Turkish Journal of Thoracic and Cardiovascular Surgery - 2004; 12(1)

EARLY SURGICAL TREATMENT IN POSTINFARCT VENTRICULAR SEPTAL DEFECT

2004-01-01

Background: The anatomical localization of ventricular septal defect (VSD) occured after acute myocardial infarction (MI) strictly affects the type of surgery. New prosthetic patches and rapid progression in surgical techniques, increased experiences in anesthesiology and reanimation augment our surgical success. In our study we searched for the factors affecting the rate of hospital mortality. Methods: Between April 1990 and October 2002, 21 consecutive patients underwent surgical repair of post-MI VSD. Group 1 consists 12 patients who were alive postoperatively, and Group 2 consists 9 patients who died. All patients were evaluated by echocardiography, and cardiac angiography and catheterization were performed on 18 patients. We studied preoperative, peroperative and postoperative clinical findings retrospectively. Results: The hospital mortality was 42.85%. The risk factors for early mortality were older age, the anatomical localization of post-MI VSD, the presence of cardiogenic shock preoperatively, low ejection fraction, late surgical treatment (72 hrs later), prolonged cross clamp time and total bypass period, and late application of intraaortic ballon pump. Conclusions: Whereever the anatomical localization of post-MI VSD is, early surgical treatment is necessary. That decreases the rate of postoperative mortality if it is performed before the occurance of multiorgan failure.

THE USE OF XENOGRAFT AND PULMONARY HOMOGRAFT IN RIGHT VENTRICLE OUTFLOW TRACT OBSTRUCTIONS

2004-01-01

Background: This study was planned to investigate the early and mid-term results of pulmonary homografts and xenograft valved conduits in the treatment of right ventricular outflow tract (RVOT) obstruction. Methods: Between January 1997 and July 2002, 19 patients with RVOT obstruction were operated in Ege University Medical Faculty. Pulmonary homografts, which provided from our homograft bank, were used in 9 (47.3%) patients and xenografts in 10 (52.6%) patients. Cryolife-Ross stentless porcine bioprosthesis were used in 8 patients and bovine jugular vein in 2 patients as xenografts. Results: The hospital mortality was 21.05% in patients with RVOT obstruction treated with pulmonary valved conduits, while 30.0% (3/10) in xenograft group and 11.1% (1/9) in the homograft group. Minimal pulmonary insufficiency was detected by transthoracic echocardiography in 85.7% (6/7) of xenograft group patients and in 12.5% (1/8) of homograft group patients at mid-term follow-up (p = 0.026). Structural deterioration, calcification and obstruction in pulmonary conduits were not detected in any of the patients. Conclusion: The performance of the right ventricle is very important to improve the survival in patients with RVOT obstructions. If there is a shortage for homografts, xenografts can be used as an alternative with reasonable early and mid-term results for a better right ventricular performance.

ATHEROSCLEROSIS IN CORONARY ARTERY ANOMALIES AND SURGICAL TREATMENT IN ADULTS

2004-01-01

Background: Coronary artery origin anomalies associated with atherosclerosis have an important role in the decision on complete cononary artery revascularization. The purpose of this study was to review our clinical experience on 12 cases with coronary anomalies, clinical presentation, location and degree of atherosclerosis, and surgical approaches. Methods: Nine cases with coronary origin anomaly underwent coronary artery bypass grafting (CABG) associated with atherosclerotic coronary artery disease. Coronary bypass was performed in 1 case for relief of anjina pectoris even his coronary arteries were found angiographically free of atherosclerosis. Two cases of anomalous coronary artery without atherosclerotic lesions did not require CABG. Results: There was no early mortality in the series. Perioperative myocardial infarction was not recorded in any of the patients underwent coronary revascularization. One case died from sepsis due to mediastinitis at 28th postoperative day. Conclusions: The relationship between coronary artery origin anomaly and atherosclerosis has to be considered especially in young CABG candidate patients. This group of patients can be operated without overwhelming mortality and morbidity risks.

DURING CARDIOPULMONARY BYPASS DAFLON DECREASES REPERFUSION INJURY BY COMPLEMENT INHIBITION

2004-01-01

Background: Daflon is basically known as a phlebotonic, vasculoprotector agent and an inhibition of complement C3 is involved in the initial part of alternative complement pathway. The inflammatory response during cardiopulmonary bypass is releated with the activation of alternative complement pathway. The aim of the present controlled-clinical study was to evaluate the potential myocardial protective effects of Daflon by measuring the serum levels of complement C3 during open heart surgery. Methods: Fifty patients selected for open heart surgery under cardiopulmonary bypass were randomly assigned to Daflon or control group. Patients were given Daflon tablet orally twice daily tablet per day or placebo 7 days preoperatively. In the Daflon group there were 25 patients (10 women and 15 men) with the mean age 59.6 � 3.2 years. In the control group, there were 11 women and 14 men with the mean age 60.3 � 2.9 years. Serial blood samples were collected preoperatively (venous), 20 minutes after cross-clamping (right atrium), 20 minutes after aortic unclamping (right atrium) and 24 hours postoperatively (venous). Results: Serum C3 levels in the Daflon group were significantly higher at 20 minutes after cross-clamping and 20 minutes after unclamping (p < 0.001). But, troponin I levels in the Daflon group were significantly lower than at 20 minutes after cross-clamping, 20 minutes after unclamping and 24 hours postoperatively than those of the control group (p < 0.001). Conclusion: As a result this study confirms the cardioprotective effect of PMFF against reperfusion injury by alternative complement activation inhibition.

A NEW OPEN HEART SURGERY CENTER: THE EXPERIENCE OF THREE YEARS IN KAYSERI GOVERMENT HOSPITAL

Alptekin Yas�m, Ramazan A��k — 2004-01-01

Background: The aim of this study is to investigate the results of open heart operations performed in our center. Methods: Between April 2000 and June 2003, total 151 patients underwent open heart surgery. Surgery was performed in 56 cases with coronary artery disease, in 70 cases with heart valve disease, in 21 cases with congenital heart disease and in 3 cases with other cardiac pathologies. Results: The patients whose ages were between 4 - 80 years were followed up total 222.8 patient years. Hospital mortality was 3.97% with 6 cases, late mortality was 3.44% with 5 cases. The most common reason was low cardiac output. The linearized rate of late mortality was 2.2% / patient year. Early complication rate was 4.63% and late complication rate was 6.89%. The most common reasons of complication were disorders of anticoagulation. The linearized rate of late complication was 4.5% / patient year. Conclusion: Open heart surgery could be performed successfully in govertment hospital in which angiography unit is absence

SURGICAL CORRECTION OF PATENT DUCTUS ARTERIOSUS UNDER DEEP HYPOTHERMIC CIRCULATORY ARREST

2004-01-01

Background: Repair of complicated patent ductus arteriosus by conventional methods is dangerous as life-threatening hemorrhages may occur. Thus, in these patients, it is safer to operate by using cardiopulmonary bypass and hypothermic circulatory arrest. Methods: We operated on 5 patients with patent ductus arteriosus with deep hypothermia and total circulatory arrest between 1993 and 2003. All of the patients were female and their ages were between 9 and 51. The mean shunt ratio was 2.7 � 0.45 and mean systolic pulmonary arterial pressure was 59 � 17.46 mmHg. In three of the patients the ductus was wide and thick, it was aneurysmatic in one and calcified in the other. All of the patients were operated under cardiopulmonary bypass and were cooled down to an average temperature of 21.6 � 2.07 �C. The mean total circulatory arrest time was 14.4 � 9.66 minutes (range 3-25). In two patients, the ductus was closed with a transpulmonary approach while in one patient a transaortic approach was used. All sutures were consolidated with pledgets. In one patient the transfixation was performed without pulmonary arteriotomy using three pledgetted sutures placed externally. In the last one patient, the repair was achieved by division. In addition to patent ductus arteriosus correction, concomitant procedures were subaortic discrete membrane resection, aortic valve replacement in two patients. In one patient, right ventricular outflow tract was enlarged with a transannular patch and foramen ovale was closed. Results: There was no early or late mortality. In two patients inotropic support was needed during weaning from cardiopulmonary bypass. No complications were seen related to the procedure itself. The mean follow up was 31.8 � 39.97 months. No recanalisation was detected with the postoperative echocardiographic assessment. Conclusions: Hypothermic total circulatory arrest can be used safely during the repair of complicated patent ductus arteriosus without exposing the patient to additional risks.

THE IMPORTANCE OF MAXIMAL OXYGEN CONSUMPTION TEST IN THE ESTIMATION OF COMPLICATIONS FOLLOWING POSTOPERATIVE LUNG RESECTIONS

2004-01-01

Background: In the preoperative period, routine �pulmonary function testing� (PFT) and �symptom-limited exercise testing� were applied to the patients, who were planned to have �major lung resection�, to evaluate the importance of maximum oksygen consumption in predicting postoperative mortality and morbidity. Methods: This study included 55 patients (49 male and 6 female) who under went major lung resection. According to the results of the exercise tests, patients were divided into two groups as the ones with VO₂ max value lower (V₁ ) or higher (V₂ ) than 15 mL/kg/min. On the other hand, the results of the PFT lead to a segregation of patients as those whose FEV₁ values were lower than 2 liters (S₁ ) and those with FEV₁ values higher than 2 liters (S₁ ). The mean age of cases was 56 years (20-74). Results: A total of 2 patients (3.6%) had mortality. A total of 19 patients (34.5%) had morbidity. None of the patients with VO_{2 max} value higher than 20 mL/kg/min had mortality or morbidity. Conclusions: Measurement of maximal oxygen consumption has successfully predicted postoperative mortality-morbidity.

