Turkish Journal of Thoracic and Cardiovascular Surgery - 2009; 17(4)

Off-pump complete revascularization: angiographic results at six months

2009-10-01

Background: In this study, perioperative characteristics of the patients in whom complete off-pump revascularization was performed were investigated, and short term angiographic results concerning the grafts used in the operations were determined by revealing the causes of initial morbidity and mortality. Methods: Between December 2002 and May 2004, 89 patients (81 males, 8 females; mean age 59.7�9.2 years; range 40 to 79 years) who had complete revascularization operation on the beating heart because of multiple vessel lesions and who were operated on by the same operating team were included in our study. Those patients who didn�t have complete revascularization in the same period were not included in the study. General anesthesia was performed in all patients by means of intravenous narcotic anesthesia. In all patients, target vessel revascularization was started by giving priority to the systems supplying the left ventricule. Following revascularization of the left system, dominant coronary artery system was given priority. A total of 43 control angiographies were performed. Results: The best patency rate was 100% and it was observed in left internal mammarian artery. Bilateral internal mammary artery grafts for left anterior descending territory had also 100% patency. The best patency rate for radial artery was observed by using radial artery to circumfleks territory. The patency rates of saphenous vein grafts was lower than any other arterial graft. Conclusion: Complete revascularization using arterial grafts on the beating heart can be performed succesfully.

Six-cases experience with Stanford type-A aortic dissection

2009-10-01

Background: In this study, we aimed to evaluate our six-case experience in the proximal aortic dissection management. Methods: We operated on six patients (1 female, 5 males; mean age 54.2�14.4 years; range 36 to 72 years) of Stanford type-A aortic dissection between August 2007 and November 2008. Right femoral, aortic or axillary artery canulation and isothermic blood cardioplegia were used. Distal anastomoses were completed by cross-clamp or open technique using reinforcement with teflon felt. In case of an insufficiency in the aortic valve, the aortic root was repaired by applying biological tissue glue and commissural suture resuspension. Results: In five cases, we used both echocardiography and contrast enhanced thoracic computed tomography for diagnosis. In one case, only contrast enhanced thoracic computed tomography was preferred. While in five cases, interposition of tubular graft was used to repair the ascending aorta, in one case, the ascending aorta and hemiarch replacement was performed. In five cases, resuspension sutures were placed due to aortic insufficiency. The mortality rate was 33.3% (n=2). Conclusion: We consider that early diagnosis, the anastomosis reinforced with teflon felt, aortic remodeling together with resuspension suture and axillary artery cannulation are safe applications in the management of acute proximal aortic pathologies.

The results of the surgical treatment of hypertrophic cardiomyopathy

2009-10-01

Background: We have reviewed the early and long term results of the patients who were operated for hypertrophic obstructive cardiomyopathy (HOCM) in our clinic. Methods: Thirty-two patients with HOCM (13 males, 19 females; mean age 35.1�17.6 years; range 7 to 68 years) who were operated on between September 1985 and September 2008 were included in the study. The main presenting symptoms were chest pain, palpitation and dyspnea. Echocardiography was performed in all patients both preoperatively and postoperatively and 27 had catheterization preoperatively. We performed septal myectomy in all cases under general anesthesia. Concomitantly mitral valve reconstruction in two (6.3%), mitral valve replacement in six (18.8%), aortic valve replacement in two (6.3%) and aortic valve replacement + coronary artery bypass in one (3.1%) were performed. Results: Three patients (9.4%) required permanent pacemaker implantation postoperatively due to complete heart block. In the follow-up one patient has arrhythmia and another one has congestive heart failure. In the postoperative period, early mortality was 6.3% with two cases and the late term mortality was 6.3% with two cases with a total four cases. The five-year survival rate was 95.2%�2.4. Conclusion: Concomitant procedures increase the mortality and morbidity in hypertrophic obstructive cardiomyopathy surgery. However, in patients unresponsive to medical treatment septal myectomy is a procedure which can be performed with low morbidity and mortality.

