteries can be used as outflow tract in femorodistal bypass surgery. Infrapopliteal bypasses can be performed easly using autogenous saphenous vein grafts and the results are better.

MID-TERM RESULTS OF SUBCLAVIAN STEAL SYNDROMES OPERATED BY CAROTICO-AXILLARY/SUBCLAVIAN BYPASS GRAFTS

Onur G�RER, Fikri YAPICI, Bayer �INAR, Mesut K�SEM, Yavuz EN�, �zge SEZERMAN — 2002-04-01

Background: The incidance of subclavian syndrome is higher than accepted and absolute cure is achived by surgical procedures in semptomatic patients. Methods: In this study, the complications, mortality and patency rates of 25 cases trented with carotico-axillary or caratico-subklavian bybass techniques were retrospectively analyzed after 5 year follow up period. Results: In one patient (4%) early and in one patient (4%) late graft occlusion were seen. The early graft occlusion was treated by emergency embolectomy, but late graft occlusion was not reoperated and followed up periodically. Total cumulative patency rate at 5 year was 96%. The 30 day and 5-year mortality rates were 4%, retrospectively. In one case (4%) hematoma of the surgical field, in one (4%) left hemiparesthesis and in another case (4%) upper extremity embolism were seen as early postoperative complications. In late postoperative period, one case (4%) was reoperated due to late graft infection. Conclusions: Based on our results, carotico-axillary/subclavian bypass grafts can be performed with an acceptable morbidity and mortality when done by surgeon in considerable indications.

A RIGHT CORONARY ARTERY FISTULA DRAINING INTO THE RIGHT VENTRICLE ASSOCIATED WITH MITRAL VALVE STENOSIS

�lyas KAYACIO�LU, C�neyt KONURALP, Mustafa �D�Z, Murat AK�AR, *Seden �EL�K — 2002-04-01

The association of mitral valve disease and coronary artery fistula (CAF) is a rarely seen antity. In most of the cases, CAF is eitherasymptomatic or represents angina-like symptoms. However, the symptoms and physical examination findings may be masked whenit is associated with a valvular disease. In this study, we report a CAF case associated with mitral valve stenosis. Aconnection betweenright coronary artery and right ventricle was detected by coronary angiographic study performed before valve replacement surgery onthe patient who had only dyspnea, fatigue and palpitation complaints. During the surgical procedure, which included mitral valvereplacement by using prosthesis, fistula site was found and ligated. Among the case presentations that represent coronary arteryanomalies associated with mitral valve disease, there is no any fistula opening into right ventricle. In the very limited cases thatpresented as CAF associated with valvular disease (mitral and/or aortic), the fistula usuallyopens into either pulmonary artery or rightatrium.

HEYDE�S SYNDROME

Hakan B�NG�L, Bilgehan Sava� �Z, Ertu�rul �ZAL, Ahmet Turan YILMAZ, Harun TATAR — 2002-04-01

Heyde�s Syndrome which is associated with calcific aortic stenosis and gastrointestinal bleeding is very rare disease. Because of itsrarity there are quite a few literatures about Heyde�s Syndrome. The pathophysiologic link between aortic stenosis and gastrointestinal bleeding is still unknown. Seventy years old male patient admitted to our department with a complaint of dyspnea and chest pain. Afterthe diagnosis of ischemic heart disease and aortic valve disease, the patient underwent coronary artery bypass grafting and aortic valvere placement with biologic prosthesis. During the first postoperative day, the patient had a gross gastrointestinal bleeding. Afterendoscopic examination and selective mesenteric angiography, we examined the postoperative period of the patient.

MOUNIER � KUHN SYNDROME: CASE REPORT

Alpay SARPER, *Necdet �Z, Abid DEM�RCAN, **Erol I�IN — 2002-04-01

Mounier � Kuhn syndrome is a rare congenital disorder due to defective development of elastic and muscle tissues in the upperair ways. A case presented with a severe life threatening pneumonia, bilateral bronchiectasia and tracheobronkomegaly. Rightpneumonectomy was performed. Symptom of the infection was diminished after the operation. The patent is a symptomatic during four year follow-up.