USE OF SODIUM NITROPRUSSIDE AND PAPAVERINE SOLUTION IN PREPARATION OF SAPHENOUS VEIN

�mer �ak�r, Ahmet Oru�, Kemalettin Erdem, *FetinY�ld�z, Nesimi Eren — 2004-01-01

Background: The aim of this study was to compare the endothelial damage in saphenous veins created with sodium nitroprusside and papaverine. Methods: Human saphenous vein graft was obtained from ten patients and then divided into four equal parts. Saphenous vein grafts were distended in the heparinized lactated ringer's solution at pressure not exceeding 20 mmHg in Group 1 (Control group), and distended 80 mmHg in Group 2 (Lactated Ringer's group). Saphenous vein grafts were distended in the heparinized lactated Ringer's solution containing papaverine at pressure not exceeding 80 mmHg in Group 3 (Papaverine group), and distended at same pressure in the heparinized lactated Ringer's solution containing sodium nitroprusside in Group 4 (Sodium Nitroprusside group). Vein segments were storaged in these solutions at room temperature for one hour. All saphenous vein segments were examined under light microscope for loss of the endothelium and damage to the media and scored from 0 to 3. Results: The mean scores were 0.7 � 0.82 in Group 1, 1.3 � 0.67 in Group 2, 2.0 � 0.66 in Group 3 and, 1.1 � 0.87 in Group 4. Score in sodium nitroprusside group was found to be significantly better than the others. Conclusions: Our results show that supplementation of sodium nitroprusside to the preservation solution preserves the endothelium.

ALTERNATIVE APPROACH FOR REVASCULARIZATION OF EXTREMITIES: EXTRA-ANATOMIC BYPASS GRAFTING

2004-01-01

Background: In this study, we aimed to determine an early mortality rate and primary graft patency, patient�s survival in an avarage follow-up of 2 years for the patients with extra-anatomic bypass (EAB) grafting. Methods: We reviewed our clinical results retrospectively in total of 14 patients with EAB grafting during the period between june 1995 to june 2001 in our clinic. 13 patients (92.8%) were male and only one patient was female, mean age was 58.4 � 14 years. Axillobifemoral (AFF) bypass in 5 patients axillofemoral (AF) bypass in 2 patients, femoro-femoral (FF) bypass in 4 patients, axilloaxillary (AA) bypass in 2 patients, obturatory bypass (OB) in 1 patient were performed. Results: Early mortality rate was 7.2% with one patient. In etiology, Takayasu�s arteritis exists in female patient, atherosclerosis exists in all of the male patients. EAB was performed as primary revascularization in 8 patients, as secondary revascularization in 6 patients. Total of 9 times various vascular interventions before EAB grafting operation were performed due to peripheral arterial occlusive disease in 6 patients. PTCA in 2 patients, CABG in 1 patient, CEA in 1 patient before EAB grafting operation were performed. Obturator bypass was performed due to graft infection in 1 patient with aorto-femoral bypass grafting. During the follow up period, 1 patient due to cerebrovascular event and 1 patient due to cardiac event died. We determined the graft thrombosis in 3 patients with AF, FF and AA bypass grafting. Secondary graft patency was provided through the embolectomy in only 1 patient with occluded graft. Conclusion: EAB is the method of choice with reasonable mortality/morbidity rate, primary graft patency of 72.2% and patient�s survival of 78.5% in an avarage follow up of 2 years for high risk patient.

PULMONARY ASPERGILLUS INFECTION AFTER ORTHOTOPIC HEART TRANSPLANTATION

2004-01-01

We present a 56-year-old male patient, who had pulmonary aspergillus abscess after his heart transplantation. He was discharged after an uncomplicated hospital stay, but on postoperative 60th day he presented with dyspnea. On chest X-ray and thorax computerised tomography there was a right lung cavern. We started Amphotericin-B 2 mg/kg/day. We proposed bronchoscopy to perform a bronchial aspiration culture. Shortly after termination of the procedure, the patient had ventricular fibrillation and was lost following cardiac arrest. A lung cavern in a heart transplant recipient may be due to an aspergillus infection, which may cause death even under appropriate treatment. Bronchoscopy may carry high risk in these patients, so non-invasive diagnostic tools should suffice to start treatment.

