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Objective The rate of patients with diffuse left anterior descending artery (LAD) disease being referred for surgery has increased as a result of advances in endovascular techniques. In surgery of diffuse or multisegment LAD disease, surgical procedures with or without endarterectomy can be performed. In this article, we report our results of longsegment onlay patchplasty of the LAD with a left internal thoracic artery (LITA) graft without endarterectomy, on the beating heart, in patients with multisegment LAD disease. Methods We retrospectively analysed patients who underwent coronary artery bypass grafting surgery in our hospital between 1 January 2015 and 31 July 2017. We included LITA onlay patchplasty patients with multisegment LAD disease who had been operated on the beating heart. We excluded patients who underwent coronary endarterectomy and were operated on under cardiopulmonary bypass. Results In this period, 54 patients with multisegment LAD disease were treated with LITA patchplasty on the beating heart. The mean length of the arteriotomy was 42.8 ± 13.3 mm (25-75 mm). There were two postoperative myocardial infarctions (3.7%) and three deaths (5.5%). In the remaining patients, there was no haemodynamic instability that needed long-term (> 24 hour) inotropic support. Patients were discharged from hospital on postoperative 9.3 ± 7.1 days with dual antiplatalet therapy. Conclusions Bypass grafting of the LAD with long-segment LITA onlay patchplasty can safely be performed in patients with multisegment LAD disease, with acceptable early-term results. In this procedure, proximal and distal segments of the diseased LAD are revascularised with LITA grafts, which may improve long-term survival and quality of life.

Amac: Karotis arter darliklarinin tedavisinde cerrahi endarterektomi ilk tercih olarak onerilmektedir. Cerrahi sirasinda serebral perfuzyonunun devamliligi icin sant uygulamasi ve arteriyotominin primer ya da yama olarak kapatilmasi klinik tecrubelere gore farklilik gostermektedir. Bu makalede klinigimizde uyguladigimiz sant kullanilmadan, primer tamir ile ilgili sonuclarimizi bildiriyoruz. Calisma Plani: Klinigimizde 01.02.2018–30.11.2018 tarihleri arasinda karotis arter darligi nedeni ile ameliyat edilen hastalar retrospektif olarak incelendi. Selektif karotis arter endarterektomi operasyonu uygulanan hastalar calismaya dâhil edilirken; es zamanli koroner arter cerrahisi operasyonu uygulanan hastalar calisma disi birakildi. Hastalarin peroperatif ve postoperatif bir aylik takip sonuclari degerlendirildi. Bulgular: Calisma periyodunda 27 hastaya karotis endarterektomi ameliyati uygulandi. Hastalarin yas ortalamasi 70,8±9 olup, 19 %70,4 ’u erkek idi. Tum ameliyatlar sant kullanilmadan ve primer tamir ile gerceklestirildi. Ortalama klemp suresi 6,7±0,9 dakika idi. Postoperatif donemde bir hastada ses kisikligi ve yutma guclugu; bir hastada sol kolda hemiparezi ve dizartri gelismis olup, semptomlar iki hafta icinde kayboldu. Hastane yatis suresince ve postoperatif bir aylik takiplerde mortaliteye rastlanmadi. Sonuc: Karotis arter endarterektomi esnasinda sant uygulamasi ve yama ile tamir cerrahi suresini ve manipulasyonu arttiran yontemlerdir. Deneyimli merkezlerde hizli bir sekilde endarterektomi uygulamasi sonrasi primer tamir yontemi ile arteriyotominin tamiri kabul edilebilir postoperatif takip verileri ile guvenle uygulanabilecek bir tekniktir.

Wereport a 36-year old woman who suffered from massive pulmonary embolism withmultiple thrombogenic risk factors. She was successfully treated with pulmonaryembolectomy. Our report reinforces the importance of early diagnosis in thepresence of a high clinical suspicion for pulmonary embolism. Furthermore,surgical pulmonary embolectomy remains one of the most effective treatmentmethods., Otuzaltı yaşında, çoklu trombojenik risk faktörüne sahip ve masif pulmoner embolitablosu ile başvuran hastanın pulmoner embolektomi ile başarılı bir şekildetedavi edilişini sunuyoruz. Olgumuz pulmoner emboli de erken tanının öneminibelirtmektedir. Ayrıca, cerrahi pulmoner embolektominin en etkin tedaviyöntemlerinden biri olduğunu vurgulamaktadır.

Background: In this study, we present our results with complete revascularization in patients with acute coronary syndrome undergoing coronary artery bypass grafting on beating heart.

Konno aortoventriculoplasty (AVP) is performed for various types of left ventricular outflow tract obstruction. We report on a 32-year-old woman who had undergone double valve replacement five years earlier. She presented with increased interventricular septum thickness, small aortic root and gradient across the aortic mechanical valve. We performed Konno AVP with repeat aortic valve replacement (AVR). The control echocardiography showed no significant residual gradient. Konno AVP with repeat AVR may be safely performed with satisfactory results.

Background Atheromatous plaques of the ascending aorta are one of the most important risk factors for postoperative mortality and morbidity in coronary artery bypass grafting (CABG). We have retrospectively analyzed the results of proximal anastomoses constructed on the innominate artery in patients with calcific atheromatous plaques (CAP) in their ascending aorta detected intraoperatively. Patients and Methods This study is a retrospective review of 16 consecutive patients who underwent CABG operations and had CAP on their ascending aorta between November 2006 and June 2009. The atheromatous lesions were detected intraoperatively and the operation plan was changed to off-pump surgery. All the proximal anastomoses were made on the innominate artery, left internal thoracic artery (LITA) or the other saphenous vein grafts (SVG). Thirteen patients were male and three were female with a mean age of 63.7 ± 5.3 (ranged, 53–71) years. Results A total of 56 distal anastomoses (3.5 per patient) and 25 proximal anastomoses on the innominate artery were performed. Of the 16 patients, seven (43.7%) had received a sequential SVG; two (12.5%) patients, sequential LITA graft; and one (6.25%) patient sequential SVG and LITA graft. One of the proximal anastomoses was performed on the SVG in four patients (25%) and on the LITA graft in one patient (6.2%). One patient (6.2%) died due to cerebrovascular morbidity. No other complications were observed. Conclusions The innominate artery is an alternative site for proximal anastomoses in patients with calcific atheromatous aorta. doi: 10.1111/jocs.12112 (J Card Surg 2013;28:228–232)

Background: Pulmonary arterial hypertension is of importance in congenital cardiac surgery as being a significant cause of morbidity and mortality. Although therapy options are limited, inhaled nitric oxide (NO) is used as a standard therapy. The present study aimed to compare inhaled NO and aerosolized iloprost in children with secondary pulmonary hypertension who underwent congenital cardiac surgery. Methods: Sixteen children included in the study were randomized into either inhaled NO or aerosolized iloprost group. For both groups, the observation period terminated at 72 h after cardiopulmonary bypass. Results: There was no significant difference between the groups in terms of mean age, weight, cross clamp time, pump time, and extubation time. No significant change was observed in the arterial tension and central venous pressure of both groups before the operation, 30 min after the pump, 45 min after the pump, and after extubation, whereas an increase was observed in the heart rate and cardiac output, and a decrease was observed in the pulmonary artery pressure. The mean values at the above-mentioned time points showed no difference between the groups. No serious adverse event and mortality was detected. Conclusions: Both inhaled NO and aerosolized iloprost were found to be effective and comparable in the management of pulmonary hypertension.

Background and Aim of the Study: This study aimed to compare the early outcomes of off-pump and on-pump myocardial revascularization in patients with stenosis in the left anterior descending artery (alone or with diagonal artery disease). Methods: We retrospectively reviewed the medical records of 300 patients: 150 who underwent on-pump coronary artery bypass and 150 who underwent off-pump coronary artery bypass grafting. There were no significant differences between the 2 groups with respect to medical data and operative findings. On-pump and off-pump groups were compared in terms of mortality and morbidity within 30 days of the operation. Results: Hospital mortality was 3.3% (5 patients) in the on-pump group and 2.6% (4 patients) in the off-pump group. Five patients (3.3%) in the on-pump group experienced myocardial infarction; 3 died of cardiogenic shock. Four patients (2.6%) in the off-pump group experienced myocardial infarction, and 2 of these patients died. Two patients (1.3%) in the on-pump group and 2 patients (1.3%) in the off-pump group experienced stroke; 1 patient in each group died. One patient (0.6%) in the on-pump group had mediastinitis and died of sepsis. Conclusions: Among low-risk patients (defined according to EuroSCORE criteria) who underwent left anterior descending coronary artery bypass, the results obtained with the on-pump and off-pump methods showed no significant differences with respect to morbidity or mortality.

Objective Sternal dehiscence after open surgery is a major cause of morbidity and mortality, and chronic obstructive pulmonary disease is a significant risk factor. Therefore, we aimed to determine whether moderate and severe chronic obstructive pulmonary disease had an effect on the development of sternal dehiscence and whether the use of the Robicsek technique for sternal closure along with sternal support vest postoperatively would reduce the incidence of sternal dehiscence in patients with moderate/severe chronic obstructive pulmonary disease undergoing cardiac surgery. Methods Two studies were performed. In study 1, 842 patients undergoing cardiac surgery and figure-of-8 wire closure were retrospectively evaluated in 2 groups: group 1a (328 patients with chronic obstructive pulmonary disease) and group 1b (514 patients without chronic obstructive pulmonary disease). In study 2, 221 patients with moderate and severe COPD who were scheduled for open surgery were prospectively enrolled. The Robicsek technique was used for sternal closure. The postoperative thorax support vest was used in 100 patients (group 2a), and no additional procedure was applied in 121 patients (group 2b). Results In study 1, the dehiscence rate was significantly higher in group 1a (7.9%) than in group 1b (1.2%; P 001), and mortality rates in patients with dehiscence were 53.8% and 33.3%, respectively. In study 2, the dehiscence rate was significantly lower in group 2a (1%) than in group 2b (11.5%; P = . 002). None of the patients with dehiscence in group 2a died, and 35.7% of patients died in group 2b. Conclusions The Robicsek technique for sternal closure and the use of a thorax support vest postoperatively are highly effective in preventing sternal dehiscence after cardiac surgery in patients with moderate and severe chronic obstructive pulmonary disease.

We report a 61-year-old patient who suffered from a type A aortic dissection that mimicked an acute inferior myocardial infarction. During a routine cardiac catheterization procedure, diagnostic catheters can be inserted accidentally into the false lumen. Invasive cardiologists should keep this complication in mind.

Duplicated internal juguler vein (DIJV) is a rare anomaly and reported incidence is 0.4 % in the literature. A 45-year-old female patient was referred to our hospital because of non pulsatile neck swelling. The magnetic resonance image (MRI) showed left IJVs divided at the angles of the mandible running anterior to the common carotid artery until anterior mediastinal level. Clinicians should be aware of the rare possibility of duplicated IJVs in patients presenting with neck swelling. The development of imaging technics have revealed more cases of duplicated internal juguler vein.

Aortopulmonary fistula associated with endocarditis complicating mechanical aortic valve replacement has been reported but very limited reports of aortopulmonary fistula following native aortic valve endocarditis in the literature. A 60 year old female presented to our hospital with high fever, dyspnea symptoms over two days. We suspect the endocarditis that Staphylococcus aureus was isolated from blood cultures. Echocardiogram and cathaterization showed that severe aortic regurgitation, aortopulmonary fistula.We urgently performed the aortic valve replacement and closure of both side of fistula with the Contegra® patch.The patient developed multiorgan failure as a cause of death at postoperative 63.day.

Subaortic stenosis (SAS) is a wide spectrum of anatomical derangements ranging from a discrete fibrous membrane to tortuous fibrous tunnel with or without aortic annulus hypoplasia. We have reviewed 88 patients undergoing surgery for SAS over a 15-year period. There were 47 male and 41 female patients with a mean age of 19.8 +/- 10.6 years (range 11 to 39). Fifty-eight patients had discrete subaortic membrane, and 30 patients had diffuse tunnel subvalvular stenosis. The mean systolic pressure gradients were found to be 86.5 +/- 31.4 mmHg (range 48 to 145 mmHg). Ten patients had mild and 13 patients had moderate-to-severe aortic insufficiency (AI) preoperatively. Nine patients had bicuspid aortic valve. Forty patients (45.4%) had associated cardiac lesions. Isolated membranectomy was performed in six patients. Membranectomy associated with septal myectomy was done in 52 patients. Fifteen patients of them associated hypoplasia of the aortic orifice necessitated aortic valve replacement (AVR) using the Konno-Rastan procedure. Fifteen patients with tunnel SAS and normal aortic valves underwent a combined approach for valve sparing, a modified Konno procedure with patch septoplasty. Also eight patients required AVR because of the severity of AI and five patients aortic reconstruction procedures. Aortic commissurotomy was performed to relief of stenosis in four patients. There were three early deaths (3.4%) and one late death (1.1%) all after the Konno-Rastan procedure. Eight patients (9.1%) had permanent conduction abnormalities. Postoperative left ventricle-aorta gradient was significantly decreased at early postoperative period (p < 0.001) and ranged from 10 to 25 mmHg (mean 14.1 +/- 4.3). Fourteen patients (16.5%) were reoperated for recurrent obstruction or progression of AI. The mean reoperation interval was 4.4 +/- 1.7 years (range 2 to 8 years). Five-year reoperation-free survival was 88.0 +/- 3.6% and 12.5-year reoperation-free survival was 75.5 +/- 7.0%. Our results of aggressive surgical approach of subvalvular aortic stenosis produces relief of obstruction and frees the valve leaflets, significantly reducing associated AI with long-term survival and long-term adequate relief of left ventricular outflow tract obstruction.

Benign pleural effusions are rarely treated with pleurodesis. We report a case of left-sided pleurodesis in a patient with rightsided destroyed lung. A 83-year-old man with right-sided destroyed lung was hospitalized because of reccurent left-sided massive pleural effusion due to cardiomyopathy. The patient was treated with left pleurodesis. He was then discharged from hospital and given diuretics therapy. At the one-year follow-up examinations, dyspnea and effusion had not recorded.

Patient: Male, 60 Final Diagnosis: Iatrogenic intercostal lung hernia Symptoms: — Medication: No medication Clinical Procedure: Surgically cerrected Specialty: Thoracic surgery Objective: Unusual clinical course Background: Iatrogenic intercostal lung hernia is a rare thoracic pathology. Injury of intercostal muscles and costocondral separation during median sternotomy and sternal dehiscence surgery are important factors in the development of hernia. We report for the first time a case of a 60-year-old man with acquired lung hernia after sternal dehiscence surgery, presenting as chest pain and exertional dyspnea. Case Report: A 60-year-old man presented with a 6-week history of progressive exertional dyspnea, particularly following vigorous coughing. Past medical history included slight chronic obstructive pulmonary disease and coronary artery bypass grafting surgery 8 weeks previously, using the left internal mammary artery for the left anterior descending artery via median sternotomy and sternal dehiscence by the Robicsek method. A chest X-ray showed intact sternal and parasternal wires, but the bilateral lung parenchyma appeared normal. A spiral computed tomography scan of the chest found intercostal herniation of the anterior segment of the left upper lobe. The lung hernia was repaired surgically to relieve exertional dyspnea and incarceration, and to improve respiratory function. The postoperative course was uneventful and the patient recovered well. Conclusions: Intercostal lung hernia after median sternotomy and sternal dehiscence surgery is rare, and it has been previously reported on. Preventive techniques include gentle manipulation of the sternal retractor, avoidance of rib fractures, and using a protective method of intercostal arteries and nerves such as Sharma technique. Thoracic surgeons should be aware of this rare complication in sternal dehiscence surgery.

Various surgical procedures have been employed to treat a greatly enlarged left atrium. We review the use of partial cardiac autotransplantation to reduce left atrial volume in 7 patients with rheumatic mitral valve disease and left atrial and ventricular volume in 2 patients with idiopathic dilated cardiomyopathy. There were 5 males and 4 females aged 25 to 62 years. The patients with rheumatic etiology had atrial fibrillation, while those with dilated cardiomyopathy had sinus rhythm. The mitral valve was replaced in 6 patients and reconstructed in 3. Mean aortic cross clamp time in the operations involving isolated left atrial resection was 119 ± 44 min. Mean left atrial volume fell from 331 mL to 92 mL, while mean left atrial diameter decreased from 8.6 cm to 4.7 cm. Sinus rhythm was restored in 5 of the 7 patients who had preoperative atrial fibrillation. There was no operative mortality. The patients with dilated cardiomyopathy died in the postoperative period, one on the 14th day from low cardiac output and the other on the 113th day from multiorgan failure. Partial cardiac autotransplantation can be effective in reducing heart chamber size in selected patients, especially those with giant left atrium.

WOS: 000221459600010, PubMed ID: 15174224, We induced ischaemia in the left anterior descending artery of 16 dogs while the heart was beating, followed by cardiopulmonary bypass (CPB), aortic cross clamping and blood cardioplegia. Half of the dogs received integrated blood cardioplegia and sudden uncontrolled reperfusion (group A) while the others received the same cardioplegia followed by pressure-controlled tepid initial reperfusion (group B). The effects on myocardial cell metabolism, oxidative stress and ultrastructure were recorded. The recovery period was significantly longer and cardiac output levels after CPB significantly lower in group A compared with group B. Group A showed a failure to uptake and utilize oxygen during the recovery period and significant lipid peroxidation. Marked tissue oedema was seen in group A but mitochondrial and organelle integrity was almost normal in both groups. We conclude that integrated cardioplegia could partially resuscitate the myocardium in this model, and pressure controlled reperfusion during the first 2 min is needed as an adjunct procedure.

Background . Replacement of the aortic root with a composite graft containing a prosthetic mechanic valve is the preferred surgical procedure for tailoring the aortic root. The aim of this study is to determine the 5-year experience with the composite root replacement using our new modification of the Bentall technique. Methods . Between January 1996 and June 2001, 96 patients underwent aortic root replacement using a flanged composite graft. Eighty patients (83.3%) were male, and 16 patients (16.7%) were female with a mean age of 48.7 ± 14.4 years. Indications for operation were a true or false aneurysm (65.6%), severe calcified aortic valve stenosis (4.2%) or severe aortic insufficiency (2.1%) with dilated ascending aorta, acute dissection (2.1%), or combination of indications (26%). Thirty-one patients (32.3%) received a concomitant cardiac procedure. Mean aortic cross-clamp time was 89.5 ± 28.6 minutes, and mean cardiopulmonary bypass time was 146.2 ± 45.6 minutes. Total follow-up was 253.9 patient-years. Results . Operative mortality was 8.3% (8 patients). The causes of hospital mortality were severe bleeding (3 patients), low cardiac output syndrome (2), acute respiratory distress syndrome (2) and cerebrovascular event (1). No patient died of flange-related complications. Univariate predictors of early mortality were low cardiac output syndrome ( p p = 0.03), and renal complication ( p = 0.03). Multivariate analysis demonstrated only low cardiac output syndrome to be significant ( p = 0.001) predictor for early mortality. There were five (5.7%) late deaths. Actuarial survival was 82.65% ± 4.8% at 5 years (1.95% patient-year). Cox proportional hazards regression analysis demonstrated only low cardiac output syndrome to be significant ( p = 0.032) predictor for late mortality. Actuarial freedom from prosthetic- and technique-related mortality was 100% at 5 years. Conclusions . The flanged composite graft offers excellent long-term results, with very low prevalence of prosthetic-related complications. The new created sinuses and the flange are especially helpful to continue physiologic function of the aortic root.

Objective The aim of this study is to investigate the effects of the duration of retrograde cerebral perfusion (RCP) in patients with aortic arch dissection. Methods Between 1993 and December 2000, 56 patients were operated on for aortic arch dissection. Elephant trunk procedure was performed in 28 patients (Group A) and semiarcus replacement in 28 patients (Group B). Type I dissection ( P=0.003), chronic ethiology ( P=0.006), medial degeneration ( PResults Hospital mortality was higher in Group A than Group B (32.1% versus 7.1%; P=0.015). Late mortality was observed only in Group A (10.5%; P=0.049). Actuarial survival was 55.1±11.55% in Group A and 91.67±5.64% in Group B at 5 yr ( P=0.0113). while cumulative survival for all patients was 78.38±5.77% at 5 yr. RCP time was longer in Group A (62.7±16.8 versus 34.2±19.5 min; P60 min) ( P=0.175) did not increase early mortality. Only hemodynamic instability was significantly ( P=0.006) predictors for late mortality. Conclusions Preoperative severity of dissection, hemodynamic instability or organ dysfunctions impair early or late outcome. Elephant trunk technique with increased RCP time do not increase early or late mortality. To shorten RCP time (

Objective: Acute type A aortic dissection (AAAD) represents an emergency in cardiac surgery that requires immediate treatment to prevent death due to its fatal complications. The surgical approach is dependent on the involvement of AAAD. Methods: Sixty-one patients were operated for AAAD at our clinic. 48 (78.7%) were male and 13 (21.3%) were female with a mean age of 51±12.3 yr (range, 21–80 yr). Only the ascending aorta was replaced in 33 (54.1%) patients (Group I) and aortic arch replacement was included in 28 (45.9%) patients (Group II). The aortic valve was preserved in 43 (70.5%) patients (Group A) and replaced in 18 (29.5%) patients (Group B). Results: Early mortality rate was 23% (14/61). Multivariate analysis revealed that previous cardiac operations ( P=0.048), renal complications ( P=0.024), pump time ( P=0.024), and cardiac complications ( P=0.017) were significantly factors increasing early mortality. Late mortality rate was 8.5% (4/47) and multivariate analysis revealed that pulmonary complication ( P=0.015) was the only statistically significant independent risk factor. Arch replacement or aortic valve replacement was not a predictor for early or late mortality. Cumulative survival was 73.8±5.63% at 1 yr and 68.3±6.46% at 7.5 yr. Cumulative survival was not different between groups (P>0.05). Conclusions: Both radical and conservative surgical approaches in AAAD do not differ in mean of early or late results. Surgery before development of hemodynamic instability and prevention of other system complications improves the outcome of surgical treatment in AAAD.

Occlusion of a coronary artery by an acute type A aortic dissection presents a life-threatening emergency that is rarely seen and easy to misdiagnose. We present the case of a 75-year-old male who experienced sudden onset of severe left-sided chest pain due to an acute type A aortic dissection that obstructed the right coronary artery. Following an initial misdiagnosis of acute coronary syndrome, imaging revealed the presence of an aortic dissection. An emergency modified Bentall procedure was performed, in which the damaged aorta and aortic valve were replaced.

Partial left atrial resection was performed in 8 males and 12 females, aged 19 to 63 years, with giant left atrium and mitral valve disease. Preoperatively, 18 patients had atrial fibrillation, and 2 had normal sinus rhythm. Echocardiography revealed left atrial thrombosis in 3 patients and spontaneous echo contrast in 5. The lateral wall of the left atrium, the region between the pulmonary veins, the roof of the atrium, and the tissue parallel to the mitral annulus were resected. Resection was performed using the cardiac autotransplantation technique in 6 patients. The mitral valve was replaced in 9 patients and reconstructed in 11. Mean aortic crossclamp time was 101 ± 35 minutes and total perfusion time was 135 ± 26 minutes. Mean follow-up was 20.4 ± 1.1 months. There was no operative mortality. One patient (5%) died suddenly in the late postoperative period. Left atrial volume was reduced from 265.3 ± 125 mL to 83 ± 43 mL (p < 0.01). Left atrial diameter decreased from 8.02 ± 1.31 cm to 4.4 ± 1.23 cm (p < 0.01). Sinus rhythm was detected in 13 patients (65%) postoperatively. No left atrial thrombosis or spontaneous echo contrast were found during follow-up. Statistically significant reductions in cardiac size and improvements in functional capacity were observed.

Between March 1996 and September 1997, videothoracoscopy was performed in 50 of 140 patients who underwent minimally invasive coronary artery bypass grafting. Mean age was 45.3 ± 6.8 years. The left internal mammary artery was harvested by thoracoscopy alone in 21 patients and by both thoracoscopy and direct vision in 29. Coronary artery bypass was then performed through a left anterior minithoracotomy. In 48 patients, the internal mammary artery was grafted directly to the left anterior descending artery; a small saphenous vein graft was interposed in the other 2 patients. The diagonal branch was bypassed with saphenous vein in 2 patients, the first obtuse marginal in 1, the right posterior descending branch in 1, and the right ventricular branch of the right coronary artery in 1. Concomitant carotid endarterectomy was performed in 1 patient. There was no mortality. Two patients had perioperative myocardial infarction. It was concluded that videothoracoscopy can help to achieve complete mobilization of the left internal mammary artery for minimally invasive coronary artery bypass grafting. These techniques can be regarded as safe and effective, giving excellent results and a shortened hospital stay with the advantage of avoiding some morbidity due to costal cartilage resection.

Background. Recently the availability and the superiority of less invasive coronary artery bypass grafting on some selected groups of patients in the meaning of patient comfort and short hospital stay has been shown by some authors. We present here the clinical results of 40 patients operated on by minithoracotomy incision on the beating heart without using cardiopulmonary bypass mostly harvesting the left internal thoracic artery by videothoracoscopic assistance. Methods. Between March 1996 and September 1996, 40 patients were operated on by harvesting the left internal thoracic artery mostly by video-assisted thoracoscopy and performing bypass through a minitoracotomy incision. Two patients in whom the procedure was switched to conventional technique were not included in this series. Nine of the patients were female and the rest were male. The mean age was 43.2 ± 7. Results. Left internal thoracic arteries were harvested by video-assisted thoracoscopy completely in 11 patients, incompletely in 24 patients (the harvesting was completed by direct vision afterwards), and under direct vision in 5 through a mini-anterior thoracotomy incision. Thirty-six patients received a bypass graft to left anterior descending coronary artery only, whereas 4 received a diagonal branch graft also. Left internal thoracic arteries were used to bypass the left anterior descending coronary artery directly in 38 patients. The left internal thoracic artery was injured in the middle portion during harvesting in 1 of the remaining 2 patients. The length was not enough in the other. A short saphenous vein graft was interposed between the left internal thoracic artery and the left anterior descending coronary artery in these 2 patients. There was no mortality. One patient had perioperative myocardial infarction. We did not see serious morbidity except one lung injury due to the trochar. Conclusions. The results obtained from our experience suggest that coronary artery bypass grafting by minithoracotomy could be applied effectively and safely without overwhelming additional risk to the patient. Furthermore, it has some advantages in reducing operative trauma and cost and also improving patient comfort.

Concomitant surgeries for unrelated diseases can be performed to minimize the risks associated with surgery and general anesthesia. In treating a male patient with breast cancer and severe coronary artery disease, we used the beating heart technique for a coronary artery bypass graft to avoid the negative effects of on-pump bypass on the possible acceleration of tumor growth. In this report, we present a unique case of concomitant off-pump coronary artery bypass graft surgery and modified radical mastectomy in a 56-year-old man.

Background: The aim of this retrospective study was to compare the results between general and local anesthesia (LA) for carotid endarterectomy (CEA). Methods: Three hundred and twenty-nine patients in whom 365 CEA procedures were performed between January 1990 and September 2001, were included in this study. Results: Operation time, shunt usage rates, hospitalization time ( P < .0001), and permanent stroke rates ( P < .05) were significantly lower in group with LA. For long-term period (121.3 ± 37.45 vs 98.6 ± 28.98 months), no significant difference was observed in these 2 group with respect to restenosis rates, neurological events, and deaths. Conclusions: Despite the lack of significant difference between LA and general anesthesia in terms of restenosis, neurological events, and death in the long-term period; LA is more preferable due its associated advantages including availability of testing the consciousness of the patients by direct contact, reduced use of shunts, shorter hospitalization periods, and less prevalence of permanent stroke in the short-term period.

Thrombocyte level and functions are vital factors during cardiac surgery. Thrombocytopenia-absent radius syndrome (TAR) is a rare genetic disorder consisting of skeletal abnormalities and thrombocytopenia. In this report, we present the management strategy for a 23-year-old female patient with TAR syndrome who underwent mitral valve repair.

Rheumatoid heart disease and the mitral stenosis secondary to it in the long term are still important cardiovascular problems in developing countries. Percutaneous balloon mitral valvuloplasty is a valid treatment option with low complication rates for relieving the signs and symptoms of selected patients with mitral valve stenosis. In this report, we describe subacute mitral regurgitation secondary to anterior leaflet rupture following percutaneous balloon mitral valvuloplasty and the management strategy in a 54-year-old female patient. Such a complication is rare in experienced hands in the current era.

Centrifugal pumps are nonocclusive pumps that offer centrifugal blood pumping known as the constrained force vortex principle. Of 2405 open heart procedures, 370 (15.4%) were performed with a centrif ugal pump (CP). In the rest of the cases extracorporeal circulation (ECC) was established with conventional roller pump (RP). The operations performed with a CP were: 34 reoperations, 11 ascending aortic aneurysms + coronary artery bypass graft (CABG), 47 multivalve replacements, 125 CABG + left ventricu lar aneurysmectomies, and 153 CABGs alone. This prospective study consisted of two groups, each group including 50 patients undergoing CABG surgery. In group I ECC was established with a CP and in group II with a conventional RR The two selected groups of patients were considered to be similar in terms of clinical, hemodynamic, and angio graphic data. Hemodynamic study concerned flow rate, systemic vascular re sistance (SVR), and urinary output. No difference was found between the CP and RP hemodynamically. Nevertheless, the alteration of the flow rate in re sponse to variation of SVR is accepted as an advantage. As for hemolytic effect during ECC of CP compared with RP: Plasma free hemoglobin, hemotocrit, platelet count, platelet factor 4, and fibrinogen levels, were investigated. These parameters revealed that there was significant hemoly sis and trauma to the blood components in the RP group when compared with the CR (p < 0.05, p < 0.01). There was no significant difference in psychoneurologic complications, but behavioral and sensory disorders were encountered sevenfold more in the RP group. This might be due to spoliation of the tubing set or to microair embo lism. Compared with the conventional RP the CP proved to have no hemodynamic advantage. The effects on blood components showed significant trauma to the RP group. Postoperative drainage verified this observation (p < 0.05). In this study the CP appears to be superior to the RP especially in compli cated and prolonged ECC.

Background Long-term results of aortic root replacements and the factors affecting long-term mortality were analyzed. Methods We operated on 254 patients from June 1993 to November 2008 for aortic root replacement with Bentall de Bono procedure. Two hundred five patients were male (80.7%) and 49 patients (19.3%) were female. The mean age was 48.3 ± 14.7 years (range, 14 to 78 years). We performed 72 concomitant procedures in 69 patients, and the most commonly performed procedure was coronary artery bypass grafting in 37 patients (14.6%). The most common indication for aortic root replacement was aneurysm in 235 patients (92.5%). Thirty-four patients (13.4%) had Marfan syndrome. Hypothermic circulatory arrest was used in 52 patients (20.5%). After removing the clamp, we had to reclamp the aorta in 26 patients (10.2%) undergoing operation. Results Postoperatively 30 patients (11.8%) had in-hospital mortality. The late mortality was 2.8% (7 patients). The most common reason for hospital mortality was low cardiac output (18 in 30 patients; 51.4%). Neurologic complications were seen in 16 patients (6.3%). The mean duration of hospital stay was 16.6 ± 11.3 days (range, 5 to 77 days). Postoperative follow-up was 6.3 ± 4.5 years (range, 0 to 15.5 years) on average. Late mortality was significantly affected by Marfan syndrome ( p = 0.025) and reclamping the aorta ( p = 0.036). Actuarial survival for the overall 254 patients is 88.4% ± 2.1%, 87.4% ± 2.2%, and 84.5% ± 2.56% at 1, 3, and 10 years, respectively. Conclusions The late-term results of aortic root replacement with the modified Bentall de Bono procedure are satisfactory. Survival is decreased in patients with Marfan syndrome and in the patients who had reclamping intraoperatively.

In a four-year period, 720 open cardiac valvular surgical procedures were performed in Kosuyolu Heart and Research Center. In 120 of these 720 cardiac valvular operations, mitral valve reconstruction was performed alone or with other cardiac procedures. The youngest patient was twelve years old and the ol dest was eighty-eight with an average age of thirty-eight. All of the patients but 2—1 with congenital mitral valve lesion and the other with ischemic mitral valve lesion—had rheumatic mitral valve lesions; 80% of the patients were in the third and fourth functional class according to NYHA classification, and nearly 60% of the patients had some other cardiac lesions in addition to the mitral valve lesion. In 60 of the patients some other cardiac surgical procedures were per formed in addition to mitral valve reconstruction. The dominant lesions of the mitral valve were as follows: stenosis, 45%, insufficiently, 15%; and combined lesions, 40%. The authors used 12 different reconstruction techniques alone or in combi nation with each other in all of the patients. Among these techniques, they used mostly Carpentier's ring implantation. In-hospital mortality was 6%. One pa tient died in the late postoperative period. Three patients had reoperations be cause of unsuccessful reconstruction. Nonfatal thromboembolism occurred in 1 patient. All living patients were reevaluated periodically in the postoperative period. In all these patients mitral valve functions were studied clinically, echocardiographically, and/or hemodynamically. In 80% of the living patients, the reconstruction was successful and in 20% it was partially successful; 95% of the living patients improved their functional class to I or II. In conclusion, mitral valve reconstruction is a good alternative to replacement in selected pa tients in an experienced center.

Some surgeons prefer pulsatile to nonpulsatile flow in extracorporeal circu lation. They believe that pulsatile flow is more physiologic, provides better tis sue perfusion, gives less damage to the blood elements and plasma proteins and causes less complement activation when compared with nonpulsatile perfusion. In order to compare the pulsatile with nonpulsatile flow during extracorporeal circulation, the authors studied two different groups of patients, each consist ing of 20 coronary bypass candidates. The patients in the two groups had almost the same properties and were operated on under the same circumstances. In the first group extracorporeal circulation was established with a nonpulsatile roller pump. In the other group a pulsatile assist device was integrated into the arterial line of the extracorporeal circuit with the roller pump. Extracorporeal circula tion was maintained with pulsatile flow obtained by an intraaortic balloon pump pneumatic console. The patients in the two groups were selected to be similar in terms of sex, age, preoperative clinical characteristics and hemodynamic and angiographic findings. Thirty-two operative and early and late postoperative parameters were compared in these two groups. In conclusion, no superiority of pulsatile flow established with the pulsatile assist device over nonpulsatile flow during extracorporeal circulation was seen.

Two hundred diabetic coronary artery heart disease patients were operated during a fifty-four-month period. The total number of coronary artery bypass grafting (CABG) operations performed in this period was 1300. Emergency CABG operations were excluded from this study. The diabetic patient population was subclassified as having latent diabetes, diabetes regulated with diet or oral antidiabetic agents, and insulin-dependent diabetes mellitus (IDDM). Congestive heart failure and left ventricular hypertrophy seen in the diabetic population was a significant clinical feature as compared with the nondiabetic patients. An giographically the distribution of localized coronary artery lesions was similar, but a diffuse atherosclerotic vessel disease pattern was prominent in the diabetic group. Segmental wall motion in diabetic patients revealed severe ventricular dysfunction as compared with the nondiabetic group. Hospital mortality was 6.8% to 8.5 % in favor of the nondiabetic group. Low cardiac output, renal complications, mediastinitis, and wound infections were encountered more fre quently in the diabetic patients. The distal coronary artery anastomosis rates in nondiabetic and diabetic patients were 2.8 and 3.1 respectively. The high rate of vascular and metabolic complications seen in this systemic disease has led the authors to accept diabetes mellitus as a risk factor in CABG surgery.

Background: Whereas the complete myocardial revascularization is necessary in high risk group patients, the CABG procedure on the beating heart on circumflex artery still presents a dilemma. Methods: Between January 1994 and September 1996, we performed complete myocardial revascularization with left heart bypass in 62 patients (54 male, 8 female, mean age: 57) who had absolute or relative contrindications for CPB. Results: The hospital mortality was 3.2%, late mortality was 1.6%. Peroperative MI was seen in 2 patients (3.2%). The mean number of distal anastomosis was 3.6 (ranged 2-6). Conclusion: Complete myocardial revascularization on the beating heart can be performed by using left heart bypass (LHBP) without using an oxygenerator safely in high risk patients.

WOS: 000221459600009, PubMed ID: 15174223, We investigated the effects of pressure, temperature and additives on aortic root reperfusion success. Cardiopulmonary bypass and heart arrest were initiated in mongrel dogs and sudden uncontrolled normothermic (group 1), pressure controlled substrate enriched normothermic (group 2a), pressure controlled unmodified normothermic (group 2b) and pressure controlled unmodified tepid (group 3) reperfusion compared. In group 1, the first cardiac rhythm was ventricular fibrillation, but dogs in the other groups showed spontaneous sinus rhythm. Recovery times were significantly longer and cardiac output levels significantly decreased in group 1 compared with the other groups. Prolonged lactate production and oxygen uptake failure were observed in group 1 compared with the other groups; oxidative stress markers and microscopic studies confirmed significant tissue injury in group 1. All parameters were similar between groups 2a, 2b and 3, indicating that low reperfusion pressure in the first 2 min is the most effective component of reperfusion.

The encouraging results of valve repair in the atrioventricular valves have influenced a decision about aortic valve (AV) reconstruction. We report our experience with pericardial cusp extension to repair rheumatic AV disease.From 1993 to 1998, 46 patients (25 women, 21 men) with a mean age of 31.5 +/- 12.2 years (range, 15 to 58 years) underwent AV repair. Twenty-two (47.8%) patients had moderate and 24 (52.2%) had severe aortic insufficiency (AI). Severe cusp retraction was repaired with glutaraldehyde-treated autologous pericardium. Twenty-one patients had more than one maneuver (mean, 1.8) to attain competence besides augmentation, which consisted of the release of stenotic commissures (in 11 cases), thinning of the AV cusps (in 10 cases), and resuspension of the cusps (in 17 cases). Simultaneous mitral valve repair was performed on 17 patients. Eight patients received triple valve reconstruction.There was no early mortality. Thirty patients no longer had AI with any significant transvalvular gradients. Five patients were followed with mild residual AI, and 2 patients with moderate AI not requiring reoperation. Nine patients developing severe AI required AV replacement with a reoperation rate 19.6% (4.26%/patient-year). The mean interval between repair and reoperation was 28.2 +/- 18.3 months (range, 3 to 58 months). The mean observation time was 4.6 +/- 3 years (211.6 patient-years). Late mortality rate was 2.2% with 1 patient. The significant negative predictors of aortic reoperation determined by univariate analysis were preoperative New York Heart Association class (p = 0.002) and postoperative severe AI (p0.001). Cox hazard studies identified that all risk factors were insignificant for aortic reoperation. The actuarial rate of freedom from aortic reoperation was 76.1% +/- 7% at 7.5 years.Although AV repair by extension with pericardium is worth considering with an acceptable solution to achieve a good geometry from unequal cusps, especially in young rheumatic patients for preservation of the native AV, the patients should be followed periodically for reoperation risk.

WOS: 000179670500008, PubMed ID: 12489907, …

WOS: 000333172400001, PubMed ID: 24631983, Objective: Cardiopulmonary bypass deteriorates pulmonary functions to a certain extent. Patients with chronic obstructive pulmonary disease (COPD) are associated with increased mortality and morbidity risks in the postoperative period of open-heart surgery. In this study we compared 2 different mechanical ventilation modes, pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV), in this particular patient population. Patients and Methods: Forty patients with severe COPD were assigned to 1 of 2 groups and enrolled to receive PCV or VCV in the postoperative period. Arterial blood gases, respiratory parameters, and intensive care unit and hospital stays were compared between the 2 groups. Results: Maximum airway pressure was higher in the VCV group. Pulmonary compliance was lower in the VCV group and minute ventilation was significantly lower in the group ventilated with PCV mode. The respiratory index was increased in the PCV group compared with the VCV group and with preoperative findings. Duration of mechanical ventilation was significantly shorter with PCV; however, intensive care unit and hospital stays did not differ. Conclusion: There is not a single widely accepted and established mode of ventilation for patients with COPD undergoing open-heart surgery. Our modest experience indicated promising results with PCV mode; however, further studies are warranted.

Background . Bioprosthetic valve use represents a crucial improvement in surgical treatment of mitral valve disease. The aim of this study is to determine the long-term durability of the Biocor porcine bioprosthetic mitral valve. Methods . Between 1985 and 1989, a total of 158 Biocor porcine bioprosthetic valves were placed in the mitral position, and long-term results of these patients were investigated retrospectively in 1999. Results . Thirty-day mortality was 4.4% (7 patients). Total follow-up was 1,499 patient-years. Actuarial survival was 83.66% ± 3% at 5 years, 77.78% ± 3.36% at 13 years (1.8% patient-year). Multivariate analysis demonstrated younger age, duration of implantation, congestive heart failure, and functional class to be significant predictors of late mortality. Actuarial freedom from valve-related mortality was 98.58% ± 1% at 15 years (0.13% patient-year). Actuarial freedom from structural valve deterioration was 95.49% ± 1.8% at 5 years, 70.2% ± 4.12% at 10 years, and 64.82% ± 5.34% at 13 years (2.6% patient-year). Actuarial freedom from structural valve deterioration-related reoperation was 98.43% ± 1.1% at 5 years, 89.15% ± 2.85% at 10 years, and 76.82% ± 7.91% at 14 years. Multivariate analysis showed younger age and duration of implantation to be significant predictors of structural valve deterioration and its related reoperation. Conclusions . By studying a 15-year time period, it is seen that this new generation porcine bioprosthetic valve should be considered an alternative for mechanical valves in selected patients.

Coronary bypass surgery that provides good long-term graft patency can be performed on the beating heart as a viable alternative to conventional coronary artery bypass grafting (CABG).From September 1993 to December 1996, 696 patients underwent CABG on the beating heart at the Koşuyolu Heart and Research Hospital in Istanbul. Among them, 70 patients were chosen randomly for angiographic assessment of off-pump coronary artery bypass grafting.The interval from operation to angiography varied from 24 to 61 months (mean, 36.1+/-10.9 months). The patency rate of left internal mammary-left anterior descending artery anastomoses was 95.59% (patency achieved in 65 of 68 patients) and of vein grafts was 47.06% (patency achieved in 16 of 34 patients) (p0.0001). The patency rates of grafts anastomosed to the left anterior descending artery were significantly higher than the rates of the grafts anastomosed to the other coronary arteries (95.71% versus 45.45%, p0.0001). Multivariate analysis showed that graft type (p0.0001) and hyperlipidemia (p = 0.023) were significant predictors for graft occlusion. Left ventricular function improved significantly after CABG (p = 0.04). Reintervention (using percutaneous transluminal cardiac angioplasty) and reoperation rates were 0.97% and 1.4%, respectively.Off-pump coronary artery bypass grafting appears to produce midterm and long-term patency rates that are comparable to those of conventional techniques; that is especially true in cases of arterial conduits and of conduits anastomosed to the left anterior descending artery.

Behcet's syndrome is a multisystem disorder presenting with recurrent oral and genital ulcerations as well as uveitis often leading to blindness. Although vascular lesions are a common complication of this disease, cardiac involvement is extremely rare. In this unusual case a young man had symptoms primarily related to recurrent right-atrial and right-ventricular thrombi unresponsive to medical treatment. The intracardiac lesion was successfully treated by surgical excision with the use of cardiopulmonary bypass. Surgical treatment should be considered in Behcet's disease complicated by cardiac thrombi, when a thrombus recurs despite medical treatment.

The occurrence of several cases of atrial septal defect in the same family is rare. A family in which the father and his two daughters presented with atrial septal defect associated with atrioventricular conduction abnormalities is described.

We read with great interest the manuscript by Antunes MJ in which the author presented an open-anastomosis technique for proximal vein-graft anastomoses in case of sclerotic ascending aorta [1]. We present our comments on the paper from a few technical aspects. A similar technique has already been published by our group in 2006 [2]. We routinely prefer fibrillation without intermittent cross-clamping in the presence of calcification at the ascending aorta. Cardiopulmonary bypass is instituted by cannulation of right atrium and aortic arch, axillary artery, femoral artery or disease-free segment of ascending aorta depending on the extent of the atherosclerotic aortic disease [2]. We always institute a vent to prevent myocardial distension and permit unloading. A left ventricular vent through the right superior pulmonary vein, a pulmonary arterial vent or, sometimes, both may be inserted. A pulmonary arterial vent is safer and does not require special care of the perfusionist against air embolism when compared with a left ventricular vent [3]. We start with the distal anastomoses to the easily accessible coronary arteries as the cooling is started. At 29—30 8C, the heart usually fibrillates spontaneously; however, the patient is cooled down to 28 8C. The mean arterial pressure is kept 65 mm Hg until all the distal anastomoses are completed [2,3]. Additionally, following each distal anastomosis, heart is defibrillated, by which, we believe the conduction tissue replenishes the energy stores. Moreover, this measure is helpful to prevent bundle or branch blocks whichmay occur in the postoperative period [3]. Necessarily, consecutive anastomoses are performed with consequent fibrillation and defibrillation periods [2,3]. Before anastomosing the internal thoracic artery to the left anterior descending artery, we perform the proximal anastomoses. Proximal anastomoses are performed to the clean segments of the ascending aorta [1—3] if available on low flow with mean arterial pressure of 20—25 mm Hg, otherwise to the innominate or the internal thoracic artery [2,3]. We place ice bags around the head of the patient and the table is tilted to place the patient in the Trendelenburg position during low flow. Each proximal anastomosis lasts 3 min and, between each proximal anastomosis, flow is increased to normal. The bypass of the internal thoracic artery to left anterior descending artery is fashioned during re-warming to attenuate the hypothermic period. At the end of the bypass procedure, the heart is defibrillated if necessary [2,3]. Single or multiple clamping of the aorta during conventional cross-clamp cardioplegia and intermittent cross-clamp fibrillation techniques carries high risk of embolisation of the atheromatous material in the presence of a calcified ascending aorta [1—3]. The aorta non-clamp technique is a safer alternative in this particular group of patients. It may be performed on a fibrillating or decompressed beating heart [1]. However, we believe the institution of a vent is important for better myocardial protection.