Deniz Göksedef

Surgical treatment of subaortic obstruction in adolescent and adults: long-term follow-up.

Abstract  Subaortic stenosis (SAS) is a wide spectrum of anatomical dearrangements 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.

The dose-related effects of dexmedetomidine on renal functions and serum neutrophil gelatinase-associated lipocalin values after coronary artery bypass grafting: a randomized, triple-blind, placebo-controlled study.

OBJECTIVES Acute kidney failure after coronary artery bypass grafting (CABG) is a serious complication that increases morbidity and mortality rates. Early detection and prevention of this complication are very important. A novel biomarker named neutrophil gelatinase-associated lipocalin (NGAL) can play an important role in early diagnosis of acute kidney injury. Recent studies on the favourable effects of Dexmedetomidine on cardiac surgery have been published. The aim of this study is to investigate whether there is a dose-dependent positive effect of Dexmedetomidine on neutrophil gelatinase-associated lipocalin levels and renal functions when used after CABG. METHODS Our randomized, triple-blinded, placebo-controlled study was conducted among 295 patients scheduled for CABG surgery between August 2009 and March 2011 in a tertiary cardiac and vascular surgery clinic. A total of 90 consecutive patients who met inclusion criteria were randomized and divided into three groups. The first group received a placebo. The second and the third groups received 4 and 8 µg/cc concentration of the Dexmedetomidine infusion, respectively. Infusion rates were regulated to obtain sedation with a Ramsey sedation score of 2 or 3. Patients were regrouped according to the total Dexmedetomidine dose. Statistical analyses of variables including serum neutrophil gelatinase-associated lipocalin values and conventional renal function tests were made for all six possibilities before the blind was broken. RESULTS Results of conventional renal function tests were not significantly different. However, neutrophil gelatinase-associated lipocalin levels for the first postoperative day for placebo, low-dose and high-dose Dexmedetomidine groups were 176.8 ± 145.9, 97.7 ± 63.4 and 67.3 ± 10.9 ng/ml, respectively. These values were significantly different among the groups (P <0.001). CONCLUSIONS In our study, we found that Dexmedetomidine infusion for sedation after CABG under cardiopulmonary bypass can be useful in the prevention of kidney injury. Conventional renal function tests, including blood urea nitrogen, serum creatinine, urine output and creatinine clearance rate measurements typically may not detect the development of acute kidney dysfunction in the first 48-h postoperative period. Differences were detected in renal function in the early postoperative period and the development of acute kidney injury, as determined by measurements of blood NGAL levels, was significant and dose-dependent.

An extraordinary cause of ischemic chest pain in a young man: Congenital ostial atresia of the right coronary artery

Chest pain in a young person without cardiovascular risk factors is usually attributed to noncoronary causes; however, if the history suggests ischemic pain, the potential presence of unusual cardiovascular abnormalities should not be disregarded. The present case describes a young man with solitary congenital ostial atresia of right coronary artery, who to our knowledge is only the second case in the medical literature. Manifestation of ischemic symptoms in a relatively advanced age in patients with coronary artery atresia may mislead clinicians to interpret them as signs of atherosclerotic coronary artery disease. Therefore congenital coronary artery atresia should be a part of the differential diagnosis particularly in young patients with ischemic symptoms and no cardiovascular risk factors.

Partial cardiac autotransplantation for reduction of the left atrium.

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.

Reverse “U”Aortotomy for Aortic Valve Replacement After Previous Coronary Artery Bypass Grafting

Abstract  The presence of patent vein grafts on the proximal aorta may give technical difficulties during exposure to aortic valve replacement after previous coronary artery bypass operations. A tongue or reverse “U” shape aortotomy allows excellent exposure of the aortic valve and antegrade cardioplegic administration without mobilizing vein grafts. This approach may facilitate uni‐ or bidirectional aortic root enlargement in patients with small aortic root.

Combined off-pump coronary artery bypass surgery and abdominal aorta aneurysm repair.

There are controversies regarding treatment protocols of concomittant coronary artery disease and abdominal aorta aneurysm, especially when patients have symptoms of both diseases. In this study, we describe the technique of combined off-pump coronary artery bypass grafting and abdominal aorta aneurysm repair succesfully performed in five patients. Coronary revascularization was first performed in all patients. