Ahmet Özkara

Diagnosis, management, and results of treatment for aortopulmonary window

The aortopulmonary window is a communication between the ascending aorta and the pulmonary trunk in the presence of two separate arterial valves. This uncommon congenital anomaly is reported rarely in the literature. We present here our experience with 16 patients, emphasizing the importance of early closure of the defect by a transaortic approach. We performed surgery on 16 patients over a period of 13 years using a transaortic approach under cardiopulmonary bypass. The median age of the patients at the time of operation was 6.5 months, with a range from 1 month to 11 years. Preoperative pulmonary arterial systolic pressure ranged from 30 to 100 mmHg. Associated cardiac anomalies were present in 7 of the patients, and were repaired at the same stage. The defect was between the ascending aorta and the proximal pulmonary trunk in 13 patients, and between the ascending aorta and the distal pulmonary trunk, with overriding of the orifice of the right pulmonary artery, in 3 patients. For closure, we used a patch of 0.4 mm Gore-Tex in 11, and gluteraldehyde-treated autologous pericardium in 5 of the patients. One patient died during surgery. The mean follow-up period for the surviving 15 patients was 52.2 months, with a range from 12 to 130 months. All the patients were in good condition during the follow-up, and no residual defects have been detected. Aortopulmonary window is a rare congenital cardiac anomaly, which can be repaired with very good operative results if surgery is performed before the development of irreversible pulmonary hypertension. We advise early correction of the defect with a transaortic patch, repairing all associated cardiac anomalies at the time of diagnosis.

Radiation-induced coronary artery disease.

Wir berichten von einem 36-jährigen Patienten der wegen neu auftretender Angina-Symptomatik aufgenommen wurde. Er hatte keine Risikofaktoren für koronare Herzkrankheit (KHK). Anamnestisch auffällig war ein Morbus Hodgkin im Alter von 10 Jahren die mit Bestrahlung von Mediastinum behandelt worden war. Koronarangiographie ergab eine zwei Gefäßerkrankung mit komplettem Verschluss von RIA und 70% Stenose der rechten Koronararterie. Beide Verschlüsse wurden erfolgreich wiedereröffnet (Ballondilatation und Stent-Implantation). Kontrollangiographie nach einem Jahr ergab keine Restenose und der Patient war auch klinisch beschwerdefrei. Bei jedem Patienten mit kardialen Beschwerden und anamnestisch bekannter Bestrahlung im Bereich von Mediastinum soll an strahlenbedingte Herzerkrankung gedacht werden. Strahlenschaden kann zur Myokard-, Perikard-, Klappenerkrankungen oder Rythmusstörungen führen. Eine andere Manifestation ist früh ansetzende KHK. In dieser Hinsicht soll Bestrahlung im Bereich von Mediastinum als Risikofaktor für KHK angenommen werden. Da heutzutage Strahlentherapie die Behandlungsmethode für mehrere mediastinale Malignitäten ist, optimale Beschirmung während der Therapie und regelmäßige Kontrolluntersuchungen sind erforderlich um die kurz- und langfristige Komplikationsrate möglichst niedrig zu halten und Komplikationen, besonders KHK früh zu erkennen. Die bevorzugte Behandlungsmethoden für Strahlenbedingte KHK sind Ballondilatation mit Stent-Implantation oder aortakoronare By-pass-Operation. Die Mammaria-Arterien sollen preoperativ kontrolliert werden. Radiation-induced heart disease must be considered in any patient with cardiac symptomatology who had prior mediastinal irradiation. Radiation can affect all the structures in the heart, including the pericardium, the myocardium, the valves and the conduction system. In addition to these pathologies, coronary artery disease following mediastinal radiotherapy is the most actual cardiac pathology as it may cause cardiac emergencies requiring interventional cardiological or surgical interventions. A 36- year-old man was admitted to the clinic with unstable angina pectoris of one month duration. The patient had no coronary artery disease risk factor. The history of the patient revealed that he had mediastinal radiotherapy due to Hodgkin’s disease at 10-year of age. Coronary arteriography showed total occlusion of the left anterior descending artery and 70% stenosis of the proximal right coronary artery. Both arteries are dilated with placement of two stents. Control coronary arteriography at the end of the first year showed patency of both stents and the patient is free of symptoms. Previous radiotherapy to the mediastinum should be considered as a risk factor for the development of premature coronary artery disease. Percutaneous transluminal coronary angioplasty with stent placement or surgical revascularization are the preferred methods of treatment. Preoperative assessment of internal thoracic arteries should be considered prior to surgery. As the radiation therapy is currently the standard treatment for a number of mediastinal malignancies, routine screening of these patients and optimal cardiac prevention during radiotherapy are the only ways to minimize the incidence of radiation-induced heart disease.