HEMIRECTUS FLAP AND BILATERAL PECTORAL ADVANCEMENT IN MEDIASTINITIS

2002-04-01

Today mediastinitis after coronary artery bypass surgery is a rare (< 1%) complication unless insulin dependent diabetes mellitus, bilateral internal thoracic artery use, older age and other major morbidities coexist. If mediastinitis occurs and can not be taken under control by means of classical treatment (partial sternal resection, debridement, Robiscek repair and closed mediastinal irrigation) in a low risk coronary artery bypass patient with left internal thoracic artery graft, best treatment might be right hemirectus flap with bilateral pectoral advancement reconstruction after complete sternal resection.

BLUNT INJURY TO THE SUBCLAVIAN ARTERY: CASE REPORT

Hasan KARABULUT, Fevzi TORAMAN, Sinan DA�DELEN, Cem ALHAN, *Ufuk NALBANTO�LU — 2002-04-01

Although they are rare, subclavian artery injuries carry a high rate of mortality and morbidity. Nonpenetrating injuries differ from the penetrating injuries by affecting the mid and the distal portion of the vessel. We report on two male patients aged 27 and 29 who were admitted to the emergency department of our hospital following blunt trauma. The arterial pulses were absent in the right upperextremity in both patients. They underwent doppler and angiographic evaluation. Angiography revealed a 5 cm long thrombotic segment in the distal portion and a 3 cm long thrombotic segment in the mid portion of the subclavian artery in two patients,respectively. The brachial plexus was injured in both patients. Subclavian-axillary artery bypass and right carotid-subclavian artery bypass with 6 mm polytetraflowrethylene (PTFE) graft were performed, respectively. Both patients had an uneventful recovery.

TRANSATRIAL CLOSURE OF AN APICAL VENTRICULAR SEPTAL DEFECT WITH THE SEPTAL OBLITERATION TECHNIQUE

Emin T�REL�, Kenan SEVER, Murat BA�ARAN, Eyl�l KAFALI, Ertan ONURSALl — 2002-04-01

The surgical treatment of apical ventricular septal defects is a common problem in pediatric cardiac surgery. The most acceptable surgical approach remains controversial because of the difficulties in obtaining adequate exposure and complete closure of these defects. We present a case of apical ventricular septal defect in a 43 days old child successfully closed transatrially with the septal obliteration technique.

ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)

Yaman �ZYURT, Hakan ERKAL, Zuhal ARIKAN, *Recep DEM�RHAN — 2002-04-01

Acute respiratory distress syndrome (ARDS) was first described by Ashbaugh and his friends 35 years ago and it is a severe respiratory failure refractory to oxygen therapy and characterized by non-cardiogenic diffuse infiltrates involving both lungs. Clinical signs ofARDS includes tachypnea and dyspnea. As the incidence is 3-8/100,000, its mortality is up to 40-90%. In the pathogenesis of ARDS,non-cardiogenic pulmonary edema occurs, according to the alveolar capillary damage. Today, as there is no spesific therapy that haltsthe pathophysiology of ARDS, the management can not be more than symptomatic and supportive. Amouq the life-saving ventilator managements the most popular ones are the lung protective ventilation, permisive hypercapnia, high PEEP and the prone position. Altough the treatments such as the extracorporeal life support, high frequency ventilation, liquid ventilation and pharmacological therapy have not been put in standart practice, some researchers indicate that these treatments give hope for the outcome. As a result; the studies focused on the pathophysiology of the ARDS and especially the systemic inflammatory response syndrome, will cause decrease on the rate of the mortality and the morbidity.