Comparison of retroperitoneal and transperitoneal procedures in aortoiliac occlusive diseases

2009-10-01

Background: In this study, transperitoneal (TP) and retroperitoneal (RP) procedures in the surgical treatment of aortoiliac occlusive diseases (AIOD) were compared advantages and disadvantages of these procedures were evaluated. Methods: Fifty-five patients who underwent surgery for AIOD between October 2003 and August 2007 were retrospectively evaluated. Retroperitoneal technique was performed in 30 patients and TP technique was performed in 25 patients. Clinical features, risk factors, peri- and postoperative medical data were analyzed and compared between two groups. Results: No statistically significant differences were observed in clinical features and risk factors. Of the eight operative parameters, five were in favor of RP procedure. Duration of intensive care unit stay (p<0.01), duration of hospital stay (p<0.01), return of bowel functions (p<0.01), beginning time of oral feeding (p<0.01), effort pain score (p<0.01) were significantly better than those observed in TP group. Pulmonary complications were also fewer in RP group (p=0.02) but the difference was not statistically significant for this parameter. There were no statistically significant differences when the other complication parameters [wound complications (p=0.09), paralitic ileus (p=0.14), re-operation (p=0.46), 30th day mortality (p=0.30)] were considered. Conclusion: When the results are compared, it is seen that RP procedure is more advantageous than TP procedure in the surgical treatment of AIOD.

Respiratory and clinical outcomes after coronary artery bypass surgery in male patients below and over 70 years of age

2009-10-01

Background: This retrospective study was planned to evaluate respiratory functions and clinical outcomes in male patients below and over 70 years of age after coronary artery bypass surgery (CABS). Methods: Medical charts of 918 patients who underwent CABS between January 2002 and September 2006 were investigated and 112 male patients with no missing data according to the inclusion criteria were recruited for the study, and they were divided into two groups according to their ages being below or over 70 years (younger group: 89 patients; mean age 57.6�5.3 years and elderly group: 23 patients; mean age 71.6�2.3). Pre- and postoperative respiratory function, respiratory muscle strength and clinical outcomes of both groups were compared, and correlations between these parameters were investigated. Results: Before the surgery, vital capacity (VC; p=0.0006), forced vital capacity (FVC; p=0.0005), forced expiratory volume in 1 second (FEV1; p<0.0001), FEV1/FVC % (p=0.02), forced mid-expiratory flow (FMF; p<0.0001), forced expiratory flow (FEF; p=0.0005), maximal inspiratory pressure (PImax; p<0.0001) and maximal expiratory pressure (PEmax; p=0.02) were significantly lower in elderly patients compared with the younger ones. The decrease in pulmonary functions, respiratory muscle strength and complication rates were similar in both groups postoperatively. Elderly patients required longer cardiopulmonary bypass time (p=0.03), intubation time (p=0.0004), intensive care unit stay (p=0.001) and postoperative hospital stay (p<0.0001) than younger patients. Conclusion: Although postoperative clinical recovery was longer in our elderly patients than younger ones, it was still better than the outcomes observed in other studies. Thus, male patients over 70 years of age should not be denied CABS solely on the basis of age.

Determining the risk and frequecy of coronary artery disease in patients who have peripheric vascular occlusive disease and who will have vascular surgery

H. Ali T�nel, �inasi Manduz, Nurkay Katranc�o�lu, O�uz Karahan, �cal Berkan — 2009-10-01

Background: The purpose of our study was to observe risks and frequency of coronary artery disease (CAD) in patients who had peripheral occlusive vascular disease (POVD) but who did not have symptoms of CAD, to determine whether the severity and rate of atherosclerosis risk factors were different in these patients and whether it was possible to predict the concurrence of these diseases by means of tests. Methods: Seventy patients who underwent medical or surgical treatment because of CAD and POVD after May 2005 were enrolled in the study. Patients with POVD was called group 1 and those who did not have POVD but only CAD were called group 2. Group 1 (n=44) was divided into two subgroups according to presence of additional CAD (group 1a, n=27) or absence of CAD (group 1b, n=17). There were 26 patients in group 2. Groups were compared with respect to age, gender, risk factors of atherosclerosis, C-reactive protein (CRP), fibrinogen, iron, ferritin. Results: Frequency of CAD in patients who had POVD was 61.36%. There was a significant difference between group 1 and 2 in terms of smoking and gender (p<0.05). There was no significant difference between group 1 and 2 in terms of other risk factors of atherosclerosis (p>0.05). There was significant difference between group 1a and group 1b about CRP levels. C-reactive protein levels were also significantly different between group 1a and 2. There were significant differences between group 1a and group 1b with respect to fibrinogen and iron (p<0.05). Peripheral occlusive vascular disease can cause severe morbidity and mortality because of risk of CAD. Conclusion: We think CAD risk can be predicted measuring the levels of acute phase reactants such as CRP and, fibrinogen, and we recommend that patients with POVD for whom revascularization is planned should be examined in detail about CAD.

The prognostic significance of histopathologic angioinvasion in stage I non-small cell lung cancer

�a�atay Tezel, Altu� Ko�ar, Ay�e Ersev, Yelda Tezel, B�lent Arman — 2009-10-01

Background: We aimed to analyze the prognostic significance of vascular invasion, which is one of the histopathological features affecting the prognosis in early stage lung cancers. Methods: Forty early stage (T1-2N0M0) non-small cell lung cancer patients (32 males, 8 females; mean age 53.8�8.7 years; range 35 to 69 years) who underwent curative surgery with mediastinal lymph node dissection between December 1997 and January 2004 were retrospectively evaluated. Tumor histology, grade, vascular invasion, and the extent of resections were evaluated. Pathological slides were re-examined and invasion of at least two vascular structures and/or presence of tumoral thrombosis in the lumen of vessels were defined as vascular invasion. Results: Three-year disease free survival was found to be 67.2�7.5% and five-year survival was 64.5�7.6%. When an evaluation was done considering whether there was vascular invasion or not, there was not a significant difference (Log rank: 0.85; p:0.357; p>0.05) However, adenocarcinoma subtype was found to be related with unfavorable outcome with high local relapses and distant metastases (p<0.01). Conclusion: Despite the limited number of the cases in our retrospective study, it was found that in early stage lung cancer the type histology was far more prognostic than histological vascular invasion.

The diagnostic value of cervical mediastinoscopy in the diseases with mediastinal lymphadenopathy other than lung cancer

2009-10-01

Background: In this study, reliability, effectivity and practicability of cervical mediastinoscopy was determined. Methods: The data were retrospectively analyzed 84 patients (68 males 16 females; mean age 34.6 years; range 20 to 71 years) who underwent diagnostic mediastinoscopy due to mediastinal lymphadenopathy. The patients were analyzed in terms of the variables of age, sex, duration of operation, the distribution of detected and sampled lymph node stations, peri- and postoperative mortality, morbidity and histopathological diagnosis. Results: Lymphadenopathy was dedected in 233 lymph node stations by means of radiological examinations. One hundred forty of all lymph node stations were sampled and 77% of these samplings were performed from right upper and right lower paratracheal lymph node stations (2R, 4R). There were complications in four cases (4.8%) but no mortality occurred. Histopathological diagnosis was established by mediastinoscopy in all but two patients in whom the diagnosis was established by thoracotomy. The sensitivity of mediastinoscopy in patients without lung cancer was 93%. Conclusion: In the light of these findings, mediastinoscopy is an diagnostic method which has a high diagnostic value and which can be performed with low morbidity and mortality rates in the majority of patients who have undiagnosed mediastinal lymphadenopaties.

Primary chest wall tumors: a 10-year experience

Recep Demirhan, Hatice Eryi�it, Bora Kaya — 2009-10-01

Background: In this study, the value of early diagnosis and reconstruction in primary chest wall tumors was investigated. Methods: The files of 25 patients (14 male, 11 female; mean age 38 years; range 16-74 years), who were operated in our clinic with the diagnosis of primary chest wall tumor between January 1998 and June 2008, were retrospectively reviewed. The masses of primary lung, pleura, mediastinal tumors invading the chest wall and metastatic lesions were excluded from the study. Reconstruction was performed in anterior chest wall defects of more than 5 cm in size. Polypropylene mesh, methyl metacrylate and the muscles of the chest and abdominal wall were used in reconstruction. In malignant tumors, all layers were resected after leaving a safe area of 4 cm. In order to provide a histopathological diagnosis, a needle, incisional, or excisional biopsy were used. Results: The most common complaints of patients were swelling in the chest wall and chest pain. On physical examination, there was chest wall mass in 19 cases (76%), sternal mass in four cases (16%), and mass-skin ulceration in two cases (8%). The diagnosis was established after removal of the mass through a wide resection in 16 cases, and it was established with a needle biopsy (tru-cut) in four cases and an incisional biopsy in five cases. Histopathological results were reported to be malignant in 13 cases and benign in 12 cases. There was no mortality observed. Conclusion: We concluded that early diagnosis in primary chest wall tumors is very important, and reconstruction with radical surgery is the ideal treatment of choice.

Dermatofibrosarcoma protuberans

2009-10-01

Dermatofibrosarcoma protuberans (DFSP) is a rare, locally aggressive tumor arising from the skin. We reported two cases who presented with a huge mass arising from the left upper anterior part of chest wall. We performed a wide local excision for two patients. Skin defect was closed with free split skin greft. Histopathological studies revealed the lesion to be dermatofibrosarcoma protuberans. Follow-up was three months for the first patient and 48 months for the second patient. There was no recurrence and metastasis in both patients.

Hybrid and staged repair in the treatment of a case with extensive aortic aneurysm

Hikmet �yem, Y�lmaz Cirban, Ahmet Memi�, Suat B�ket — 2009-10-01

In this article we present a successful management of a case with extensive aortic aneurysm which was treated by a combination of open surgery and endovascular stent grafting. Cardiopulmonary bypass was established via right femoral and right atrial cannulation. Patient was cooled down till 18 degrees and following the cardiac arrest, Bentall procedure was performed by using a composite graft. A 26 mm Talent endovascular stent was placed into the descending aorta through arcus aorta under direct vision. Later on, distal anastomosis was performed for the total hemiarcus replacement. The distal part of the composit graft and the proximal part of the hemiarcus graft was anastomosed during rewarming. After one week, a second endovascular stent graft was placed into the descending aorta under general anesthesia in peripheric angiography laboratory and the treatment was completed.

A peritoneal, pleural mesothelioma case who has survived for six years

Murat Bayram Kaplan, O�uz K�ksel, Erhan Ayan, Ali �zd�lger — 2009-10-01

Malignant mesothelioma, which has a poor prognosis and fatal course, is a primary malignant tumor of serosal membrane of pleura, pericardium and peritoneum. Expected mean survival time is 4-12 months when no treatment is administered. Malignant mesothelioma is commonly located in the pleural space and its clinical behaviour and biology has not been understood exactly yet. Epidemiological studies, diagnosis, grading methods and treatment modalities concerning this disease have been the subject of investigations. We are presenting a pleural and peritoneal malignant mesothelioma case who has survived for six years without any other curative treatment except for the first line chemotherapy and we evaluate etiological factors along with the information in the literature.

Aortic pseudoaneurysm formation following multiple valve replacement

Ahmet Akg�l, �lknur Bahar, Seyhan Babaro�lu, Adnan �obano�lu — 2009-10-01

Pseudoaneurysm formation at the ascending aortic suture line is a rare but life-threatening complication. After reincisions of the ascending aorta as in re-aortic valve replacement, the patient should undergo regular echocardiographic studies and re-reoperation should quickly follow a diagnosis of pseudoaneurysm formation. Interposition of supravalvular aortic graft may be the surgical treatment of choice because its long term results are better when compared with those of other surgical techniques. We present a case with a giant pseudoaneurysm following re-aortic valve replacement and its treatment.

Chylopericardium following double valve replacement

2009-10-01

Chylopericardium is a rare complication following open heart surgery. Chylopericardium occurs because of the unintentional damage of the small pericardial lymphatic ducts, draining to thoracic duct, and/or thymic intraglandular ducts during the operation. Initial treatment of chylopericardium is dietary modification. In this article we present a 24-year-old female with chylopericardium who underwent aortic and mitral valve replacement. In our patient diet was arranged as high-protein with medium chained triglycerides in her first two weeks and in the third week oral intake was ceased and total parenteral nutrition was initiated. Since there was a non-decreasing continuous leakage after three weeks of operation, we performed an exploratory second surgical intervention. After sternotomy, 3x4 cm of chylous collection was detected around thymus. Thymus tissue and pericardial edges were sutured continuously with 4/0 polypropylene. Pericardial collection was not detected after echocardiographic and radiographic evaluation and the patient was discharged one week after surgical revision. In the postoperative third month, she was completely normal. In the cases of continuous chylous drainage following open heart surgery after three weeks, exploratory surgery can be recommended.

A newborn with aorticopulmonary window associated with coarctation of the aorta: a successful single-stage surgical treatment

Mustafa K�r, Ula� Karada�, G�l Sa��n Saylam, H�dai �ataly�rek, Nurettin �nal — 2009-10-01

Aorticopulmonary window is a septation defect between ascending aorta and main pulmonary artery. It is usually seen with other congenital heart diseases. It is mostly seen together with interrupted aortic arch and coarctation of aorta. When the diagnosis of aorticopulmonary window is certain, immediate surgery is needed during neonatal period. In this article, a newborn with aorticopulmonary window and aortic coarctation is reported. The window was repaired with Gore-Tex patch and aortic coarctation was corrected with subclavian flap technique at the same time in a three-day-old boy. He was discharged on the seventh day of the operation without any problems.

Venous thromboembolism and inherited thrombophilia

Erhan Atahan, Erkan �a�lar, Cihat �ark��, Serdal U�urlu — 2009-10-01

Inherited thrombophilia is a genetic tendency to venous thromboembolism. Coagulation abnormalities are common in the general population and therefore will present spontaneously in some individuals. Patients with a family history of thrombosis are at an increased risk for a mutation. Factor V Leiden and the prothrombin, G20210A mutation the commonest inherited risk factors for thrombosis, are associated with an increased risk of venous thromboembolism. These causes of thrombophilia increase the risk of venous thromboembolism recurrence. Deficiencies in protein C, protein S, and antithrombin-III account for most of the remaining cases of thrombophilia. Inherited thrombophilia should be suspected in patients with one or more of the following clinical features: idiopathic thrombosis, thrombosis at a young age, recurrent thrombosis, and thrombosis at an unusual site. Reliable assays are now available to test for the presence of the various causes of inherited thrombophilia.

Unroofing procedure

Nihan Kayalar, Harold M. Burkhart — 2009-10-01

Anomalous origin of the coronary artery from the opposite sinus may have a potential for life-threatening presentation including myocardial infarction, arrhythmia, or sudden death. Surgery is generally indicated when the course of anomalous artery is interarterial between the aortic root and right ventricular outflow tract/pulmonary artery. Specific morphologic details, mainly the ostial status and intramural course, influence the type of surgical repair. The unroofing procedure is a technique suitable for those with intramural course, and it creates a new coronary ostium in the correct valsalva sinus, thereby eliminating the course between the pulmonary artery and aorta as well as the intramural course.