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Background: In this study, we aimed to investigate the autonomic dysfunction in patients with primary Raynaud’s phenomenon with using sympathetic skin response (SSR) as a neurophysiologic test, R-R interval variation analysis and composite autonomic symptom score (COMPASS)-31 questionnaire. Methods: Palmar SSR to median nerve electrical stimulation was recorded in 38 patients with 36 healthy age and sex-matched control subjects. The SSR was recorded from the palmar surface of both left and right hands for patients and control groups. The amplitudes and latencies formed as a result of electrical stimulation were calculated and compared between the two groups. Additionally, R-R interval variability was examined during normal breathing, deep breathing, standing up and Valsalva maneuver in both groups. Furthermore, we asked to complete the COMPASS-31 questionnaire, a validated tool to assess symptoms of autonomic dysfunction. And by calculating total COMPASS-31 scores, the relationship between the two groups was investigated. Results: The Raynaud’s phenomenon and control groups were similar in age (37.4 ± 11.6 vs. 34.9 ± 13.0 years), had identical gender ratios and similar body mass index (24.5 ± 6.1 vs. 25.7 ± 4.6%). Palmar SSR to median nerve stimulation of RP patients shows significantly delayed latency (1890 ± 146) (p=0.03). And no difference between amplitudes in comparison to the control group. In the patient and control groups, R-R interval measurements were evaluated during rest and deep breathing, standing up and Valsalva maneuver. When the R-R interval measurements of the patient and control groups at rest and deep breathing were compared, there was no statistically significant difference between the groups. In addition, COMPASS-31 questionnaire scoring system was applied to both groups. The mean COMPASS-31 score was higher in patient group (22.8 ± 13.8), than from healthy controls (8.9 ± 7.8) (p=0.02) Conclusions: Autonomic dysfunction plays a role in the etiology of Raynaud’s phenomenon, due to latency prolongation in the sympathetic skin response and significant difference between COMPASS-31 tests, and these tests can be used in the diagnosis stage of this disease.

The aim of the study is to show the effects of cytoimmunological monitoring and its role in the patient’s follow-up period after heart transplantation. Material and methods: Between 2002 and 2009, 8 patients underwent heart transplantation at Gulhane Military Medical Academy Hospital. Seven patients were male. The average age was 43 ± 12 years. Donor hearts were implanted orthotopically in all patients. The patients were then subjected to cytoimmunological monitoring and endomyocardial biopsy. 431 laboratory blood tests were carried out for all patients to analyze their cytoimmunological profiles and diagnose a possible infection or rejection. Results: The total and average follow-up periods were 17.5 patient years and 30 ± 36 months (1-120 months), respectively. The first patient had two rejection episodes in 3 months. A viral infection was diagnosed in the third patient, who had painful muscle spasms in both lower limbs and the CD4/CD8 ratio was below 0.4. In the fourth patient, the CD4/CD8 ratio suddenly increased and a urinary infection was diagnosed. Only one patient passed away in the early period (less than 30 days). Four patients died because of an infection or hemodynamic deterioration within three months. Conclusions: Cytoimmunological monitoring is a simple and effective technique of evaluating the patient’s immunological profile. It may provide an adjunctive laboratory test and may decrease the number of endomyocardial biopsies.

The aim of the study was to show the efficacy and results of aneurysm reconstruction that was developed for relieving the patients from pain and mass effects and to give an early hemodialysis option.Medical records were retrospectively screened over a period of 17 years to identify patients diagnosed with and surgically treated for aneurysm of an AV fistula. Twenty-eight patients were included in this study. The mean average age was 44 ± 3 years (31-60). Seventeen (60.7%) patients were female. Twenty-two (78.5%) patients had hypertension and 9 (32.1%) patients had diabetes mellitus. Aneurysm was examined by using ultrasonography to reveal the flow dynamics. The aneurysm was resected and an appropriate sized graft was interposed under local anesthesia. The same vein was dissected and anastomosed over the graft in an end-to-side fashion.Mean aneurysm diameter was 40 ± 12 mm. All aneurysm tissues and thrombotic materials were removed from the surgical field. Mean graft length was 37 ± 11 mm. Three (10.7%) patients need surgical revision because of postoperative bleeding. Dermal necrosis occurred in 1 (3.5%) patient. Infection was noted in 1 (3.5%) patient. Vascular access was started from the reconstructed venous area 2 or 4 days later in all patients. The patency rate was 100% in three years.Surgical reconstruction of the arteriovenous fistula aneurysm can be safely performed in hemodialysis patients with low complication rates. It gives early vascular access with high patency rates. All patients are relieved from pain and distended mass effect.Celem pracy było wykazanie skuteczności i efektów rekonstrukcji tętniaka przetoki tętniczo-żylnej przeprowadzonej celem wyeliminowania bólu, ograniczenia efektów masowych i umożliwienia wczesnej hemodializy.Przeanalizowano dokumentację medyczną obejmującą 17 lat, aby zidentyfikować pacjentów operowanych z powodu tętniaka przetoki tętniczo-żylnej. Do badania zakwalifikowano 28 pacjentów, w tym 17 kobiet (60,7%). Średnia wieku wynosiła 44 ± 3 lata (31–60 lat). Dwudziestu dwóch pacjentów (78,5%) miało nadciśnienie tętnicze, a 9 pacjentów (32,1%) cukrzycę. Tętniaki badano z wykorzystaniem ultrasonografii, aby ocenić dynamikę przepływu. Następnie tętniaki usunięto i w znieczuleniu miejscowym wstawiono odpowiednio dobrane przeszczepy. Tę samą żyłę ponad wszczepem poddano dysekcji i zespoleniu w sposób koniec do boku.Przeciętna średnica tętniaka wynosiła 40 ± 12 mm. Wszystkie tkanki tętniaka i materiały zakrzepowe usunięto z pola operacyjnego. Średnia długość przeszczepu wynosiła 37 ± 11 mm. Trzech pacjentów (10,7%) wymagało ponownej interwencji chirurgicznej z powodu krwawienia pooperacyjnego. Martwica skóry wystąpiła u 1 pacjenta (3,5%). Infekcję stwierdzono u 1 pacjenta (3,5%). U wszystkich badanych 2–4 dni później rozpoczęto dostęp naczyniowy ze zrekonstruowanego obszaru żylnego. Współczynnik drożności w ciągu 3 lat wynosił 100%.Chirurgiczną rekonstrukcję tętniaka przetoki tętniczo-żylnej można wykonywać u pacjentów poddanych hemodializie w sposób bezpieczny, przy niskim ryzyku powikłań. Umożliwia ona wczesny dostęp naczyniowy o wysokim współczynniku drożności. U wszystkich pacjentów wyeliminowano ból i powiększające się efekty masowe.

Background : Chronic obstructive pulmonary disease (COPD) has customarily been associated with increased surgical morbidity and mortality rates after coronary artery bypass graft surgery (CABG). The aim of this study was to determine whether there is a relationship between epistaxis and COPD after CABG surgery. Methods : There were 3 443 patients who consecutively underwent isolated CABG from January 2002 to March 2012. We retrospectively analysed the data of 27 patients (0.8%) with newly developed and serious spontaneous epistaxis, which required consultation with the Ear Nose and Throat (ENT) Department. The patients were divided into three groups according to severity of nasal bleeding. Twenty-one (77.7%) patients in the three groups had COPD. Results : There were 19 males (70%) and eight females (30%). Their ages ranged between 52 and 72 years (mean 61 ± 5). Fifty-five per cent of the patients had hypertension and 78% had COPD. The overall duration of hospital stay was six to 11 days (mean 7.9 ± 1.1). Epistaxis was seen particularly on the fourth and seventh days postoperatively and 17 patients (63%) were treated with anterior, posterior, or anterior and posterior nasal packing (group 1). Nasal bleeding was controlled with electrocautery in six patients (22%) (group 2), and four (15%) were treated with surgical excision and blood transfusions (group 3). All patients (100%) had a good recovery with no mortality. Conclusion : The high coincidence between epistaxis and COPD made us wonder whether COPD may be a risk factor for epistaxis after CABG surgery. However, we could not find any direct causative link between COPD and epistaxis in patients who had undergone CABG. Epistaxis was more common in patients with COPD and it was more serious clinically in patients who had both COPD and hypertension.

Objective Total correction of classical tetralogy of Fallot (TOF) by transatrial approach has become a standard procedure in the goal to minimize structural damage to the pulmonary pump. The most critical point in transatrial repair of TOF is infundibular dissection. Right atrial approach provides better surgical exposure for parietal extension of the infundibular septum when compared to the right ventricular approach. However it is not always easy to determine the localization and amount of muscle bundles to be resected and this surgical maneuver requires experience. Methods Nineteen patients who had repair of isolated TOF using this technique from 1993 to 2001 were reviewed. The mean age of patients were 5 +/- 2 years. Transatrial-transpulmonary approach were performed for all patients. To make easier the infundibular muscle bundles resection and to determine the localization and amount of muscle bundle to be resected, we placed a Hegar dilator into the right ventricle through pulmonary arteriotomy. The muscle bundles between the dilator and the anterior leaflet annulus of the tricuspid valve were totally excised until the intraventricular part of the dilator and pulmonary annulus became completely visible. The area between the Hegar dilator and the margins of the ventricular septal defect (VSD) was left untouched. None of the patients had transannular patch. To improve exposure, tricuspid valve detachment was performed in 11 patients. All patients were followed-up in our clinic every 6 months using echocardiography. Results There were no early or late deaths, and no reoperation for residual VSD or residual right ventricle (RV) outflow obstruction. All patients were in NYHA Class I. RV on the echocardiography was spared late dilatation and had a good late functional status. Eighteen patients had no or mild pulmonary regurgitation. One patient who had undergone tricuspid anterior leaflet detachment showed mild tricuspid insufficiency. Conclusion On the basis of hemodynamic outcomes, this procedure for elective repair of TOF in selected cases shows excellent early and mid-term results.

It has not clearly been defined in the literature which side of the pedicled LIMA graft should be anastomosed to the posterior coronary arteries. Using the ventral side of pedicled LIMA graft causes an 180 degree torsion of the pedicle. Sometimes this torsion may cause reduction or cessation of LIMA flow as we have seen in two of our patients. In this paper we point out that using the dorsal side of the pedicled LIMA graft for anastomosis to the posterior coronary arteries is helpful.

Although all beta blockers appear to be effective in the prevention of postoperative atrial fibrillation (AF) following coronary artery bypass surgery (CABG), carvedilol was found to be much more effective than metoprolol in this respect as the current study clearly delineated. We believe that the ongoing COMPACT trial will answer the question of whether or not carvedilol is more superior than metoprolol to prevent postoperative AF in patients undergoing CABG.

Pediatric supracondylar fractures of the humerus are generally associated with neurovascular complications due to the deformity and sharp nature of bone fragments. When treated inadequately, these injuries may result in catastrophic complications, such as Volkmann's contracture and amputation. To our knowledge, late onset brachial arterial thrombosis and total temporary peripheral neuropathy after surgery of pediatric supracondylar fracture in the setting of normal preoperative vascular examination has not been reported yet. In this study, a 2-year and 6- month-old girl, who had delayed brachial arterial thrombosis after a displaced humerus supracondylar fracture surgery treated with embolectomy, was reported. Total lesion of median, ulnar and radial nerves completely resolved four months after surgery. Close neurovascular monitoring on the postoperative phase especially in severely displaced supracondylar fractures is strongly emphasized even in the setting of well-perfused hand.

Angiotensin-converting enzyme inhibitors, calcium channel blockers, and preoperative intravenous heparin use are independent risk factors for vasoplegic syndrome after cardiac surgery. We prospectively studied whether preoperative methylene blue administration would prevent the vasoplegic syndrome in these high-risk patients.One hundred patients scheduled for coronary artery bypass graft surgery who were at high risk for vasoplegia because they were preoperatively using angiotensin-converting enzyme inhibitors, calcium channel blockers, and heparin were randomly assigned to either receive preoperative methylene blue (group 1, n = 50) or not receive it (group 2, controls, n = 50). Methylene blue (1% solution) was administered intravenously at a dose of 2 mg/kg for more than 30 minutes, beginning in the intensive care unit 1 hour before surgery.Although similar in terms of all demographic and operative variables, the two groups differed significantly in terms of vasoplegic syndrome incidence (0% in group 1[0 of 50] vs 26% in group 2 [13 of 50]; p0.001). In 6 patients, the vasoplegic syndrome was refractory to norepinephrine. Four of these patients survived; the other 2 had vasoplegic syndromes that were refractory to aggressive vasopressor therapy, and they ultimately died of multiorgan failure. Stroke occurred in 1 patient. The two study groups also differed significantly in terms of average intensive care unit stay (1.2 +/- 0.5 days in group 1 vs 2.1 +/- 1.2 days in group 2; p0.001) and average hospital stay (6.1 +/- 1.7 days in group 1 vs 8.4 +/- 2.0 days in group 2; p0.001).Our results suggest that preoperative methylene blue administration reduces the incidence and severity of vasoplegic syndrome in high-risk patients, thus ensuring adequate systemic vascular resistance in both operative and postoperative periods and shortening both intensive care unit and hospital stays.

Aim: To delineate whether coronary arteriovenous malformations have different properties than classical discrete coronary artery fistulae. Methods: Group 1 included 17 patients with discrete coronary fistula that represents a coronary artery fistula draining into any cardiac chamber. Group 2 included six patients with coronary arteriovenous malformations representing extensive coronary artery malformation. Cardiopulmonary bypass was used in 12 of the Group 1 patients and 5 in Group 2. Results: There was no operative mortality in either group. Following a hemodynamically nonsignificant residual fistulous communication, which was detected by repeat coronary angiography in Group 2; we changed our surgical technique of suture ligation on beating heart. Then we preferred pulmonary arteriotomy and sutured the orifice of coronary arteriovenous malformations from within the chamber. Conclusions: Coronary arteriovenous malformations have different morphology and also complex progression properties when compared with discrete coronary artery fistulae. Surgical repair of coronary arteriovenous malformation should be done by suturing the multiple drainage holes inside the draining chamber. Suture ligation of coronary arteriovenous malformation is difficult due to the fragile vessel.

We report our experience of surgical treatment of coronary artery fistula and focus on the electrocardiographic changes that may be seen postoperatively. Between 1988 and 2003, cardiac operations were carried out on 9,487 patients, of whom 21 had a coronary artery fistula. The mean age of these 21 patients was 36.8 ± 4.9 years. The fistula originated from the right coronary artery in 9 cases and from the left side in 12. The fistulous connection was to the right ventricle in 5 patients, to the right atrium in 6, to the pulmonary artery in 8, and to the coronary sinus in 2. There was no operative mortality. Two patients (10%) had nonspecific electrocardiographic changes during the postoperative period. Repeat coronary angiography revealed normal coronary anatomy in both, and their electrocardiograms normalized within 2 months. Patients suspected to have myocardial ischemia related to the surgical procedure, with ST segment depression or T wave abnormalities on the electrocardiogram, should undergo repeat angiography to eliminate the possibility of coronary artery damage.

Nonspecific constitutional symptoms are reported mostly in patients with left-atrial myxomas, which occur five times as often as its right-atrial counterpart. We present huge right-atrial myxoma, which obstructs tricuspid orifice with nonspecific constitutional symptoms without any pulmonary embolism attack. (J Card Surg 2003;18:550-553)

We present here the fourth patient in the literature, over the age of 50 years old, with an abnormal right coronary artery arising from the pulmonary artery, who was successfully treated with surgery. Pre-operative computerised tomography (CT) angiography revealed an abnormal right coronary artery arising from the pulmonary artery. The right coronary artery was surgically transposed from the pulmonary artery to the ascending aorta with the aid of cardiopulmonary bypass. The patient had an uneventful postoperative course and the corrected anatomy was documented by postoperative CT angiography.

We performed an extended extra-anatomic bypass to salvage the both lower extremities in a diabetic and obes woman who had critical ischemia in her both lower extremities. Patient also had several abdominal operations. The patient did not have a good arterial vasculature as inflow or outflow conduit in the right femoral region and she also had femoro-popliteal bypass which was occluded on the left lower limb. Firstly, trombectomy was performed to the occluded graft. Secondly, left axillofemoral, thirdly, left to right cross-over, finally, femoro-popliteal bypasses were performed to make an axillobipopliteal bypass functionally. The case will be evaluated under the literature knowledge.

Aim: The aim of this study was to evaluate the early and mid-term results of total arterial myocardial revascularization in elderly patients. Material and Method: 65 patients aged 60 years and older (mean 64.8+5.4, range 60-78 years) who underwent total arterial myocardial revascularization between January 2002 and June 2004 were evaluated prospectively. 41 patients (63.1%) had three-vessel coronary artery disease, 18(27.7%) had two-vessel disease and 6(9.2%) with left main lesion. 22 patients had an old myocardial infarction and 11 unstabile angina pectoris. Mean EF was 55%. All patients underwent TAMR. In total 167 distal anastomoses were constructed (2.6 per patient) Pedicled LITA and RITA, free RITA and Radial arter were used as single or composite T-or Y- graft. Results: Patient were followed-up in a mean period of 17.6+7.3 months (range 1-28 month). There was no ocluded grafts in the early postoperative period (less than 90 days) patency 100%. Late(mean 16+2 month) LITA patency was 98.1% (one graft ocluded), RITA patency was 93.4% (one graft ocluded) and RA patency was 93.2% (three grafts ocluded).One patient died in this period (1.5%) one underwent PTCA (1.5%) two suffered angina pectoris (3.1%), there was no reoperation in this period. Conclusion: This study showed that using only arterial conduits in coronary bypass surgery in elderly (patient aged over 60 years) were clearly evident with respect to higher patency rate, surgical reintervention and freedom from cardiac events., Aim: The aim of this study was to evaluate the early and mid-termresults of total arterial myocardial revascularization in elderlypatients.Material and Method: 65 patients aged 60 years and older (mean64.8+5.4, range 60-78 years) who underwent total arterial myocardial revascularization between January 2002 and June 2004 wereevaluated prospectively. 41 patients (63.1%) had three-vessel coronary artery disease, 18(27.7%) had two-vessel disease and 6(9.2%)with left main lesion. 22 patients had an old myocardial infarctionand 11 unstabile angina pectoris. Mean EF was 55%. All patientsunderwent TAMR. In total 167 distal anastomoses were constructed(2.6 per patient) Pedicled LITA and RITA, free RITA and Radialarter were used as single or composite T-or Y- graft.Results: Patient were followed-up in a mean period of 17.6+7.3months (range 1-28 month). There was no ocluded grafts in theearly postoperative period (less than 90 days) patency 100%.Late(mean 16+2 month) LITA patency was 98.1% (one graft ocluded), RITA patency was 93.4% (one graft ocluded) and RA patencywas 93.2% (three grafts ocluded).One patient died in this period(1.5%) one underwent PTCA (1.5%) two suffered angina pectoris(3.1%), there was no reoperation in this period.Conclusion: This study showed that using only arterial conduits incoronary bypass surgery in elderly (patient aged over 60 years) wereclearly evident with respect to higher patency rate, surgical reintervention and freedom from cardiac events.

We prospectively investigated the patency of venous repair in a quantitative fashion with measurement of vein blood flow velocities after lower extremity injuries caused by either military or civilian trauma.During a 10-year study period (March 1990 to December 2000), surgical intervention was performed after lower extremity vascular injuries in 130 patients. Most of these patients were men (n = 125), with a mean age of 23 +/- 5 years (range, 17 to 44 years). One hundred ten direct venous injuries were identified in 97 patients, involving the common femoral vein in seven, the deep femoral vein in three, the superficial femoral vein in nine, the popliteal vein in 46, and the posterior tibial (n = 21), anterior tibial (n = 17), or peroneal veins (n = 7) in 45. Popliteal vein thrombosis without apparent venous injury was found in seven patients. Bone fractures (n = 45), nerve injuries (n = 27), or extensive tissue loss (n = 7) often were associated with vascular injuries. Duplex color ultrasonography was used to evaluate patency and to measure blood flow velocity in repaired veins during the early postoperative period and at the time of late follow-up examinations.Significant differences were seen in venous blood flow velocities between severe (extremity diameter more than twice normal) and moderate (diameter 1.5 to 2 times normal) reperfusion injuries. The mean flow velocity in repaired popliteal veins was 15 +/- 2 cm/s with severe reperfusion injuries compared with 8.4 +/- 1.1 cm/s with moderate reperfusion injuries (P.0001). Flow velocities were lower than 5 cm/s in repaired infrapopliteal veins, and most of these veins occluded on the first postoperative day. Amputations were necessary in 11 patients, all of whom had both tibial fractures and extensive tissue loss. Sodium warfarin therapy was routinely administrated before hospital discharge. The mean follow-up period was 6.2 years (range, 1.3 to 10 years). Repaired common femoral and superficial femoral veins had relatively high patency rates (100% and 89% at 1 year, 100% and 78% at 6 years, respectively), whereas the patency rates for repaired popliteal veins were disappointing (86% at 1 year, 60% at 6 years). All seven popliteal veins that required thrombectomy in the absence of direct injuries remained patent, however. Patch angioplasty had the highest 6-year patency rate (75%) in comparison with all other techniques that were used for venous injuries (lateral repair, 58%; end-to-end anastomosis, 43%; saphenous vein graft interposition, 36%).Venous repair has a high patency rate at the femoral and popliteal levels, but the patency rate for infrapopliteal venous repair is extremely poor because of low flow velocities. Therefore, we conclude that repair of infrapopliteal venous injuries is unnecessary.

Background: We aimed to highlight the use of a minimally invasive approach in uncomplicated congenital heart surgery. Patients and methods: We investigated retrospectively 32 children below 10 years of age who underwent elective closure of ostium secundum type ( n = 27), sinus venosus type ( n = 4) and ostium primum type ( n = 1) atrial septal defects through a limited skin incision and partial lower sternotomy between August 2001 and December 2008. All patients had cannulation through the same incision for cardiopulmonary bypass. Results: A pericardial patch was used to close the defect in 8 patients and direct suturing in 24. The mean time from the skin incision to cannulation was 56 ± 23 min. Total bypass time was 27 ± 12 min, and crossclamp time was 15 ± 8 min. Mean length of hospital stay was 4 ± 2 days. We did not encounter any complications or mortality. Conclusions: A minimally invasive approach, consisting of a limited skin incision and partial lower sternotomy, is a safe, reliable, and cosmetically advantageous method in uncomplicated congenital heart disease surgery, which can be performed widely, and may replace the standard approach without increasing mortality and morbidity.

During mitral valve replacement, total chordae preservation is very important for left ventricular functions. But leaving anterior leaflet and chordae may cause serious complications, such as left ventricular outflow tract obstruction and impairment in prosthetic valve functions. In this article, we present the anterior leaflet preservation technique by excising the central portion of the anterior leaflet. The rim of the leaflet tissue containing the marginal chordae was divided in two parts without destroying the chordae, and then the rim of leaflet tissue was sutured to the left atrium. This technique provided optimal chordae tension and improved avoidance of complications due to total chordae preservation, in mitral valve replacement operations.

Since improvement in reinforced expanded polytetrafluoroethylene (ePTFE) grafts, true aneurysm and pseudoaneurysm formation have become relatively rare complications after axillofemoral reconstruction. This is a case report of a true aneurysm of an axillofemoral graft. The true aneurysm occurred 29 months after insertion of a reinforced ePTFE graft for aortoiliac occlusive disease. A mid-graft true aneurysm was identified during examinations without any trauma history. Continuous long-term follow-up is recommended for these reinforced ePTFE grafts because of rare aneurysm formation, preferably using duplex ultrasonography.

Arteriovenous (AV) fistulae, pseudoaneurysms, and lacerations may occur during disc surgery. AV fistula after lumbar disc surgery is rare. Early diagnosis and treatment of vascular complications associated with disc surgery is essential due to their high mortality and morbidity rates. We report a case report who was presented with fistulous shunt between right common iliac artery and inferior vena cava fifteen days after operation for herniated discs at L4-L5 and L5-S1 levels. Treatment was transcatheter covered stent placement at the fistulous site of right common iliac artery using a self expandable stent-graft. We suggest use of minimally invasive interventional techniques in the management of suitable vascular injuries following lumbar disc surgery.

UNLABELLED: The aim of this clinical study is to assess the characteristics of penetrating heart injury and its surgical challenges for urgent surgical approach. MATERIALS AND METHODS: Seventeen patients suffering from penetrating heart wounds were evaluated retrospectively in the department of cardiovascular surgery between 1996 and 2004. All patients were male, with ages ranging from 19 to 36 years, with a mean age of 23.6 +/- 5 years. RESULTS: Median sternotomy, left anterior thoracotomy, and right anterior thoracotomy were performed to control the bleeding or to reach the heart for internal cardiac massage in 5, 11 and, 1 control, respectively. The right ventricle was the most commonly injured chamber (64.7%, n = 12), followed by left ventricle (17.7%, n = 4), and right atrium (17.6%, n = 3); a left atrial injury was not seen. Mortality rate was 29% (5 cases), and 12 controls were discharged without any complications. CONCLUSION: Although the most important factor affecting mortality in penetrating heart injuries is rapid transport, an urgent approach applied by a specialist team can decrease potential mortality and morbidity rates.

The reinsertion rate of intraaortic balloon pumps (IABP) has not been clearly reported. We evaluated the use of left-ventricular ejection fraction (LVEF), fractional shortening (FS), and cardiac index (CI) values to asses cardiac performance as weaning criteria for IABP in a prospective study performed in 100 patients who required IABP. Patients were randomly divided into 2 groups of 50 patients. In group 1, classical hemodynamic criteria were considered as weaning criteria of IABP. In this group, IABPs were removed when measurements of general hemodynamic criteria were established to be in normal ranges. In group 2, LVEF, FS, and CI values reflecting cardiac performance were used to monitor patients under IABP support, and IABPs were removed when LVEF, FS, and CI values reached >30%, >20%, and >2.4 L/min per m2, respectively. Reinsertion of IABP was necessary in 13 patients in group 1 and in 9 patients in group 2 (P = .48). Vascular complications were the main cause of reinsertion of IABP in 7 and 9 patients in group 1 and group 2, respectively (P = .59). Nine patients died in group 1 and 2 in group 2 (P = .025). In group 1, death due to myocardial dysfunction occurred in 8 of 13 patients (62%) who had required reinsertion of IABP; 6 of these patients required reinsertion of IABP because of hemodynamic deterioration, whereas no patients in group 2 required reinsertion of IABP because of hemodynamic deterioration (P = .027). LVEF, FS, and CI values higher than 30% (P = .008), 20% (P = .005), and 2.4 L/min per m2 (P = .013), respectively, showed good outcomes in regard to avoiding reinsertion of IABP, indicating that these measurements were significant predictors for reinsertion of IABP.

We report a case of orthotopic heart transplantation in a 42-year-old man who had cardiomyopathy with severe biventricular heart failure, ascites, and large umbilical hernia. He successfully received an orthotopic heart transplantation. After heart transplantation, renal failure was noted. Ascites and renal failure were successfully managed with repeated paracentesis. His cardiac and abdominal symptoms subsided gradually following transplantation. His umbilical hernia was repaired 55 days after the heart transplantation because of strangulation. In this case study, we report a patient with ascites who was treated for postoperative renal failure with repeated paracentesis.

Summary Background There is little information available about any link between the levels of adiponectin, intercellular adhesion molecule-1 (ICAM-1), tumour necrosis factor-α (TNF-α) and heart-type fatty acid-binding protein (H-FABP) in coronary atherosclerotic plaque specimens. Aim To analyse tissue levels of adiponectin, ICAM-1, TNF-α and H-FABP in the plaques obtained from coronary artery bypass grafting (CABG) and to evaluate whether there is any relationship between these variables and other characteristics. Patients and methods Coronary artery specimens from 37 consecutive patients (28 men and nine women) at time of CABG procedure and preprocedural blood samples were obtained. Tissue concentrations of adiponectin, ICAM-1, TNF-α and H-FABP in the atherosclerotic plaques were measured. Results Blood glucose and tissue levels of TNF-α and ICAM-1 were negatively correlated with tissue levels of adiponectin, whereas TNF-α was positively correlated with ICAM-1 in atherosclerotic plaques. In addition, there was a positive correlation between blood glucose and tissue levels of both TNF-α and ICAM-1. TNF-α and ICAM-1 levels in atherosclerotic plaques appear to progressively increase whereas adiponectin levels progressively decrease with smoking status. Atherosclerotic tissue levels of these substances are also altered in diabetes. Conclusions The data are in accord with those in prior publications on the detection and quantification of various inflammatory cytokines in atherosclerotic plaques. Our results indicate that diabetic state and smoking, in addition to other physiopathological mechanisms, may create a chronic inflammatory situation in the atherosclerotic process.

Objective: Supraventricular tachyarrhythmias (SVT) is common after coronary artery bypass grafting in chronic obstructive pulmonary disease (COPD). Preoperative FEV1 is the major predetermining factor of mortality, morbidity and SVT. Methods: Patients were divided into two groups according to their preoperative FEV1 values. FEV1 is ,75% of predicted value in group 1 (no. 200), and $ 75% of predicted value in group 2 (no. 100). Group 1 is divided into two subgroups. SVT prophylaxis was not done in A subgroup (no. 100) whereas arrhythmia prophylaxis was done with amiodarone in all B subgroups (no. 100) in the early postoperative period. Results: Atrial fibrillation developed in 28 patients in group 1A, whereas it developed in 12 in group 1B ðP ¼ 0:005Þ: Atrial flutter developed in 10 patients in group 1A but in 3 patients in group 1B ðP ¼ 0:045Þ: Multifocal atrial tachycardia developed in 13 patients in group 1A and in 4 in group 1B ðP ¼ 0:022Þ: Multivariate analysis identified ejection fraction (P , 0:002; odds ratio (OR) 0.93), inotropy requirement (P , 0:001; OR 3.98) amiodarone (P , 0:001; OR 0.18), and FEV1 , 75% of predicted value (P , 0:048; OR 1.84) as predictor of SVT. There were statistically significant differences between A and B subgroups of group 1 for hospital ðP , 0:001Þ and intensive care unit (ICU) stay ðP , 0:001Þ: There was also statistically significant difference between groups 1A and 2 comparison for ICU ðP , 0:001; 6.4 ^ 3.4 versus 1.4 ^ 0.6 days) and hospital stay ðP , 0:001; 17.6 ^ 8.2 versus 6.9 ^ 0.6 days). Conclusions: Early prophylactic amiodarone not only significantly reduces SVT but also reduces SVT-related hospital and ICU stay. We strongly recommend prophylactic early use of amiodarone in COPD patients. q 2003 Elsevier B.V. All rights reserved.

Celiac artery aneurysm is a rare and its rupture is the most frequent and serious complication. The patient who underwent aneurysmectomy and aorto - celiac artery synthetic prosthesis graft interposition in another cardiovascular surgery center two years ago, was admitted to our department with complaints of fever and abdominal discomfort. Computed tomography revealed an aneurysm with 1 cm of diameter at the beginning of celiac artery and intraperitoneal hemorrhage. Acute hematocrit descent was occurred and then cardiac arrest was taken place. So, emergency thoracotomy was done. Aorta was compressed with hand and at the same time internal cardiac resuscitation was done then cross clamp was placed onto aorta. Median abdominal incision was done and ruptured celiac artery aneurysm was observed. Infected graft was removed and PTFE graft was interposed from descending aorta to a. hepatica propria, away from the infected area. During 17 months of follow-up period graft no complication was observed. We believe that because of its rarity, tendency to be asymptomatic along with high incidence of rupture, celiac artery aneurysms should not be underestimated.

Division of the sternum is primarily a blind procedure in reoperation and carries an increased risk of injury for major cardiac structures in the presence of adhesions between the posterior table and the heart.Two hundred patients were randomly divided into two groups. Cardiopulmonary bypass was established through the femoral artery and vein in group 1 (n = 100) patients before sternal reentry. Carpentier dual-stage femoral venous return cannula was used in all group 1 patients. Cardiopulmonary bypass was performed after sternal reentry in group 2 (n = 100) patients.Six severe cardiac injuries developed in group 2. Cardiopulmonary bypass time was 93 +/- 9 minutes in group 1 and 71 +/- 11 minutes in group 2 (p = 0.011), and the operation time was 155 +/- 23 minutes in group 1 and 185 +/- 32 minutes in group 2 (p = 0.024). Inotropic therapy was required in 52 patients in group 1 and 76 patients in group 2 (p = 0.032). Average chest drainage was 450 +/- 135 mL in group 1 and 850 +/- 250 mL in group 2 (p0.001). Average fresh whole blood transfusion was 3.3 +/- 1.2 U in group 1 and 5.8 +/- 0.9 U in group 2 (p = 0.033). Average intensive care unit stay was 2.2 +/- 1.3 days in group 1 and 4.5 +/- 2.3 days in group 2 (p = 0.025). Average hospital stay was 7.3 +/- 2.4 days in group 1 and 9.1 +/- 3.1 days for group 2 (p = 0.011).Cardiopulmonary bypass by bicaval Carpentier femoral venous cannula before resternotomy not only allows adequate cardiopulmonary bypass flow but also significantly reduces the risk of cardiac injury and catastrophic hemorrhage and allows safe reopening. Although this procedure increases cardiopulmonary bypass time, the operation time, bleeding, and blood transfusion requirement are significantly reduced.

Circular elasticity cannot be obtained in standard patch aortaplasty in patients with coarctation of aorta. We inserted Dacron patch perpendicularly to standard fashion. The creases of Dacron patch became parallel to descenden aorta. Circular elasticity, that reduces both true and false aneurysm incidence in the long-termperiod, can be obtained with this modification.

Objective: Former studies have pointed out that hemodynamic stress imposed by associated valvular disease is the primary factor in the development of ascending aorta dilatation. At present, intrinsic wall pathology is blamed for dilatation and aneurysm formation in bicuspid aortic valve (BAV). Materials and Methods: Aortic valve replacement (AVR) was performed on 78 adult patients with BAV. Patients were divided into two groups. Group I(n = 27)underwent only AVR. Group II(n = 51)underwent AVR and additional ascending aorta procedures such as Shawl-Lapel aortoplasty(n = 12)and tailoring aortoplasty(n = 9). Dacron wrapping was performed after both techniques were done. Ascending aorta replacement was done on 11 patients by using composite graft. Supracoronary graft replacement was performed in 3 patients after AVR. Results: Ascending aorta diameter increment was 1.25 mm/year in normotensive and 2.80 mm/ year in hypertensive patients. Ascending aorta aneurysm (diameter > 55 mm) developed in eight patients in the postoperative period in group I. Ascending aorta dilatation did not develop in group II patients. Mean survival time ± standard error (SE) was 128 ± 11 and 99 ± 4 months and survival possibility was 77.78% and 92.16%. Freedom from reoperation was 65.4% and 95.9% in 8 years in group I and group II, respectively. Conclusion: Aortic wrapping with or without aortoplasty has a beneficial effect not only in dilated ascending aorta but also in all nondilated BAV patients with normal-sized aortic diameter. Ascending aorta wrapping in BAV patients preserves the endothelial lining and prevents further dilatation, aneurysm formation, and dissection.(J Card Surg 2003;18:173-180)

The mortality and morbidity of aortic valve replacement (AVR) after prior coronary artery bypass surgery (CABG) with patent left internal thoracic artery (LITA) is significant. The risk of LITA injury and inadequate myocardial preservation during the cross-clamp period may cause myocardial pump failure.A total of 43 patients with a patent LITA graft underwent AVR. The patients were divided into the two groups. Group 1 included 19 patients who underwent AVR with deep hypothermia (20 degrees C) without LITA clamping. Group 2 included 24 patients in whom LITA flow was controlled through supraclavicular occlusion and AVR performed with moderate hypothermia (28 degrees C).Average cardiopulmonary bypass time (CPB) time was 118.79 +/- 20.36 minutes in group 1 and 102.67 +/- 9.66 minutes in group 2 (p = 0.006). Average cross-clamp time was 53.79 +/- 7.26 minutes in group 1 and 49.63 +/- 6.7 minutes in group 2 (p = 0.022). Inotropic support was required in 12 patients in group 1 and 4 patients in group 2 (p = 0.002). Average intensive care unit stay was 4.68 +/- 2.24 days in group 1 and 2.29 +/- 0.46 days in group 2 (p0.001). Average hospital stay was 11.84 +/- 2.91 days in group 1 and 8.04 +/- 2.38 days in group 2 (p0.001). Mortality due to myocardial failure developed in 4 patients in group 1 but in none of the patients in group 2 (p = 0.02).Proximal control of LITA flow by extrathoracic supraclavicular occlusion reduces the incidence of myocardial failure due to nonhomogenous cardioplegia delivery to the anterior wall of the heart, resulting in improved myocardial protection and the elimination of the need for deep hypothermia.