Sequential In Situ Left Internal Thoracic Artery Grafting to the Circumflex and Right Coronary Artery Areas

BACKGROUND Several bilateral internal thoracic artery (ITA) grafting patterns have been proposed to enhance 3-vessel coronary artery revascularization. We present the outcomes of sequential in situ left ITA grafting to the circumflex and right coronary artery (RCA) areas. METHODS Between January 2001 and September 2007, 102 patients with 3-vessel coronary artery disease underwent arterial myocardial revascularization with bilateral in situ ITA grafts. The circumflex and distal RCA branches were revascularized sequentially with the left ITA. The left anterior descending artery area was grafted with the right ITA. RESULTS Ninety-nine patients (97.0%) were monitored for 37.2 ± 2.9 months, and 77 (75.4%) underwent postoperative coronary imaging after 27.8 ± 5.8 months. The bilateral ITA grafts were 97.1% patent (FitzGibbon grade A+B) overall. The sequential anastomoses of the left ITA to the circumflex and RCA territories were 96.7% patent overall, with competitive flow (FitzGibbon grade B) in 3 patients. The patency rates of sequential anastomoses to the circumflex and RCA branches were 98.0% and 95.0%, respectively. The right posterolateral and right descending posterior artery anastomoses were 91.8% and 100% patent, respectively. The in situ right ITA grafts to the left anterior descending artery area were 98.0% (FitzGibbon grade A+B) patent overall. Angina recurred in 1 patient (0.9%) 6 months after the operation. Percutaneous coronary interventions were performed in 3 patients (3.8%). No cardiac deaths occurred during the follow-up period. CONCLUSIONS Sequential in situ left ITA grafting to the circumflex and RCA areas yields acceptable midterm results in selected patients with 3-vessel disease.

Postinfarction ventricular septal rupture: surgical intervention and risk factors influencing hospital mortality.

Postinfarction rupture of the interventricular septum is usually fatal without surgical intervention and requires urgent closure. Between 1989 and 2003 twenty consecutive patients (15 male, 5 female), underwent postinfarction ventricular septal rupture (VSR) repair. Mean age of the patients was 62.05 ± 7.51 years. Fifteen patients were operated within 48 hours after myocardial infarction. Patch reconstruction was performed in all patients. Infarct locations were anterior in 65%, posterior in 35%. Coronary artery surgery was performed in 14 patients (70%). Hospital mortality was 30% (6 patients). Four patients were presented for surgical therapy with frank cardiogenic shock or low cardiac output syndrome.A residual shunt was detected in 4 patients and three of these patients were reoperated. One of them, who has been reoperated on the first day of the postoperative period, did not survive.The statistical analysis of the patients’ records demonstrated that time period between MI and surgery, applied additional CABG procedure, the sex of the patients and the site of the rupture are significant factors influencing in-hospital mortality. Preoperative condition, age of the patients and the number of the affected coronary vessels do not have an important effect on the mortality. Postinfarction ventricular septal rupture is a fatal complication of the myocardial infarction and must be treated surgically. The time interval between septal rupture independent from the preoperative haemodynamic condition, the location of the defect and additional myocardial revascularization procedure are the factors influencing the early outcome.

Long term follow up results of sequential left internal thoracic artery grafts on severe left anterior descending artery disease

PurposeSeveral alternative procedures have been proposed to achieve complete revascularization in the presence of diffuse left anterior descending coronary artery (LAD) disease. With the extensive use of internal thoracic artery grafts in coronary artery bypass procedures, sequential anastomosis of the left internal thoracic artery (LITA) to LAD has gained popularity in these challenging cases. The long term results of sequential LITA to LAD anstomosis were examined in this study.Patients and MethodsIn order to determine the long term results of the sequential revascularization of LAD by LITA graft, 41 out of 49 patients operated between January 2001 and December 2005 were selected for control coronary arteriography. The median period for control coronary arteriography was 64 months.ResultsSeventy five anastomoses were found to be fully patent (91,46%) among the 82 sequential LITA anastomoses (41 LITA grafts) on the LAD at a median follow-up period of 64 months (53 to 123 months). Among the 41 LITA grafts used for this purpose, 36 were found intact (complete patency of the proximal and distal anastomoses) (87,8%). Two LITA grafts (4 anastomoses) were found to be totally occluded (4,87%). The proximal anastomosis of the LITA graft was observed to be 90% stenotic in one patient (1,21%). In one patient tight stenosis of the distal anastomosis line was observed (1,21%), while in another patient 70% narrowing of LITA lumen after the proximal anastomosis was detected (1,21%).ConclusionWe strongly beleive that sequential LITA grafting of LAD is a safe alternative in the presence of severe LAD disease to achieve complete revascularization of the anterior myocardium with patency rates not much differing from conventional single LITA to LAD anastomosis.

Coronary Artery Bypass Grafting in Cold-Induced Urticaria

Cold-induced urticaria is an unusual systemic disorder that develops in response to exposures to cold temperatures in susceptible individuals. Patients with cold urticaria are potentially at risk of severe systemic anaphylactic shock-like reactions. This disorder is of unique clinical importance in cardiac surgery, considering the use of cardiopulmonary bypass and hypothermia. Contact of blood with hypothermia and subsequent warming can be associated with hemodynamic instability, hypotension, and cardiovascular collapse, mainly during the period of rewarming. We report the case of a 41-year-old woman with chronic cold-induced urticaria, who underwent a successful coronary bypass grafting, and describe perioperative management of this rare disorder.

Sinus of valsalva aneurysm: surgical approaches to complicated cases

Background:  The authors herein report surgical experience with the aneurysms of sinus of Valsalva (SVA) complicated by coexisting pathologies.

Combined internal mammary artery graft in coronary bypass: 18-year follow-up.

Graft preference is a key point for long-term patency in coronary artery bypass grafting. We present a patient with multivessel coronary artery disease who underwent coronary artery bypass grafting 18 years ago. Revascularization of the left coronary system was performed by using a combined internal mammary artery (IMA) graft, which consisted of an end-to-end anastomosis of left IMA (in situ) and right IMA (free), with the interposition of a small piece of vein. A coronary angiography at the 18-year follow-up revealed patency of all sequential anastomoses with an enlarged combined IMA graft.

A novel technique for creation of a systemic-to-pulmonary arterial shunt.

A systemic-to-pulmonary arterial shunt is still widely used for palliation of some neonates with cyanotic congenital cardiac lesions. This procedure, however, is well known to be associated with some degree of morbidity and mortality. To reduce the incidence of iatrogenic pulmonary arterial deformities, we have devised a new and simple technique to create the shunt using a partial sternotomy, and have used our technique in 10 neonates with cyanotic cardiac malformations. All but one of our patients survived, and an early reoperation was needed in only one further patient for revision of the shunt. Successful bidirectional Glenn procedures were performed in five of the nine surviving patients within 18 months of the initial procedure. We believe that our technique provides superior palliation by permitting equal enlargement of the right and left pulmonary arteries, and thus facilitates subsequent completion of the Fontan circulation.

Myocardial Ischemia after Cabrol Operation

A 33-year-old woman who had undergone a Cabrol-type aortic root replacement for acute aortic dissection during labor 27 months ago was admitted with chest pain. Electron-beam tomography and coronary angiography showed stenosis at the level of the anastomosis. Urgent coronary revascularization was performed using bilateral internal mammary artery grafts. Although graft occlusion after the Cabrol procedure is an infrequent complication, it should be considered during follow-up.