Turkish Journal of Thoracic and Cardiovascular Surgery - 2006; 14(1)

Our clinical experience of axillary artery cannulation in stanford type a aortic dissections

2006-01-01

Background : In this study, our surgical experience on axillary artery cannulation in Stanford type A aortic dissection was evaluated. Methods : Sixty patients (22 females, 38 males; mean age 52.0�10.9; range 23 to 73 years) were in the study who had been operated between April 2001 and February 2005. The first 19 patients (31.7) were operated by using direct axillary artery cannulation whereas the other 41 patients (68.3%) were operated by cannulating the graft which was anastomosed to the axillary artery in an end to side fashion. The patients were evaluated according to the cannulation related complications and neurologic events. Results : Mean postoperative hospital stay was 8.2�3.9 days. Axillary artery dissection in two patients (10.5%) and right upper extremity ischemia in one patient (5.2%) were seen in the patients with direct axillary artery cannulation. No surgical complication was met in side graft cannulation. The difference was not statistically significant although neurologic complications were higher in direct cannulation. Six patients died in the postoperative period. Conclusion : Axillary artery cannulation is a technique that has low morbidty and mortality rates and should be routinely used in Stanford type A aortic dissections.

Permanent pacemaker implantation after open heart surgery

2006-01-01

Background : Permanent pacemaker (PP) implantation is rarely required after open heart surgery. A retrospective analysis of patients operated within last 10 years was performed to determine the frequency and risk factors. Methods : Forty-three of patients, who were operated within the last 10 years in our clinic, required PP implantation. Thirteen (30%), (10 males, 3 females; mean age 66.8�8.1; range 43 to 77 years) of these were operated for coronary artery disease (CAD), 24 (55%), (10 males, 14 females; mean age 52.5�5.6; range 16 to 73 years) for acquired valvular heart disease (AVD) and 6 (13%), (5 males, 1 female; mean age 11.1�10.8; range 3 to 32 years) for congenital heart disease. Eight of the CAD patients had AV block preoperatively. Nineteen of these patients had aortic valve replacement (AVR), 2 had reoperation for mitral valve replacement (MVR), 2 had AVR + MVR and 1 had MVR and CABG. Indications for PP implantation were; persistent complete AV block lasting for 10 days postoperatively, atrial fibrillation/ flutter with slow ventricular response leading to hemodynamic compromise and paroxysmal atrial fibrillation leading to sinusoidal arrest >3 seconds. Results : PP implantation was required for persistence of preoperatively existing complete A-V block in 8 patients and for the new onset A-V block in 35 patients. Mean interval from operation to implantation was 10.8�4.3 days. Mean times of intensive care unit stay and hospital stay were 42.6�14.6 hours and 16.8�4.7 days respectively. Mean follow- up time was 23.1�18.3 months. In long term, one patient had pace-maker battery protrusion, one had pulmonary arterial thromboembolism. During follow-up, 36 patients were in NYHA (New York Heart Association) Class I, 5 were Class II. Conclusion : Preoperative estimation of conduction defects may effect the surgical plan directly. Detailed risk scoring systems are essential to guide the surgical team. In long term follow-up, permanent pacemaker implantation does not affect the functional capacity adversely.

The predictors of the saline irrigated radiofrequency ablation treatment success rates for the atrial fibrillation

Hakk� Kazaz, M. Adnan Celkan, Ha�im �st�nsoy, Bahad�r Da�lar, �smail K�rk — 2006-01-01

Background : The successful sinus rythm restoration rates were 80-90% with the saline irrigated radiofrequency ablation (SIRFA) in the surgical treatment of atrial fibrilation (AF). The aim of the study is to define the predictors of the SIRFA procedure's success. Methods : SIRFA was performed 50 patients (36 females, 14 males; mean age 42.3�13.8, range 17 to 68 years) with an available unipolar probe (Cardioblate TM, Medtronic) between October 2001-April 2003. All of the demographic variables of the patients (age, sex, atrial fibrillation duration, left atrial size, etc) were collected on a standart data form by prospectively. Continuous datas were expressed as means � SD and univariate and multivariate analysis were done for the early postoperative and at the end of the firsth year. Results : The univariant analyses have revealed that, patients older than 60 years old, AF for more than 6 months, left atrium diameter >60 mm, left atrium diameter >60 mm after left atrium diameter reducing procedure, postoperative antiarrhythmic treatment requirement and pacemaker implantation at the end of surgery are significant risk factors. Multivariant analyses have revealed that, patients older than 60 years old, patients with left atrium diameter >60 mm, with left atrium diameter >60 mm after left atrium diameter reducing procedure, and with postoperative antiarrhythmic treatment requirement are under significant risk. Conclusion : The discussion will be continue on the predictors of the saline irrigated radiofrequency ablation success. In our study we find out that the significant predictors are; elderly patients and left atrial size.

Hemodynamic changes during distal anastomosis of coronary arteries in off-pump CABG surgery

2006-01-01

Background : The aim of this study was to assess the hemodynamic changes during off-pump coronary artery bypass graft (OPCAB) surgery following mobilization and stabilizaiton of the heart in different positions for distal coronary artery anastomoses. Methods : The study was designed as a prospective clinical trail in between March-June 2002. Thirty patients (22 males, 8 females; mean age 69.5�6.3; range 49 to 81 years) operated on by OPCAB surgery were included in the study. The measurements of mean baseline systemic arterial pressure, right atrial pressure, pulmonary capillary wedge pressure, and cardiac index were compared with those that recorded during the mobilization and stabilization of the heart together with ST segment changes and cardiac specific enzyme analysis. Results : The cardiac index drop was statistically significant in all territories while the mean systemic arterial pressure dropped in the left anterior descending and the posterior descending artery territories. The right atrial pressure increased 70% while performing the circumflex and the posterior descending artery anastomosis. Pulmonary capillary wedge pressure increased 13% in LAD and 39% in cirtumflex territories. No significant ST segment changes and cardiac specific enzyme rise was observed. Conclusion : Significant hemodynamic changes can be seen during OPCAB surgery that can effect the whole course of the operation. A surgeon experienced in off pump surgery can overcome the problems caused by hemodynamic changes. Patient selection and certain manoveurs during OPCAB are important aspects that surgeons should be familiar with.

Evaluation of the inflammatory response in coronary artery surgery: comparison of extracorporeal circulation and beating heart techniques

2006-01-01

Background : In this study, the inflammatory response after beating heart and conventional coronary artery bypass surgery is compared. Tumor necrosis factor-α (TNF) is used as a determinant of the inflammatory process. Methods : Twenty patients who will undergo elective coronary artery bypass graft operation were divided into two groups (group I (7 males, 3 females; mean age 63.6�6.8; range 50 to 69 years); group II (8 males, 2 females; mean age 62.2�8.5; range 42 to 69 years)). In group I, a beating heart coronary artery bypass surgery was performed Patients in group II were operated under cardiopulmonary bypass. Blood samples were collected 24 hours before and 4 hours after surgery, and TNF-α values were noted. Results : Postoperative values of TNF-α in group II were significantly higher than group I (p=0.026). Postoperative intensive care unit (ICU) and hospital stay were also higher in group II than group I, and these were statistically significant (p=0.013 and p=0.008 respectively). Conclusion : Tumor necrosis factor-α levels were significantly higher in conventional cardiopulmonary bypass technique than the beating heart operations. But, this increase in the inflammatory response did not cause any difference in ICU and hospital stay among patients who undergone coronary artery bypass surgery.

The effect of physical properties on postoperative bleeding in coronary artery bypass surgery

2006-01-01

Background : In the early postoperative period of open heart surgery, most common complication requiring 3-5% of exploration appears as bleeding. Bleeding in the early postoperative period is important risk factor in terms of morbidity and mortality. In this study, we investigated the effects of sex and physical properties on postoperative bleeding. Methods : Of 525 patients undergoing coronary artery bypass grafting, 209 were randomly divided into two groups according to the amount of bleeding (group I ≥750 ml/24 h, group II <750 ml/24 h) and were retrospectively evaluated for physical characteristics, preoperative, operative, and postoperative parameters. Results : At the end of the first day, drainage was less than 750 ml (mean 459�131.8 ml) in 174 patients (83.3%), and 750 ml or above (mean 948�188.3 ml) in 30 patients (16.6%) (p=0.0001). Bleeding indices were 528�102.7 ml/m² and 266.0�77.7 ml/m.² in group I and II respectively (p=0.0001). In group I, there were five females (16.6%) and 25 males (83.3%). In group II, there were 95 females (54.5%) and 79 males (45%), the number of females in group II was significantly higher (p<0.02). There were significant differences between the two groups with respect to the mean height (1.64�0.08 m in group I, 1.59�0.09 m in group II; p<0.005) and body mass index (27.1�4.0 kg/m.² in group I, 28.6�4.1 kg/m.² in group II; p=0.04). Conclusion : Severe postoperative hemorrhage is associated with significant morbidity and mortality. Preoperative risk stratification may help identify subgroups of patients who has high risk for bleeding after coronary artery bypass grafting. Further studies are needed to understand the factors relevant to less hemorrhage in patients with short height and in female subjects.

