Askin Ali Korkmaz

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.

Effects of Thoracic Epidural Anesthesia on Flow and Endothelium of Internal Thoracic Artery in Coronary Artery Bypass Graft Surgery

OBJECTIVES The internal thoracic artery (ITA) is the preferred conduit for coronary artery bypass graft (CABG) surgery. The authors investigated whether thoracic epidural anesthesia (TEA) as an adjunct to general anesthesia (GA) can increase the blood flow of the ITA. DESIGN A prospective randomized study. SETTING A university hospital. PARTICIPANTS Patients with ischemic heart disease. INTERVENTIONS Thirty patients scheduled for elective CABG surgery were randomized to receive either GA (n = 15) or GA + TEA (n = 15) after receiving institutional review board approval. Demographics showed similarity between the groups. The epidural catheter was inserted in the thoracic region between T1 and T5 levels. In the GA + TEA group, the patients received a 20-mg bolus of 0.25% bupivacaine through epidural catheters 1 hour before surgery, and this was followed by the infusion (20 mg/h) of 0.25% bupivacaine. In all patients, ITA free blood flow was measured before cardiopulmonary bypass and without the administration of any vasodilatory agent. A short segment of ITA was excised for histologic examination; immunocytochemistry analysis was performed using antirabbit polyclonal VEGF antibody, rabbit polyclonal inducible nitric oxide synthase (i-NOS) antibody, and adenosine anti-A2B receptor antibody. The immunoreactivity rates then were evaluated. MAIN RESULTS The mean ITA free flow in the GA + TEA group was significantly higher than in the GA group (56.0 ± 9.0 mL/min v 39.6 ± 14 mL/min, p = 0.001). Immunostaining intensity in the sections after incubation with each primary antibody increased in the GA + TEA group compared with the GA group. CONCLUSIONS The results of this study indicated that TEA increased ITA free blood flow significantly via increased VEGF, i-NOS, and adenosine-A2B receptor expressions. Therefore, the use of TEA as an adjunct to GA might be considered as an alternative to vasoactive agents for increasing ITA flow in CABG surgery.

Combination of Right Atrial and Left Ventricular Myxoma

Myxomas are common cardiac tumors that are managed by complete excision. The combination of a right atrial and left ventricular myxoma is very rare. We discuss a patient with right atrial and left ventricular myxoma who underwent successful surgical excision of both myxomas. There was no clinical or echocardiographic recurrence or valvular insufficiency at the 6-month follow-up.

Comparison of the results of irrigated monopolar and bipolar radiofrequency ablation in the surgical treatment of atrial fibrillation

OBJECTIVE Chronic atrial fibrillation (AF) is a frequent arrhythmia in patients undergoing open-heart surgery. In this study, we compared the results of irrigated monopolar and bipolar radiofrequency (RF) ablation in the surgical treatment of AF. METHODS Sixty-three patients with chronic AF, who underwent open cardiac surgery and concomitant irrigated RF ablation between October 2004 and January 2006, were retrospectively studied in two groups. Group 1 included 31 patients (22 female, 9 male), who underwent monopolar RF ablation, and Group 2 included 32 patients (18 female, 14 male), who underwent bipolar RF ablation. All patients received amiodarone during the first 6 months after surgery. Rhythm status of patients after RF ablation was followed-up postoperatively in the intensive care unit, on the day of discharge, and at their follow-ups with electrocardiography. In patients with a documented sinus rhythm (SR) at follow-up, the presence of atrial transport function was assessed with transthoracic echocardiography. Statistical analyses were performed by using t-test for independent samples, Chi-square test and McNemars test. Complication-free survival during follow-up was evaluated using Kaplan-Meier analysis. RESULTS There was no hospital mortality in both groups. One patient from Group 1 had non-cardiac mortality (colon carcinoma). While in monopolar ablation group SR was documented in 83.3% of patients at a mean follow-up period of 11.5 ± 4.0 months (between 4-18 months), 68.8% of patients from bipolar ablation group was in SR at a mean follow-up period of 9.3 ± 3.0 months (between 4-15 months). In patients with documented SR during follow-up visits, atrial transport function was 76.6% in cases undergoing monopolar ablation, whereas it was 72.7% in cases undergoing bipolar ablation (p=0.797). Pacemaker implantation was performed in one (3.4%) patient from Group 1 after hospital discharge and in one (3.1%) patient from Group 2 during hospital stay. CONCLUSION Irrigated monopolar and bipolar RF ablation are both safe and effective in terms of restoring SR and atrial transport function in patients with chronic AF, who underwent open cardiac surgery.