MINIMAL INVASIVE TECHNIQUES IN PEDIATRIC OPEN HEART SURGERY: MINI STERNOTOMIES

K�van� MET�N, Nejat SARIOSMANO�LU, Ey�p HAZAN, Baran U�URLU, �ztekin OTO — 2002-04-01

Background: Minimally invasive techniques are in use for many cardiac pathologies. Most recent methods such as off-pump, Midcab or robotic surgery are mostly usable for adult coronary by-pass surgery cases. Methods: We have performed some types of minimal invasive techniques for pediatric cases in our institution since 1993. Ten cases with different cardiac lesions were operated via a mini sternotomy. We did not observe any operative or postoperative complication in those cases. Results: There was no early or late morbidity and mortality. Patients were discharged from the hospital between 3 and 8 days (mean 5 days). Conclusions: We believe that mini sternotomy is a very useful and safe method for open heart surgery. There is no need for specialized instruments and it allows a familiar exposure to the surgeon.

THE EFFECT OF INSULIN ADMINISTRATION ON GLUCOSE LEPTIN METABOLISM IN OPEN HEART SURGERY

2002-04-01

Background: We aimed to put forward the relation between glucose and leptin under hypothermic cardiopulmonary bypass and effect of insulin administered to achieve normoglycemia on glucose � leptin levels. Methods: Patients were divided into two groups as control and study groups. Insulin was given to the patients in the study group. Blood samples were collected from all of the patients with 20 minutes intervals beginning at the preanesthesia period until the closure of the sternum and the last sample was taken in the intensive care unit. Glucose and leptin levels were recorded. Results: In the study group 71 � 12 units of insulin was given. Intraoperative hyperglycemia was present in both groups but in the study group the levels were lower. The difference between the values during and after cardiopulmonary bypass was statistically significant (p < 0.05). During the same process there was inverse correlation between glucose and leptin levels. Conclusions: In this study we demonstrated that glucose levels are lowered by crystallized insulin application under hypothermic cardiopulmonary bypass. Furthermore as we estimated an inverse correlation between glucose and leptin we are convinced that leptin is one of the influential factors in the development of hyperglycemia under hypothermic cardiopulmonary bypass.

SEVERE FUNCTIONAL TRICUSPID REGURGITATION: �MODIFIED SEMICIRCULAR CONSTRICTIVE ANNULOPLASTY� TECHNIQUE AND MIDTERM RESULTS

2002-04-01

Background: The aim of this new annuloplasty was to prevent the occurence of recurrent tricuspid regurgitation secondary to Bowstring (Guitar string) phenomenon as a result of gliding (jiggle) effect seen in De Vega annuloplasty, and to provide symmetrical annular reduction and constriction and also to protect the physiological movements of the annulus. Methods: Twentyfive patients, who had severe functional tricuspid regurgitation and operated for left sided rheumatic valvular disease, were included into this study. 0 No and 2/0 No polypropylene suture materials were used for this annuloplasty. Every one of both sutures were fixed and knotted at anteroseptal and posteroseptal comissural regions in both ends of free wall annulus. 2/0 polypropylene sutures coming from the anchoring points were used to wrap the free wall annulus itself totally as well as the 0 No polypropylene sutures in spiral fashion. For proper correction of regurgitation 0 No polypropylene sutures were used for reduction and constriction, 2/0 No polypropylene sutures were used for the fixation of 0 No polypropylene sutures in annular level. Results: Functional tricuspid regurgitation had improved totally in 16 patients (66.7%); 4 patients (16.7%) had 1�, 3 patients (12.5%) had 2� and only one patient (4.2%) had 3� residual tricuspid regurgitation in mid-term period. 2 patients (8.4%) had evolved transvalvular gradient (2.55 mmHg and 2.8 mmHg). One patient died from low cardiac output in early post operative period. Mean follow up period was 17.8 months (range between 1 and 32 months). Conclusion: This new annuloplasty can be performed easily. Moreover, this technique is reproducible and also cost effective.