RIGHT ATRIAL MASS: MYXOMA

Birol Yamak, Altay Tando�an, Feragat Uygur, *Alper Ser�elik, Yuri Pya — 2004-01-01

70% of the cardiac tumors are benign. Majority of them are myxomas. 80-90% of the myxomas are located in the left atrium, less freqently in the right atrium. When compared the right atrial myxoma with the left atrial myxoma, right atrial myxomas are more solid and have larger based attachment to inter atrial septum or atrial wall. In this case report we wolud like to present a fourty six years old with right atrial myxoma woman who admitted to the with coughing. A right atrial myxoma was diagnosed by echocardiography. The myxoma was excised with normal atrial septal cuff. Postoperative period was uneventful. No pathologic finding was found at the sixth months control.

RECURRENT MYCOTIC PSEUDOANEURYSM OF THE AORTA AFTER CORONARY ARTERY BYPASS

2004-01-01

Even in young non-diabetic patients with single internal mammary artery, the risk for mediastinitis still exists. Free latissimus dorsi myocutaneus flap was chosen to repair the mediastinal defect and to protect the aortic patch repair for this case with pseudoaneurysm of the aorta after coronary artery bypass. Although the early result was successful, pseudoaneurysm recurred. Lifelong antibiotic therapy could be useful in order to prevent the recurrence of this fatal complication.

RARELY ENCOUNTERED INTRATHORACIC MASS: INTRATHORACIC DESMOID TUMOR

2004-01-01

Desmoid tumor is an uncommon, hystologically benign tumor originating from facial and musculoapaneurotic tissues, however, it is locally aggressive. It is frequently observed in the abdominal zone. Nevertheless, it is rare in the chest wall. The most efficient and outstanding treatment is surgery. The eighteen-year-old female case was admitted our hospital with complaints of left chest and back pains. When she was 14, the case had surgery due to bilateral lung cyst hydatid, and in the same session bilateral cystectomy and capitonnage were applied. Four years later, when a chest x-ray was taken with complaints of severe chest and back pains, an abnormal view was observed on her left lung. Following this, a computerized thorax tomography showed a mass of size 10x9x8 in the soft tissue, and she was operated on. She had no post-operative complications and was discharged on the 10th day. As a result of pathological examination, the mass was diagnosed as desmoid tumor.

A BRACHIAL ARTERY PSEUDOANEURYSM DEVELOPED IN THE LATE POSTTRAUMATIC PERIOD AND ITS SURGICAL THERAPY

Ufuk Yetkin, Banu Laf��, G�khan �lhan, Serdar Bayrak, Ali G�rb�z — 2004-01-01

The frequency of upper extremity peripheral artery aneurysms is much less than lower extremity peripheral artery aneurysms. Their diagnosis and surgical treatment is important because they can cause functional loss such as upper extremity and finger losses. In this study we investigated the diagnosis methods and surgical therapy of a case which was completed its maturation 5 years after a gunshot injury and admitted to our clinic at 7th year under the light of literature knowledge. Surgical therapy of brachial artery aneurysm is critical because it may cause thromboembolism in that extremity which may end up with gangrene or amputation. Besides the first choice of immediate surgery and routine surgical repair, we recommend selective revascularization procedure.

RENDU OSLER WEBER DISEASE ASSOCIATED WITH SYSTEMIC SUPPLY TO PULMONARY ARTERIOVENOUS FISTULA

Alpay Sarper, *Necdet �z, Abid Demircan, **Erol I��n — 2004-01-01

A 20-year-old man presented with hemoptysis, epistaxis and severe fatique. Chest X-ray film revealed an abnormal shadow. On the physical examination, multiple telangiectases were found at the oral and nasal mucous membrane and tongue. Computed tomography and pulmonary angiography showed an arteriovenous fistula of the left lower lobe. The diagnosis was Rendu Osler Weber Disease. Lobectomy was performed because of the systemic supply to the large pulmonary arteriovenous aneurysm.

DOUBLE OUTLET RIGHT VENTRICLE

2004-01-01

Double outlet right ventricle is a relatively uncommon anomaly among the congenital heart diseases. It is a form of abnormal ventriculoarterial connection. Great arteries originate from the morphologically right ventricle. The differential clinical signs and symptoms depend on the ventricular septal defect type and also the additional cardiac anomalies. Various anatomic subtypes are present. Many different types of either palliative or corrective surgical procedures have been developed. The clinical findings like cyanosis or congestive heart failure become apparent in the first two months of life. Right ventricular failure and low cardiac output are important predictors of postoperative early mortality for the patients who are not operated on in time. The surgical results depend on the ventricular septal defect localization. Types of double outlet right ventricle, additional cardiac anomalies, clinical signs and symptoms, diagnosis and surgical procedures are discussed in this literately reviewed article.