Objective: Total correction of classic tetralogy of Fallot (TOF) by transatrial approach has become a standard procedure with a principal theoretical aim of minimizing structural damage to the pulmonary pump. The most critical point in transatrial repair of TOF is infundibular dissection. Right atrial approach provides better surgical exposure for parietal extension of the infundibular septum when compared to a right ventricular approach. However, it is not always easy to determine the localization and amount of muscle bundles to be resected and this surgical maneuver requires experience. Methods: Nineteen patients were reviewed who had repair of isolated TOF by this technique from 1993 to 2001. The mean age of patients was 5 ± 2 years . Transatrial-transpulmonary approach was performed for all patients. To make the infundibular muscle-bundle resection easier and to determine the localization and amount of muscle bundle to be resected, we placed a Hegar dilator into the right ventricle through pulmonary arteriotomy. The muscle bundles between the dilator and the anterior leaflet annulus of the tricuspid valve were totally excised until the intraventricular part of the dilator and pulmonary annulus became completely visible. The area between the Hegar dilator and the margins of the ventricular septal defect (VSD) was left untouched. None of the patients had transannular patch. Tricuspid valve detachment in order to improve the exposure was done in 11 patients. All patients were followed up in our clinic at regular six-month intervals by echocardiography. Results: There was no early or late mortality nor reoperation for residual VSD or residual right ventricle (RV) outflow obstruction. All patients were in NYHA class I. RV on the echocardiography was spared late dilatation and had a good late functional status. Eighteen patients had no or mild pulmonary regurgitation. One patient who had undergone tricuspid anterior leaflet detachment showed mild tricuspid insufficiency. Conclusions: On the basis of hemodynamic outcomes, this procedure for elective repair of TOF in selected cases gives excellent early and mid-term results.(J Card Surg 2002;17:490-494)

J Thorac Cardiovasc Surg 2003;125:206-8

Ventrikuler septal defekt (VSD), tipik olarak genellikle perimembranoz tip olan VSD’lerin belirlenmesi ve tamirinde iyi bir gorus saglayan transatriyal yaklasim ile tamir edilir. Fibroz ve kordal yapisikliklar lezyonu cevreleyebilir ve bu anormal yapilar VSD’lere ulasmayi guclestirebilir. Bu yazida, perimembranoz tip VSD’si olan ve defektin trikuspid septal yaprakcik ve cok kalin pek cok kordal yapisikliklarla cevrelendigi bir olgu sunuldu. Kordal yapisikliklar dikkatle diseke edildi ve VSD basarili bir sekilde ortaya cikarildi. Defekt, Gore-Tex yama kullanilarak tamir edildi. Anah tar soz cuk ler: Kordal ayrisma; ventrikuler septal defekt tamiri. Ventricular septal defect (VSD) is typically repaired via a transatrial approach, which usually provides a good exposure for the assessment and repair of VSDs, generally the perimembranous type. Fibrosis and chordal fusion may surround the lesion, and these malstructures may compromise to reach VSDs. In this article, we present a case with the perimembraneous-type of VSD surrounded by a tricuspid septal leaflet and many thick chordal attachments. The attachments were carefully dissected, and the VSD was successfully exposed. The defect was then repaired using a Gore-Tex patch.

We present a modified bileaflet preserving mitral valve replacement technique to eliminate left ventricular outflow tract obstruction and larger size prosthesis implantation. Mitral anterior leaflet was incised from the middle of leaflet to mitral annulus. Pletgetted sutures were firstly bitten from mitral annulus and then passed from the bottom to the tip of anterior leaflet. These sutures were anchored to prosthesis. Bileaflet prosthesis was put down into the annulus and sutures were ligated on the strut of prosthesis. Posterior leaflet was also preserved. Excessive anterior leaflet tissue was attached to left atrium wall by deeply bitten sutures.

We have read with great interest the recently published letter by Hellman and coworkers in which they showed misplacement of the Angioseal device anchor in the right common artery by using CT angiography accompanied with 3-D reconsctruction [1]. A 56-year-old male patient underwent stent implantation in the left anterior descending coronary artery due to stable angina uncontrolled medical treatment. Following 24 hour heparin treatment sheath was removed and the puncture site in the right femoral arterywas closedwith AngioSeal vascular closure device (St.Jude Medical, Minnetonka, MN). In early post-inventional period the patient complained with pain in the right thigh. At physical examination distal pedal pulses were absent. There was extensive occlusion on the right superficial femoral artery with slight flow and vast filling defect in selective digital arterial angiography performed from theleft femoral artery (Fig. 1). Surgical intervention was performed to remove the material with vertical incision of the superficial femoral artery. In surgery the material with a diameter of 0.5×1.5 cmwas foundandexcised (Figs. 2–4).Anteriorwall of the superficial femoral artery was damaged because of collagenouse material and it was repaired with saphenous vein patch plasty. No complications were observed at post-operative period, and the patient was discharged on the 5th post-operative day. Vascular access site complications result in significant morbidity after vascular interventional procedures,with an incidence of 0.5–16.8% of cases. Although manual compression is effective in achieving hemostasis in most cases, it requires 10–20 min sustained compression

One of the biggest problems encountered during complete arterial revascularization is difficulty obtaining sufficient graft length to perform multiple distal anastomoses. We describe a technique of dividing the radial artery during harvest and forming one or more composite Y-grafts to allow end-to-side rather than sequential anastomoses without substantially decreasing usable conduit length. This approach has merit and may be helpful in some patients who require complex arterial grafting.

Late thrombosis of prosthetic graft material is rarely managed successfully by simple thrombectomy or thrombolytic therapy. Replacement with a new graft may be necessary. Although several techniques have been described, mobilizing and removing an old thrombosed prosthetic graft is usually extremely difficult because of a firm attachment to its tunnel. This attempt is more difficult especially for ringed grafts. We describe a simple technique of using an internal varicose vein stripper for the removal of such a late thrombosed axillofemoral spiral polytetrafluoroethylene graft and positioning a new graft into the old tunnel.