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.

Clinical outcomes of mitral valve repair in mitral regurgitation: a prospective analysis of 100 consecutive patients.

OBJECTIVE Mitral valve repair has become the procedure of choice for almost every type of mitral regurgitation (MR) in the current surgical era. We assessed clinical outcomes of mitral valve repair in severe MR. METHODS In this prospective cohort study, 103 patients (61 male, 42 female, mean age 53.2±14.8 years), who were planned to undergo valve repair were included. Mitral valve pathology was regurgitant in 86% and mixed in 14% of patients. The intention to perform mitral repair was successful in 100 (97.1%) of patients. Concomitant procedures were performed in 57 (57%) patients including 31 coronary artery bypass grafting and 13 tricuspid valve repairs. After surgery, early (<30 days) and late (>30 days) complications were recorded. Postoperative echocardiography was performed in all patients at discharge and during clinical follow-up. Late survival and freedom from adverse events including thromboembolism, endocarditis, reoperation, and residual severe MR were estimated by using the Kaplan-Meier survival analysis. RESULTS There was no early mortality. Echocardiographic assessment of patients at discharge revealed no/trivial regurgitation in 89% and mild (1+) MR in 11% of all patients. Late mortality occurred in only one patient at 14 months because of renal failure. The mean follow-up period of patients was 21.2±10.3 months. Echocardiographic examination during follow-up revealed that mitral insufficiency was none or mild in 96% of patients. Three (3%) patients had moderate (2+) MR and were treated medically. Mitral insufficiency recurrence with severe (3+) regurgitation occurred in one (1%) patient undergoing coronary artery revascularization and concomitant left ventricular aneurysmectomy. Re-operation was needed in only one (1%) case because of infective endocarditis that was treated with mechanical valve replacement. Kaplan-Meier estimates were 99±2.7% for late survival and 98±2.2%, 99±2.7%, 99±2.7% and 99±0.9% for freedom from thromboembolism, endocarditis, reoperation, and residual severe MR, respectively. CONCLUSION This study showed that mitral valve repair provides excellent surgical outcomes. Repair procedures are safe, and highly effective, but operations require a considerable surgical experience.

Left ventricular mass regression after aortic valve replacement

OBJECTIVE Our objective was to evaluate the degree of change in left ventricular mass index (LVMI) regression after aortic valve replacement (AVR) using three different valves. METHODS Group 1 (n=17) included patients with bioprosthesis (Medtronic Hancock 2), Group 2 (n=21) included patients with mono-leaflet mechanical valve (Medtronic Hall), and Group 3 (n=17) included patients with bi-leaflet mechanical valve (St Jude). The mean ages of Group 1, 2 and 3 patients were 70.8±9.1, 61.6±13.7 and 56.2±18.3 years, respectively. In this observational study, patients were followed-up after surgery and left ventricular wall thickness and valvular functions were evaluated with echocardiography. The findings were compared with preoperative values. Statistical analyses were performed using one-way variance analysis (ANOVA), Kruskal -Wallis, and Chi-square tests. RESULTS Statistically significant difference was observed among the three groups with respect to age (p=0.015). LVMI regressed in all groups; Group 1 from 232.74±53.36 g/m² (preoperative) to 174.64±46.33 g/m² (postoperative) (p=0.0001), Group 2-from 198.49±40.53 g/m2 to 167.04±33.9 g/m² (p=0.0001), and Group 3-228.77±47.87 g/m² to 185.44±37.76 g/m² (p=0.0001). No statistically significant difference was observed among the groups with respect to LVMI regression (p=0.054, p=0.363). CONCLUSION Mid-term results of AVR with three different aortic valve prosthesis revealed that all groups showed a similar regression of left ventricular mass. However, we advocate that long-term results of an increased number of patients should be evaluated for assessment in depth.