Azmi Ozler

Cardiac hydatid cysts with intracavitary expansion

BACKGROUND Hydatid cyst disease is a significant health problem for undeveloped and developing countries. Although cardiac involvement is rare, early diagnosis and treatment of this situation is important. METHODS To investigate the long-term outcome of patients who underwent operation for cardiac hydatid cysts with intracavitary expansion, we reviewed 8 patients who had cardiac hydatidosis and who underwent operation in our institution between January 1988 and November 1999. All patients presented with intracavitary protrusion of the cysts. Seven patients were women. The mean age was 33 +/- 14.3 years with a range of 17 to 55 years. The cysts were located on the right ventricular outflow tract (2 patients), right midventricular part of the muscular septum, left atrial free wall and apical portions of the right (2), or left (2 patients) ventricle. Standard cardiopulmonary bypass and crystalloid antegrade cardioplegia with aortic cross-clamping were used in all patients. In one, with right ventricular hydatid cyst, we used cardiopulmonary bypass with femoral cannulation and total circulatory arrest at less than 18 degrees C systemic hypothermia. This patient, who was arrested because of pulmonary emboli could not be weaned from cardiopulmonary bypass and died. RESULTS The cystic cavity was cleaned and closed with multiple pursestring sutures in 4 patients. In 2, cardiac and cystic cavities were united by partially resecting part of the cyst facing the cavity. In another patient, a left ventricular patch plasty was performed after removal of the cystic material in the left ventricle. Mebendazole was used postoperatively in all patients. Except for 1 patient who died, all were discharged without postoperative complications. The mean follow-up was 7.5 +/- 5 years. There was no late cardiac mortality or recurrence. CONCLUSIONS Cardiac hydatid cysts with intracavitary expansion should be treated surgically without delay. Gentle handling of the heart during cardiopulmonary bypass minimizes operative risk. All patients should be investigated for systemic cysts.

Prosthetic replacement of tricuspid valve: bioprosthetic or mechanical.

BACKGROUND Tricuspid valve replacement is one of the most challenging operations in cardiac surgery. Selection of the suitable prosthesis is still debatable. METHODS In our institution, between January 1980 and December 2000, 129 tricuspid valve replacements were performed in 122 patients (14.7%). Bioprosthetic valves were used in 32 patients, whereas 97 patients had mechanical valve implantation. Twenty-two percent of replacements were done on men. Mean age was 35.27+/-11.56 years. In all patients, initially an annuloplasty technique was tried. Tricuspid valve replacement was performed when annuloplasty was not sufficient. In most of the cases, tricuspid valve interventions were done under cardiopulmonary bypass and on a beating heart. RESULTS Early mortality was 24.5%. Patients were followed for 2 to 228 months. Seven patients underwent reoperation because of tricuspid valve dysfunction (7.6%). Nine patients died during the follow-up period. Late mortality was 9.7%. Actuarial estimates of survival in 20 years of follow-up for all tricuspid prosthetic valves, mechanical valves, and bioprosthetic valves were 65.1%+/-9.3%, 68.3%+/-10.6%, and 54.8%+/-12.1%, respectively. For the bioprosthetic valve group, freedom from structural valve degeneration was 90%+/-5.5%; for the mechanical valve group, freedom from deterioration, endocarditis, and leakage was 97.8%+/-4.2%, and freedom from thromboembolism was 92.6%+/-6.9%. CONCLUSIONS We found that there was no statistically significant difference between the two groups in terms of early mortality, re-replacement, and midterm mortality (p > 0.05). Nevertheless, we recommend low profile modern bileaflet mechanical valves for prosthetic replacement of the tricuspid valve, due to their favorable hemodynamic characteristics and durability.

Continuous positive airway pressure does not improve lung function after cardiac surgery.

