Turkish Journal of Thoracic and Cardiovascular Surgery - 2004; 12(4)

OPEN HEART SURGERY IN PATIENTS WITH LOW-GRADE SMALL LYMPHOCYTIC MALIGNANCY

2004-10-01

Background: The unknown but presumably reduced life expectancy of patients with malignant neoplasms may dissuade surgeons from performing necessity coronary and valvular heart operations. Low-grade small lymphocytic malignancies (encompassing chronic lymphocytic leukemia and some types of non-Hodgkin lymphoma) are seen in elderly patients. Open cardiac procedures are known to have increased risk of postoperative infection and other morbidities in these immunodeficient patients. Methods: Between June 1999 - January 2002 five patients (aged 49-72 years; 1 woman, 4 men) with these lymphocytopathologic diseases (2 with chronic lymphocytic leukemia and 3 with non-Hodgkin lymphoma) underwent cardiac operations. One patient underwent mitral valve replacemant and four patients underwent coronary artery bypass grafting. Results: There was no operative death and morbidity. Average stay in hospital was 8 days. During the follow-up to 12 months, 1 patient with chronic lymphocytic leukemia underwent chemoteraphy. Cardiac and lymphocytopathologic status remained stable in others. Conclutions: Patients with low-grade small lymphotic malignancies can undergo cardiac surgery under extracorporeal circulation with acceptable mortality but with possible increased risk of postoperative infection. If a cardiac operation is planned to a patient with low grade lymphocytic leukemia, an additional prrocedure or approach would not be required than other patients who will be undergone cardiac surgery.

DO THE SILVER COATED SILZONE VALVES CAUSE AN INCREASE IN THE MIDTERM PARAVALVULAR LEAK INCIDENCE RELATED TO OTHER ST. JUDE VALVES?

2004-10-01

Backgraound: Mechanical valve replacement in native valvular endocarditis is known to increase the recurrence of endocarditis and incidence of paravalvular leak. Aim of our study was to evaluate midterm results of Silzone valvular prosthesis manufactured and presented as resistant to infections and used in patients with infective endocarditis in our center. Methods: Twentysix patients with the same demographic findings, who had mechanical valve replacement due to infective endocarditis between 1998 - 2000, were included in this study. Nineteen of the patients were male and remaining 7 were female, with an average age of 42.35 � 13.6 years (17-80). In 12 of these patients, mechanical valve replacement by Silzone valvular prosthesis was performed (Group S). Control group consisted of the remaining 14 patients who received mechanical valve replacement by St Jude mechanical valvular prosthesis (Grup K). In Group S, six patients received aortic valve replacement, three mitral valve replacement, and three patients both mitral and aortic valve replacement. Average follow-up time of the patients was 38.23 � 19.89 months. Results: No early mortality was seen in both groups. Late mortality was seen only in one patient in Group S (8.33%) ( p= 0.481). In all patients, paravalvular leak was detected in four patients (33.3%). All of the paravalvular leak detected patients belonged to Group S ( p = 0.02). One of the patients needed reoperation due to paravalvular leak ( p = 0.417) and it was repaired using three separated single sutures. There was no significant difference in ventricular and left atrial diameters and ejection fraction between two groups. Conclusions: In our study, there seems to be an increase in the incidence of paravalvular leak significantly in Silzone group. However, the degree of leakage was low and paravalvular leak was persistent in the reoperated patient. Morover the number of valves used is not enough to evalute the condition. Thus we believe that the Silzone valvular prosthesis may not cause an increase in mortality an morbidity and the incidence of reoperations.

COMBINATION OF ATRIAL PLICATION AND WALL RESECTION PROCEDURES FOR THE SURGICAL TREATMENT OF GIANT LEFT ATRIUM SECONDARY TO RHEUMATIC MITRAL VALVE DISEASE

Mehmet Adnan Celkan, Hakk� Kazaz, Ha�im �st�nsoy, Celalettin Kay�ran — 2004-10-01

Background: Giant left atrium secondary to mitral valve disease produces postoperative hazardness in relation to hemodynamic and respiratory management. Many surgical procedures have been proposed to reduce the size of the left atrium. We have combined these surgical techniques and aimed to provide effective reduction in the left atrial size. In this report we describe the techniques used for the giant left atrium reduction in nine consecutive patients with rheumatic mitral valve disease. Methods: Nine patients (3 men and 6 women aging between 22 and 50 years) were operated for mitral valve replacement and left atrial volume reduction between 2001 and 2003. We used three surgical techniques for the reduction of the giant left atrium (1- Posterior paraannular plication, 2- Posterior wall plication, 3- Wall resection), and outcome of patients were evaluated. Results: There was no early mortality. Postextubation period was uneventful in all patient. No patient needed reintubation. Preoperative mean left atrial size (7.92 � 1.6 cm.) was reduced to mean 5.12 � 0.95 cm, postoperatively. Left ventricle ejection fraction rate improved from 54.22% � 6.87% to 55.44% � 6.28% in postoperative first week. Conclusions: The combined atrial reduction procedures showed marked decrease in the incidence of low output syndrome and respiratory failure postoperatively. We conclude that plication and wall resection procedures are effective techniques for the treatment of compression in the presence of giant left atrium.

THE COMPARISON OF THE EARLY AND MIDTERM RESULTS OF THE PROXIMAL ANASTOMOSIS TECHNIQUES IN SEQUENTIAL RADIAL ARTERY GRAFTING

2004-10-01

Backgorund: Complete arterial revascularization has become a favoured surgical treatment for coronary artery disease because of the excellent long-term patency of the arterial grafts when compairing the venous grafts. Methods: From June 1998 - December 2002, radial artery (RA) sequential anastomosis technique was used in 65 patients. The patients was diveded into two groups as performing of proximal anastomosis to the ascending aorta (Group A, n = 49) and to the left internal mammmary artery (LIMA) (Group T, n = 15). The patients were two-vessel (18.7%) or tripple-vessel (81.3%) coronary disease. No patients with tripple-vessel coronary disease in Group A underwent complete arterial revascularization . Six patients of 13 patients with tripple-vessel coronary disease in Group T underwent complete arterial revascularization . Results: Complete arterial revascularization was prominent in Group T with a rate of 46% when compaired to the other group. Also, the number of the graft/per patients in Group T was less than graft other group (2.6 � 0.6 versus 2.2� 4 ( p= 0.003). There was neither mortality nor morbidity in both of the groups. Low cardiac output detected in three cases in Group A (6.1%) and in one case (6.7%) in Group T ( p= 0.67). Peropertive myocardial infarction occurred in two cases in Group A (4.8%). The angiographic controls were performed in the patients Group A and Group T 13 � 8.5 and 9 � 5.1 months later postoperatively. The patency rates of LIMA and RA grafts were detected in the Groups A and T 95% and 90%, 90% and 60%, respectively. Conclusions: In sequential grafting technique, the patency rate of radial artery grafts with proximal anastomosis to the ascending aorta are superior than those with proximal anastomosis to the LIMA. Although this findings need to be supported with a large series, the radial artery sequential technique with proximal anastomosis to the ascending aorta is a reliable and effective method in coronary artery surgery.

RETROSPECTIVE RISK ANALYSIS OF MORTALITY AND MORBITIDY IN CORONARY ARTERY BYPASS GRAFT REOPERATION CANDIDATES USING EUROSCORE

2004-10-01

Background: Coronary artery disease is progressive in nature and the rate of reoperations is increasing in close relation with the coronary bypass surgery rates in our country as well. In our study, we evaluated patients, who are candidates for reoperation, retrospectively and analyzed their risk scores using EuroSCORE. Methods: Fiftyfive (2.53%) patients, who were candidates for reoperation, among the 2,172 patients scheduled for coronary bypass surgery in the same period, were taken into the study. Their clinical status, first angiographic findings, the data concerning angioplasty and/or the first operation and the patients� risk factors according to EuroSCORE risk analysis system were evaluated. Results: Fortyfive (85.5%) of the patients were male and eight (14.5%) of them were female. They had had their first coronary bypass surgery 5.37 � 4.6 years ago at different medical centers. Twentyone (38.2%) of the patients had hypertension, 24 (43%) had type II diabetes mellitus, 31 (56.5%) of the patients were smokers. Forty (72%) of the patients had hyperlipidemia and 13 (23.5%) were morbidly obese. According to EuroSCORE, 26 (47.2%) of the patients were found to be in medium risk group and 29 (52.7%) were in high risk group. Conclusions: The patients who had arterial graft in their previous operation were found to require longer periods for reoperation. Total arterial revascularization is recommended in all of the convenient patients. Analysis of expected mortality using EuroSCORE is a suitable method for standardization.

EMERGENCY MYOCARDIAL SURGICAL REVASCULARIZATION

2004-10-01

Background: The aim of this study is to evaluate efficacy and safety of surgical myocardial revascularization. Methods: We have analysed the 112 patients who underwent emergent myocardial surgical revascularization between 1994 and 2002. Ninety of the patients (80.4%) were male and 22 (19.6%) were female. The mean age was 58 � 10 years (36-77). Twelve patients (10.7%) were operated for the acutely evolving occlusion during the cardiologic intervention within the first 6 hours. Eighty patients (75.9%) were operated on with cardiopulmonary bypass. Complete revascularization was performed in 79 (70.5%) patients. Left internal thoracic artery was used in 60 (53.5%) patients. Results: Mortality was 8% with nine patients. In the postoperative follow up, need for inotropic support occurred in 44 (39.2%), intraaortic baloon pump in 39 (34.8%), perioperative myocardial infarction in 34 (30.4%), ventricular arrhythmias in 22 (19.6%), atrial arrhythmias in three (2.7%) patients. Five (4.9%) patients required angioplasty in the following year. Conclusions: Despite the frequent need for the inotropic and the mechanical support during postoperative follow up, the encouraging results show that with meticulous intensive care, patients may benefit from emergency surgery.

MUSCLE-SPARING THORACOTOMY TECHNIQUE: SIX YEARS EXPERIENCE

2004-10-01

Background: Muscle sparing thoracotomy can be used in all ages, especially prefered in pediatric patients. In this study we reviewed the results and complications of muscle sparing thoracotomy operations in a six years period and discussed the superiority of this technique over the classical standard thoracotomy techniques. Methods: Forty pediatric and adult patients, who were operated with muscle sparing thoracotomy since 1998, were chosen for this retrocpective study. There was no other selection criterion. The complications and cosmetic of wound recovery, postoperative pain, analgesic requirement, extubation time, intensive care and hospitalization periods were analysed. Results: We observed that in muscle sparing thoracotomy patients normal joint and muscle functions were regained in a shorter period of time (48 � 7 hours) after the operation. The postoperative analgesic requirement was found in eight patients (20%), wound infection was none, prolonged air leakage in three patients (7.5%) and seroma, a complication effecting hospitalization period, in two patients (5%). Conclusions: After the extubation the periods of regaining the normal respiratory functions and extremity motions were rather short. The surgical results of the technique was very esthetic.

SUPPLEMENTAL VASCULAR PROCEDURES FOR ENDOVASCULAR ANEURYSM REPAIR

2004-10-01

Background: Patients with abdominal or thoracic aortic aneurysms which have the concomitant arterial diseases that may complicate or even exclude them from necessary endovascular stent graft repair (EVAR). In the current study, we aimed to describe arterial injuries encountered during EVAR and supplementary vascular surgical procedures to enable EVAR. Methods: Between 2002 - 2003, 13 selected high-risk patients treated for thoracic aortic aneurysm (TAA) and/or abdominal aortic aneurysm (AAA) with endovascular devices were reviewed. Seven patients were treated for TAA, four patients for AAA, and two patients for both AAA and TAA. Femoral artery was the access site for 12 patients and common iliac artery for one patient. Aortoiliac stent graft was used in four patients treated due to AAA and aorto-biiliac stent graft in two patients. Results: In four cases, femoral artery injury was encountered during EVAR. In two cases saphenous vein graft interposition and patch plasty was performed for revascularization. Femoro-femoral bypass was performed in four patients who were treated with aorto-iliac stent grafts, after EVAR. The right subclavian to left carotico-subclavian bypass was performed in one patient with TAA, in order to enable endovascular stent deployment. Conclusions: Endovascular stent graft treatment is widely used for the treatment of aortic aneurysms in selected and high-risk patients. However, vascular surgical interventions are always the part of the treatment, used either to repair access site injury or as supplementary to enable stent graft deployment.

COMPARISON OF THE ANGIOGRAPHY AND COLOURED Doppler ULTRASONOGRAPHY TO EVALUATE OUTFLOW IN INFRAINGUINAL PERIPHERIC ATHEROSCLEROTIC ARTERIAL DISEASE

2004-10-01

Background: In current study we compared the results of the angiography and coloured Doppler ultrasonography (CDU) for the investigation of the outflow in the infrainguinal peripheral atherosclerotic arterial disease. Methods: Ten patients who were presented with critical lower limb ischemia due to atherosclerotic peripheral arterial disease were included in the study. The average age was 60 � 6.4 years. Two of the patients were female and eight were male. The patients did not have diabetes mellitus. Seven patients had rest pain and three patients had ischemic ulcer and neither popliteal nor distal pulses were palpated on physical examination. Preoperative mean ankle-brachial index (ABI) was 0.26 � 0.07. Digital subtraction angiography revealed total occlusion of superficial femoral artery in four cases at the bifurcation level and in four cases at the level of Hunter cannel. The common femoral artery was detected to be totally occluded in one patient at the level of inguinal ligament and in one patient popliteal artery (PA) was totally occluded just at the knee level. No outflow was detected in all cases. We used CDU in order to examine vascular structures below the knee and to find if there is a suitable segment for surgical reconstruction. Results: By using CDU a monophasic flow at the tibialis anterior artery (ATA) were detected in three patients. They were male with primarily complained of rest pain and without ischemic ulcer. Operative exploration showed patent lumen at the ATA level just in accordance with the CDU results. In two cases common femoro-ATA reversed saphenous vein bypass and in one case proximal PAATA reversed saphenous vein bypass were performed. Postoperative ABI measurements were 0.66 � 0.06. There were no postoperative surgical complications. Conclusions: CDU imaging can be used reliably for planning infrainguinal reconstruction strategies.

PREGNANCY AND OPEN HEART SURGERY: A SWORD WITH SHARP ENDS

2004-10-01

One of the most important issues for the women who have cardiac disease at their reproductive ages is pregnancy and the effects of the new physiological conditions that occur due to pregnancy. Pregnancies of the women who have applied prosthetic valve implantation at reproductive ages need to be watched very closely for the lives of the mother and the fetus. Furthermore, an urgent intra-cardiac operation for the pregnant patient must be required to protect the mother�s life as well as the fetus� and thus have to be taken necessary precautions. A patient who had undergone mitral valve replacement in our clinic 3 years ago, urgently operated due to prosthetic valve thrombosis at the 27.th weeks of the pregnancy, and another patient who was in the 33rd weeks of pregnancy, had undergone valve replacement in emergency conditions because of pulmonary edema and heart failure from calcified severe mitral stenosis, have been evaluated in the accompaniment of the literature findings about the effects of the open heart surgery during the pregnancy over the mother and the fetus

GIANT HYDATID CYST LOCALIZED IN RIGHT VENTRICLE WALL: CASE REPORT

�mer Tetik, Ufuk Yetkin, *Mehmet Yaz�c�, Engin Tuluko�lu, Ali G�rb�z — 2004-10-01

Echinococcosis is a serious health problem occurring in some geographical region of the world. Although cardiac involvement is rare, early diagnosis and treatment of this situation is important. We present a case of 18-year-old man who underwent an operation because of a giant cardiac hydatid cyst localized in right ventricular wall.

CONSTRICTIVE PERICARDITIS AND INTRAPERICARDIAL TROMBUS AFTER OPEN HEART SURGERY

2004-10-01

The incidence of constrictive pericarditis has been increasing progressively following open heart surgery. Since, it is rarely encountered the diagnosis and treatment of this entity are somewhat controversial. A patient who developed constrictive pericarditis and organized hematoma leading to mass effect posteriorly to the left atrium, 16 months after aort-coronary bypass operation was presented with literature rewiew and treatment options.

RUPTURED PSEUDOANEURYSM INTO THE RIGHT VENTRICLE OUTFLOW TRACT AFTER ASCENDING AORTA REPLACEMENT

Murat �kizler, *Bahad�r G�ltekin, *Atilla Sezgin, *At�lay Ta�delen — 2004-10-01

Mediastinal pseudoaneurysm is a rare complication of cardiac and aortic surgery. We report a 55-year-old woman with mediastinal pseudoaneurysm ruptured into the right ventricle outflow tract. The pseudoaneurysm developed after the ascending aort replacement due to suture line dehiscence and it was re-operated successfully with no need to replace the graft. This case illustrates that mediastinal pseudoaneurysm is a potential complication after aortic surgery and it has the ability of rupture into the neighboring structures.

TRACHEOBRONCHIAL TIMOMA TREATED BY LASER RECANALIZATION THERAPY: CASE REPORT

2004-10-01

Endobronchial laser therapy is generally safe and well tolerated. Fifty year-old male patient was referred to our clinic because of severe dyspnea and massive hemoptysis related to endobronchial thymoma three years ago. Rigid bronchoscopy was performed under general anesthesia, Nd-YAG laser resection and silicone stent insertion were applied to an endobronchial tumoral mass that was found in his bronchoscopy as almost completely obliterating the left main bronchus. In the next two years the same procedure was repeated six times to prevent distal tracheal obliteration with endoluminal tumoral mass. Although the left lung has been totally collapsed at the and of the second year the patient is still alive. Endoscopic laser resection of lung malignancies is rapid, effective, repeatable, and complementary to other treatments.