Prevalence of chest wall deformities in primary school children of Afyon city

H�d�r Esme, Ay�eg�l B�k�lmez, �mer Do�ru, Okan Solak — 2006-01-01

Background : The prevalence, severity and variety of chest wall deformities, and the associated anomalies in the primary school students of Afyon city were investigated. Methods : Between November and December 2004; 3779 primary school students were evaluated for chest wall deformities and the associated abnormalities. Results : As a resault of physical and X-ray examinations, prevalences were found for chest wall deformities, for pectus excavatum, for pectus carinatum, and for costal deformities 0.89%, 0.5%, 0.15%,0.23%, respectively. Family history of chest wall deformity (5.8%), abnormality in ECG (5.8%), cardiac murmur (5.8%), mitral valve prolapse (2.9%), scoliosis (5.8%), syndactyl (2.9%), kyphosis (2.9%), and bronchial asthma (2.9%) were associated with chest wall deformities. Conclusion : The prevalence of chest wall deformities in the primary school students of Afyon city was 0.89%. Severe deformities were present in only 14.7%.

Tracheobronchial foreign body aspirations in adults

2006-01-01

Background : Tracheobronchial foreign body aspiration is a life treatening clinical problem which is not much frequently seen in adults. In this study, we aimed to present our experienceswith the diagnosis and treatment of foreign body aspirations in adults. Methods : Thirty three patients (7 male, 26 female; mean age 32; range 16 to 68 years) who were hospitalized and treated with the diagnosis of foreign body aspiration between 2000 and 2004 in our clinic were prospectively evaluated by sex, age, complaints, duration of application, physical findings, radiological findings, nature of foreign bodies, location of foreign bodies, treatment methods and complications. Results : Thirty three patients who were hospitalized with the diagnosis of foreign body aspiration underwent rigid bronchoscopy under general anesthesia. Foreign body was detected in 31 cases (94%). Foreign bodies were removed with rigid bronchoscopy in 28, with tracheostomy plus rigid bronchoscopy in 1 and with thoracotomy in 2 cases. The commonest complaint was cough. 48% of foreign bodies were removed from right bronchial system and 42% from left one. 64.5% of foreign bodies were pins. We observed complications, including 1 pneumothorax and 1 division of foreign body into 2 pieces causing need for a second bronchoscopy, in 2 (6.4%) cases. Conclusion : Rigid bronchoscopy under general anesthesia is gold standart in diagnosis and treatmentof roreign body aspirations. If foreign body can not be removed with rigid bronchoscopy, it must be removed by surgical procedures.

Comparison of thoracic paravertebral and epidural blocks for pain relief after thoracotomy

2006-01-01

Background : The aim was to compare the effects of thoracic paravertebral and epidural blocks on pain relief and respiratory function after thoracotomy. Methods : 50 patients (38 males, 12 females; mean age 49.8�17.7; range 15 to 78 years) were included in the study. Patients were randomly divided into two groups to be applied epidural (group I), paravertebral (group II) block. Patients had supplementary doses of morphine by a patient-controlled analgesia (PCA) device. Postoperative total morphine consumption was noted by the PCA device. During the first 24 hours using visual analoque scale (VAS) patients were asked to assess their pain at rest; 1 hour after being in the intensive care unit and every 2 hours Results : There were no significant differences between the groups regarding morphine consumption and VAS scores. Additionally, on the first postoperative day FEV1 and FVC measurements were not significantly different. Conclusion : Paravertebral block may be an effective and safe altenative for the pain relief after thoracotomy.

Abdominal aortic aneurysm surgery: retroperitoneal or transperitoneal approach?