PurposeDespite the well-documented impairment of pulmonary function after cardiopulmonary bypass, effective precautions and ideal management strategies for this problem are still under debate. This study aimed to evaluate the effects of continuous positive airway pressure (CPAP) applied during cardiopulmonary bypass on respiratory and hemodynamic variables.MethodsIn this randomized, prospective, controlled trial, 120 male patients, aged 45 to 70 yr undergoing first-time elective bypass surgery, were randomly assigned to receive either 10 cm H2O of CPAP (Group I; n = 60) during cardiopulmonary bypass, or serve as control (Group II; n = 60), where the patient’s lungs were vented to atmosphere during the bypass period.ResultsAlveolar-arterial oxygen partial pressure difference and shunt fraction were significantly higher in the control group compared with the CPAP group after cardiopulmonary bypass (T2) and after closure of sternum (T3), (P < 0.05). No differences between groups with respect to hemodynamic variables were observed at any time. Postoperative pulmonary function variables were lower in both groups compared to baseline values.ConclusionsContinuous positive airway pressure administered during cardiopulmonary bypass decreased shunt fraction and alveolar-arterial oxygen partial pressure difference during surgery, but had no sustained effect on either variable postoperatively. We conclude that, in patients with normal preoperative pulmonary function, application of 10 cm H2O CPAP does not improve lung function after cardiac surgery.RésuméObjectifMalgré les connaissances acquises sur l’atteinte de la fonction pulmonaire après la circulation extracorporelle, les précautions efficaces et le traitement idéal touchant ce problème font toujours l’objet de débats. Nous voulions évaluer les effets d’une ventilation en pression positive continue (CPAP pour «continuous positive airway pressure») pendant la circulation extracorporelle sur les variables respiratoires et hémodynamiques.MéthodeDans notre étude randomisée, prospective et contrôlée, 120 hommes de 45 à 70 ans devant subir un premier pontage électif, ont reçu soit 10 cm H2O de CPAP (Groupe I; n = 60) pendant la circulation extracorporelle, soit ont servi de témoins (Groupe II; n = 60) et les poumons ont été ventilés à la pression atmosphérique pendant le pontage.RésultatsLa différence alvéolaire-artérielle de pression partielle en oxygène et la fraction de shunt ont été significativement plus élevées chez les témoins que chez les patients sous CPAP après la circulation extracorporelle (T2) et après la fermeture du sternum (T3), (P < 0,05). Les variables hémodynamiques ont toujours été similaires dans les deux groupes. Dans les deux groupes aussi, les variables de la fonction pulmonaire postopératoire étaient plus basses que les valeurs de départ.ConclusionLa ventilation à pression positive continue pendant la circulation extracorporelle a réduit la fraction de shunt et la différence alvéolaire-artérielle de pression partielle en oxygène pendant l’opération, mais n’a pas eu d’effet postopératoire prolongé sur chacune des variables. Donc, chez les patients dont la fonction pulmonaire préopératoire est normale, une CPAP de 10 cm H2O n’améliore pas la fonction pulmonaire après la cardiochirurgie.

Dexmedetomidine in cardiac surgery patients who fail extubation and present with a delirium state.

BACKGROUND We evaluated the use of dexmedetomidine to facilitate the weaning of delirious postoperative patients from mechanical ventilation. METHODS We included 72 consecutive patients who underwent elective cardiac surgery in this prospective observational study. Each patient had failed at least 1 trial of continuous positive airway pressure (CPAP) and had agitation. Patients were assessed with the Richmond Agitation-Sedation Scale (RASS) and the Confusion Assessment Method for the Intensive Care Unit (CAMICU) 12 to 18 hours after their admission to the ICU. Midazolam and fentanyl were then given to all patients according to the sedation protocol. At 36 hours in the ICU, patients who had agitation and an inability to wean were randomly divided into 2 groups: group M, 34 patients who continued to follow the routine sedative protocol; and group D, 38 patients who were given dexmedetomidine. Arterial blood gas measurements, hemodynamic parameters, and time to extubation were recorded. Statistical analysis was performed with GraphPad InStat (version 2.02 for DOS). RESULTS All patients tested positive in the CAM-ICU assessment, and all had a delirium diagnosis. The 38 patients in group D tolerated a spontaneous breathing trial with CPAP and were extubated after a mean (±SD) of 49.619 ± 6.96 hours. The 2 groups had significantly different extubation times (58.389 ± 3.958 hours versus 49.619 ± 6.96 hours). The 2 groups had significantly different RASS scores at 48 and 60 hours and significantly different heart rates and PO2 values at 12 and 24 hours. The 2 groups showed no significant differences with regard to hemodynamic parameters. CONCLUSIONS Dexmedetomidine may help to eliminate the emergence of agitation and can be a good treatment choice for the delirium state after cardiac surgery.

Effect of Normothermic Papaverine to Relieve Intraoperative Spasm of the Internal Thoracic Artery

BACKGROUND After mobilization, vasospasm often reduces flow through the internal thoracic artery. An established method of relaxing the artery and increasing flow is to use papaverine at ambient temperature (20 degrees to 22 degrees C) as a topical vasodilator. However, the pharmacologic actions of papaverine generally have been assessed at 37 degrees C. METHODS In 60 patients in whom the left internal thoracic artery was used for myocardial revascularization, we investigated the effects of normal saline solution at 20 degrees C (group I), papaverine at 20 degrees C (group II), and papaverine at 37 degrees C (group III). Under controlled hemodynamic conditions, free flow was measured before any pharmacologic intervention and a median of 16 minutes after the pedicle had been sprayed with one of the agents. RESULTS Normal saline solution at 20 degrees C produced a small increase in flow from 37.5 +/- 8.1 mL/min to 50 +/- 10.2 mL/min. A significant increase occurred with papaverine at 20 degrees C, from 38.05 +/- 6.5 mL/min to 78.75 +/- 21.2 mL/min (p < 0.0001). Papaverine at 37 degrees C, however, produced an increase in flow from 36.9 +/- 12.6 mL/min to 103.3 +/- 44.6 mL/min (p < 0.0001) and proved to be more effective than papaverine at room temperature (p = 0.0174). CONCLUSIONS We recommend topical use of papaverine at 37 degrees C to relieve intraoperative spasm of the internal thoracic artery.

US-accelerated catheter-directed thrombolysis for the treatment of deep venous thrombosis

PURPOSE We aimed to evaluate the efficacy and feasibility of ultrasonography (US)-accelerated catheter-directed thrombolysis for the treatment of deep venous thrombosis. MATERIALS AND METHODS A total of 26 patients with deep venous thrombosis were prospectively selected for thrombolysis. Overall, 80.8% of the occlusions were in the lower extremities, and 19.2% were in the upper extremities. US-accelerated catheter-directed thrombolysis was performed using a recombinant human tissue plasminogen activator (alteplase), which was delivered using the EKOS EkoSonic® Endovascular System (EKOS Corporation, Bothell, Washington, USA). Postprocedure venography was repeated after the treatment, which included angioplasty and stenting if stenosis was present. RESULTS Thrombolysis was successful in 92.3% (24/26) of the patients, with complete clot lysis in 14 patients and partial clot lysis in nine patients. The mean symptom duration was 54.9±51 days (range, 6-183 days), and the mean thrombolysis infusion time was 25.3±5.3 hours (range, 16-39 hours). Pulmonary embolism was not observed; however, there were three cases of bleeding at the catheter insertion site. In three patients, the underlying lesions were successfully treated with balloon angioplasty and stent insertion. Two patients developed early recurrent thrombosis due to residual venous obstruction. CONCLUSION US-accelerated thrombolysis was demonstrated to be a safe and efficacious treatment for deep venous thrombosis in this study. The addition of US reduces the total infusion time and increases the incidence of complete lysis with a reduction in bleeding rates. Residual venous obstruction should be treated by angioplasty and stent insertion to prevent early rethrombosis.

Comparison Between Local and General Anesthesia for Carotid Endarterectomy: Early and Late Results

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.

Endovenous Laser Ablation of Incompetent Perforating Veins with 1470 nm, 400 μm Radial Fiber

OBJECTIVE To evaluate the efficacy of endovenous laser ablation (EVLA) of incompetent perforating veins (IPVs) with 1470 nm laser with 400 μm radial fiber. BACKGROUND DATA EVLA for perforating veins can be performed with insignificant postprocedural morbidity. This allows treatment to be offered to elderly patients with comorbidities that would preclude anesthesia for surgical treatment or subfascial endoscopic perforator surgery (SEPS). METHODS A total of 24 perforating veins in 16 limbs of 13 patients were treated between July 2010 and December 2011 in our clinic. Follow-up duplex scans were performed at 1 week and 1, 3, 6, and 12 months after the procedure, to determine the treatment outcome. RESULTS Of the 23 treated IPVs, 20 (86.9%) were occluded on the duplex examination at 12 months. The average energy administrated per perforating vein treated was 174 J (range 105-236 J). Four of five ulcers had healed after 8 weeks in clinical-etiology-anatomy-pathophysiology (CEAP) C6 group. Two patients reported localized paresthesia, which subsided spontaneously, but no deep venous thrombosis or skin burn was observed. All components of the Venous Clinical Severity Score (VCSS) demonstrated significant improvements at each postprocedural visit (p<0.001 for all), except for pigmentation and compression, which exhibited variation throughout the follow-up period. CONCLUSIONS Especially in the case of liposclerotic or ulcerated skin in the affected region, EVLA of IPVs with 1470 nm diode laser is highly effective and safe, and appears to be feasible. Additionally, repeat treatment can easily be performed should recurrence of IPVs arise.

Resection of a Right Coronary Artery Aneurysm With Fistula to the Coronary Sinus

We are reporting the successful surgical management of a challenging right coronary artery aneurysm with a giant fistula into the coronary sinus. We performed fistula division, coronary sinus size reduction, and complete resection of the right coronary artery aneurysm with bypass to the posterior descending artery.

A case of prosthetic mitral valve Brucella endocarditis complicated with torsades de pointes.

Brucella endocarditis is a zoonosis transmitted by contaminated dairy products. Endocarditis is a rare complication of brucellosis and mainly the aortic valve is infected. We present the case of a female patient with prosthetic mitral valve endocarditis associated with QT prolongation and torsades de pointes. Transesophageal echocardiography revealed vegetation on both anterior and posterior mitral annulus. She was seropositive with Brucella agglutination titers of up to 1/320. The QT interval was markedly prolonged upon admission (QTc 530 ms). She experienced torsades de pointes several times. She underwent reoperation under an appropriate antibiotic regimen. She continued on triple antibiotic therapy for 12 months. She is now well and free of symptoms.