THE SURGICAL APPROACHES IN CAROTID BODY TUMORS

2004-10-01

Carotid body tumor is a rare neoplasm deriving from the embryological neural crest. Malignity is rare although it has a slow course, for the invasion of the adjacent vascular and neural tissues. Early diagnosis and the planning of a surgical therapy is essential. Four female cases aged between 33 and 62 were analysed together with the literature review.

SUBCLAVIAN ARTERY STEAL FROM BOTH OF HEART AND BRAIN: CASE REPORT

Cenk Tataro�lu, *Ramazan Akdemir, **H�seyin G�nd�z, **Cihangir Uyan — 2004-10-01

We report a 68-year-old patient who pesented with symptoms of both coronary and cerebrovascular insufficiency. Physical activity of the left arm aggrevated the occurance of symptoms. He received a coronary bypass operation ten years ago and symptoms of double insufficiency started two years ago. Angiographic examination demonstrated total occlusion of the subclavian artery and stealing of subclavian artery from the left anterior descending artery via the left intrnal mammary artery and from brain via the left vertebral artery. Symptomatic coronary steal syndrome together with subclavian steal syndrome is a recognised but uncommon cause of coronary and cerebral ischemia.

EFFECTS OF IOHEXOL ON PULMONARY FUNCTIONS IN PATIENTS UNDERGOING DIAGNOSTIC CORONARY ANGIOGRAPHY

2004-10-01

Background: Adverse respiratory reactions have been reported with intravascular radiographic contrast media. The aim of the present study was to assess the effects of iohexol on pulmonary functions in patients undergoing diagnostic coronary angiography. Methods: Thirty patients diagnosed as coronary artery disease undergoing diagnostic coronary angiography were enrolled in the study. Subjects with chronic obstructive pulmonary disease, asthma, allergic bronchitis, myocardial infarction and documented systolic dysfunction by transthoracic echocardiography were excluded. The respiratory functions of the patients before and immediately after the coronary angiography were measured and arterial blood gas analyses were performed. The subjects were divided into two groups according to results of angiography as having coronary artery disease (Group 1) and without significant coronary artery disease (Group 2). The angiography procedures were performed by a single, experienced angiographer. Left Ventriculography was not performed on any patient Results: The results gathered before and after angiography procedure were compared. Forced expiratory volume in the first second (FEV₁ ), maximum mid-expiratory flow rate, (MMFR) 25-75, arterial oxygen pressure (PaO₂ ) and bicarbonate (HCO₃ ) were significantly reduced ( p < 0.01), where as forced vital capacity (FVC), pH, oxygen saturation and arterial carbondioxide pressure were not changed. The comparison between two groups resulted that FEV₁ and PaO₂ were significantly decreased after angiography in Group 1. Conclusions: Diagnostic coronary angiography using iohexol decreases ventilatory functions in a small but significant extent in patients without any overt pulmonary disease. Therefore they should be used cautiously in patients with chronic lung disease.

COLOR Doppler ULTRASONOGRAPHY GUIDED COMPRESSION THERAPY OF IATROGENIC POSTCATHETERIZATION PSEUDOANEURYSMS OF FEMORAL AND BRACHIAL ARTERIES

Meltem Ceylan, Sinan �ahin, Levent �elik, �ule Bilgin — 2004-10-01

Background: To evaluate the effectiveness of color Doppler ultrasound guided compression therapy of postcatheterization pseudoaneurysms and the factors that may effect the success. Methods: Twenty-two pseudoaneurysms were included in the study. Direct compession was applied by the lineer probe on the neck of lesions in a manner not obstmating the main artery flow. The pseudoaneurysms thrombosed after compression formed the successful group and the lesions didn�t thrombose formed the unsuccessful one. To investigate the factors that may effect the results (age, sex, usage of anticoagulants and/or antiplatelets, origin, age and volume of lesions, dimensions of neck, flow speed in neck, and total compression time) were recorded. Results: Fifteen pseudoaneurysms originated from main femoral artery, four from superficial femoral artery and three from brakial artery. The two cases that could not tolerate pain were sent to surgery. Eighteen cases totaly thrombosed after compression. In two cases, it was unsuccessful. No complications occurred. The compression therapy of femoral and brachial postcatheterization pseudoaneurysms was successful 90%. The quantitative factors that may effect the results could not be evaluated as there were not enough cases in one of the groups. The qualitative factors did not have any significant effect on the results. However, the relation between the usage of anticoagulants and the results was nearer to the statistical border than the other factors. Conclusions: It was shown that the color Doppler guided compression therapy of pseudoaneurysms was effective and safe, so it could reduce the need for surgery.