2006-01-01

Background : Mortality and morbidity of abdominal aortic aneurysm surgery have decreased significantly in time and transperitoneal approach still preserves its firm ground although retroperitoneal approach is known to serve with various advantages. In this study, two approaches were compared for elective and emergency cases. Methods : Patients that underwent abdominal aortic aneurysm repair between January, 1994 and March, 2004 were reviewed and analyzed based on the elective/emergent nature of the surgery and the type of the incision. Preand perioperative data including hospital mortality and various morbidities were analyzed. Results : Fourty five patients were operated with retroperitoneal approach (RPA) among 155 patients and 35 patients had a ruptured aneurysm in 10 years period. Significantly shorter mechanical ventilation and nasogastric decompression periods, less need for intravenous fluid supplementation with shorter ICU stay were observed with the RPA (p<0.001). Need for allogenic blood transfusion was similar (p>0.05). Analysis of mortality and morbidity revealed bleeding as the major cause of mortality in the ruptured cases. A similar comparison between two groups, however, revealed no significant difference (p>0.05). Conclusion : Retroperitoneal approach serves many advantages as rapid weaning from mechanical ventilation and shorter stay in intensive care unit in addition to rapid restoration of gastrointestinal physiology. It also provides adequate surgical exposure.

The effect of normovolemic hemodilution on lung injury after ischemia-reperfusion of lower extremities

2006-01-01

Background : Acute transient aortic occlusion with subsequent ischemia/reperfusion (IR) of the lower extremities is known to predispose to the lung injury characterized by inflammation and interstitial edema. In this study, we aimed to investigate whether normovolemic hemodilution by ringer lactate (RL) could have any beneficial effect on the lung injury caused by IR of the lower extremities. Methods : Thirteen wistar albino male rats were used for the study. A rat model in which bilateral lower extremities were tightened by plastic tourniquet for ischemia of 2 hours and then loosened for reperfusion of 3 hours were used as an experimental model. Ischemia/reperfusion of the lower extremities were performed in group of IR (group I, n=6) without hemodilution and in group of RL (group II, n=7) after hemodiluted with ringer lactate solution. At the end of the experiment, the rats were sacrificed by an intravenous overdose of pentobarbital sodium. The lungs were histologically examined. Lung injury was rated with a semiquantitative score based on congestion, interstitial edema, PMN infiltration and airspace hemorrhage, as follows: 0+, no changes; 1+, focal, mild, subtle changes; 2+, multifocal mild changes; 3+, multifocal prominent changes; 4+, extensive prominent changes. Student's t-test and Mann-Whitney U-test were used for statistical analysis. Results : Mean Hct. value were %48.2�1.7 and %35.1�0.9 in group I and II respectively (p<0.001). The lung injury score after IR of lower extremities in rats were significantly higher in group I (mean 3�0.63) than group II (mean 1.42�0.53) (p<0.05). Conclusion : Normovolemic hemodilution reduces the lung injury caused by IR of the lower extremities.

Pregnancy and open heart surgery: how can we change mother and fetus mortality

2006-01-01

It is well-known that in women with cardiac disease, pregnancy and accompaniying physiologic changes might cause serious additional problems. Rheumatic valvular disease has historically been the most common type of heart disease in pregnant women. Although it has diminished significantly as a result of controls of acute rheumatic fever eradication, it still continues to be a serious problem in the young, pregnant women. Additionally, pregnant women, who have prosthetic valves need to be kept under surveillance for the lives of both the mother and the fetus. A likely emergent intracardiac operation which is caused by valve dysfunction and/or endocarditis in a pregnant patient with a prosthetic valve requires to take all precautions for the safety of both the lives of the mother and the fetus. The operative mortality rate increases by the associated maternal and fetal mortality and shows the necessary precautions and makes it striking how serious the situation is. That there are very limited number of cases and appear to be sporadic all over the world and there is no established well known classical management methods makes this situation controversial. Publications from the devoloping and undeveloped countries where valve disease is commonly seen will shed light on questions.

Left atrial myxoma mimicking coronary artery disease: a case report

2006-01-01

Coronary embolization from left atrial myxomas is a rare and mortal complication when it occured. Seventy-five year old man, after four months of a successful percutaneous transluminal coronary angioplasty intervention to the lesion having thrombus on his left anterior descending coronary artery; was readmitted with the symptoms of embolization to the central nervous system, left atrial myxoma was detected. Myxoma was extirpated succesfully surgical resection. Diagnosis of the myxoma was confirmed by pathological assessment. It was concluded that, embolization to coronary artery system and after that central nervous system was resulted from tumoral tissue itself or formation of thrombi on this tumoral tissue.

Isolated solitary splenic metastasis of a pulmonary tumor: a successful surgical approach in one stage

2006-01-01

The splenic metastases of solitary organ cancers are extremely rare. In this paper, we present a case having an adenocarcinoma in left lung and isolated solitary splenic metastasis; which has undergone a left 3rd, 4rd, 5th ribs partial resection and left pneumonectomy, afterwards thoracic wall reconstruction with prolene mesh and splenectomy by using left phrenotomy. The case has been discussed together with the relevant literatures by bringing up isolated solitary splenic metatasis encountered in lung carsinomas and performance facilities of multiple surgeries in only one stage.

A case of scimitar syndrome diagnosed by magnetic resonance angiography

2006-01-01

A 21-year-old male patient presented with chest pain and exertional dyspnea was investigated for an abnormal image on the postero-anterior chest radiography. On the chest radiography enhancement a nonhomogeneous opacity resembling �Turkish Sword� through right heart border was noted. Scimitar syndrome was diagnosed and partial venous return abnormality observed, which is one of the components of the syndrome, by magnetic resonance angiography. No treatment was given and informed about his disease and was asked for control revisits.

Severe traumatic asphyxia: two case report and literature review

2006-01-01

Traumatic asphyxia is a clinical syndrome associated with cervicofacial cyanosis, petechia and subconjonctival hemorrhage, neurological symptoms. The syndrome appears following severe and transient compressive blunt chest trauma. Its morbidity and mortality is linked by the associated cardiovascular, pulmonary, and neurological injuries. In these two cases, traumatic asphyxia developed as a result of an abrupt thoracic compression. Both cases were admitted to the emergency in an unconscious state resulting from compression of the whole of the right arm, the shoulder and the right side of the thorax extending to the neck, caused by a heavy machine in the shape of a paint clinder. On the pulmonary x-ray of the firs case fractures of the 7th and 8th ribs were determined and tube thoracostomy performed. The CT of the brain was not unusual, and the patient was discharged without neurological sequele, with complete recovery. The second case was admitted to the emergency service with cardiopulmonary arrest and by the15th minutes, cardiac rhythm was on its normal course. On the computerized tomography of the brain, extensive edema was detected. The patient was neurologically observed with Glasgow Coma Score E1M2Ve. He was discharged with spontaneous breathing with traceostomia and with Glasgow Coma Score E1M4Ve on the 65th day, informing his family on his condition and the care of such patients.

Left circumflex coronary artery arising as a terminal extension of right coronary artery in a patient treated with coronary artery bypass grefting

Atila Bitigen, Ali Cevat Tanalp, Orhan Hakan El�n�, Ramazan Karg�n, Cevat K�rma — 2006-01-01

Coronary artery anomalies are noted while doing coronary angiograms with an incidence of 1-1.5%. Most of them are benign and observed as a coronary artery originating from the contralateral aortic sinus. Coronary artery anomalies are more often in patients with congenital heart disease and its identification is of vital importance preoperatively. It is presented a very rare case of coronary anomaly where circumflex coronary artery is a terminal extension of right coronary artery.

Recurrent deep vein thrombosis in a 11-year-old girl with hereditary protein-C deficiency

Mustafa G�z, �mer �ak�r, Nesimi Eren — 2006-01-01

Protein-C is a plasma protein, which plays an important role in the physiologic anticoagulan system. In its hereditary insufficiencies, venous and arterial thromboses occur. An 11-year-old girl presented with pain, edema and movement restriction of the left leg, we learned these occured four days after a febrile upper respiratory tract infection. It was pointed out that she had oedema on the same leg but received no treatment while being hospitalized and treated due to a febrile attack when she was 1-year-old. In physical examination there were 3 cm differences between two lower extremities in diameter. Homans test was positive. In Doppler USG there were distally chronical and proximally acute deep vein thrombosis. In family search familial protein- C insufficiency was found. Subcutaneus heparin and oral anticoagulan were initiated. There were no recurrences during six month-oral thromboemboli profilacty period.

Conduit usage in surgery for Tetralogy of Fallot

Emin Alp Alayunt, Y�ksel Atay — 2006-01-01