COST-EFFECT COMPARISON BETWEEN CORONARY ARTERY BYPASS ON BEATING HEART AND STENT IMPLANTATION FOR ISOLATED STENOSIS OF LEFT ANTERIOR DESCENDING CORONARY ARTERY

2002-04-01

Background: This study was made to compare the average cost of the procedures in coronary artery bypass grafting on beating heart (OPCAB) and in that of stent implantation in patients with isolated stenosis of left anterior descending coronary artery (LAD). Methods: Between November 1, 2000 and March 30, 2001, 17 consequent patients underwent OPCAB operations (14 male, 3 women, the average age 55.6 � 6.8 year) and stent implantations were performed in 30 patients (23 male, 7 women, the average age 54 � 7.9 year) at our center. Results: There was no mortality in both groups. Any complications which may affect the total cost such as perioperative myocardial infarction, revision, cerebral accident, prolonged ventilation, intraaortic balloon pump insertion and arrhythmia were not observed in OPCAB group. Unsuccessful stent implantation was observed in one patient in stent group. Another patient was urgently operated with using cardiopulmonary bypass because of acute coronary occlusion in the stent group. The average cost of total hospital and nonreusable materials were higher in stent group than that of the OPCAB group (p = 0.04). The total cost of transfusion was significantly higher in OPCAB group comparing with in that of the stent group (p = 0.039). Regarding the cost of the complications both groups were similar. Conclusions: The total average cost of the procedures in OPCAB is much more advantageous than that of stent implantation for isolated stenosis of LAD.

INCIDENCE OF AORTO-CORONARY GRAFT MARKERS USAGE IN OUR COUNTRY AND THE INFLUENCING FACTORS OF IT�S USAGE

Enver DURAN, Mustafa �IKIRIK�IO�LU, Turan EGE — 2002-04-01

Background : Implantation of a radioopaque graft marker around the proximal saphenous vein-aorta anastomosis has beneficial clinical and economic effects at postoperative re-angiography. It is usually the surgeon who performs the operation that has to decide whether or not to use this technique. The aim of this study is to evaluate the incidence of aorto-coronary graft marker usage and to obtain national data about the factors influencing its usage. Methods : A questionnaire consisting four questions was used in this study. Copies of the questionnarie were posted to 150 cardiac surgeons who perform open heart surgery in Turkey. Results : The questionnaire responding rate was 50% (75 surgeons). Sixty six percent of the surgeons said that they did not use graft markers in their patients. The most frequent reasons for this desicion were: re-angiography is performed in the same institution (38%), graft markers increase the operation costs (18%), re-angiography requirement is low (14%). The percentage of the surgeons who use graft markers was 33%. The most common reasons behind the usage of graft markers were to decrease catheter manuplation in the aorta at reangiography (68%) and to decrease the cost of re-angiography (42%). The mostly used type of graft markers were hemostatic clips (52%) and specially designed commercial markers (44%). Seventy six percent of the surgeons who use the graft markers apply the graft markers to all proximal anastomosis. The rest of them use graft markers only for selected patients. No surgeon responding the questionnaire mentioned a complication that may have to do with graft markers. Conclusion : In conclusion, most of the responders do not apply graft markers at the time of the surgery. The aorto-coronary graft markers have beneficial properties at re-angiography for patients, angiography teams, surgeons and the national economy. The proper strategy for the usage of graft markers must be determined with the collaboration of cardiac surgery and interventional cardiology teams.

AIR BLOWING TO CORONARY ANASTOMOTIC AREA AND ENDOTHELIAL INJURY

2002-04-01

Background: High flow gas insuflation is a useful method in order to remove blood out of the surgical field and improve the sight during off-pump coronary surgery. An experimental study was planned to investigate the potentially harmful histopathologic changes on coronary endothelium of this technique. Methods: Under general anaesthesia left thoracotomy was carried out on eight Mongrel dogs. The left anterior descending coronary artery was stabilized using Octopus2 and occluded with a bulldog clamp. Coronary arteriotomy was carried out and filtrated high flow room air was insufflated for ten minutes. Tissue samples were taken from the procedure area as Group I (n = 8), and from the proximal part of the occlusion as control Group II (n = 8). Tissue samples were processed for scanning electron microscopic examination. Examination and scoring of endothelial injury were performed in blind fashion, and results were analyzed statistically. Results: There was no endothelial damage in one sample while Type I injury in six samples and Type II injury in one other were observed in Group I. In Group II, Type I injury was observed in only one sample, whereas no damage was observed in the other seven samples. There was statistically significant difference between the groups in the meaning of frequency of endothelial injury. Conclusion: This study reveals that intermittent insufflation of the filtrated high flow room air to the coronary anastomotic area for ten minutes may frequently cause Type I and rare Type II endothelial injury. Because of the risk of endothelial injury, air blower should be used cautiously and be modified so as to decrease the risk of endothelial injury.

THE EFFECT OF PENTOXIFYLLINE, CARNITINE AND ASCORBID ACID ON IMPROVEMENT OF LUNG INJURY CAUSED BY ISCHEMIA-REPERFUSION

2002-04-01

Background: In this study, injury in the lungs due to ischemia/reperfusion (I/R) and preventive effect of pentoxifylline, carnitine and ascorbic acid were investigated. Methods: Twenty-nine rats were randomized into five groups: 1) Control (Group 1); 2) I/R group (Group 2); 3) Animals were pretreated with pentoxyfilline (Group 3); 4) Animals were pretreated with carnitine (Group 4); 5) Animals were pretreated with ascorbic acid (Group 5). Rats in the Group 1 were undertaken laparotomy and closed after exploration of abdominal aorta. In the second group, the infrarenal aorta of the rats were clamped for a period of 3 hours. After ischemic period, aortic clamping were removed and waited for 1 hour of reperfusion period. The rats in the 3., 4., and 5. Group were administered pentoxifylline, carnitine and ascorbic acid, respectively. The animals were sacrificed and the histological specimens of the lungs were examined. Lung injury was rated with a semi-quantitative score based on congestion, interstitial edema, and polymorph nuclear leukocyte (PMNL) infiltration. Results: Edema, congestion and the more prominent accumulation of PMNL were determined in the specimens of other four groups as compared to the control group. The average scores were 0.6 in Group 1; 2.6 in Group 2; 2.16 in Group 3; 2.28 in Group 4; 1.83 in Group 5, respectively. Conclusions: Pretreatment with pentoxifylline, carnitine and ascorbic acid were found to be beneficial in prevention of lung injury after IR of infrarenal aortic occlusion.

THE ROLE OF OPERATION IN BRONCHIECTASIS: COMPARISON OF SURGICAL AND MEDICAL TREATMENT

2002-04-01

Background: To assess the role of operation in the management of bronchiectasis, 162 patients with bronchiectasis were reviewed in the modern era of antibiotic therapy. Methods: One-hundred-eighteen patients were treated surgically (Group A), and 28 nonoperatively (Group B). Both two groups were similar by taking the features of age, involved segment and mean follow up, into consideration. Results: The indication for operation was failure of medical therapy (51.7%), hemoptysis (20.3%) and failure of growth (14.4%). The disease was bilateral in17.8% of group A and in 21.4% of group B. Lower lobes basal segments were involved most frequently (39% versus 32.1%). The mean number of the involved segments was 4.8 versus 4.7. Lobectomy was performed in 73.7%, pneumonectomy in 9.3 % and wedge-segmentectomy in 8.4% of surgical group. Complete resection was achieved in 95% of uniletaral bronchiectasis and in 28.5 % of bilateral bronchiectasis. Morbidity was 21.2% and mortality was 3.4%. Mean postoperative hospital stay in group A was less than in group B (8.6 vs. 13.2 days). The patients involving 94.4% of group Aand 60% of group B were asymptomatic, during 2 year follow-up period (p < 0.05). Conclusion: Resection, in selected patients, can be done with low mortality and morbidity and superior to medical therapy in long term follow up.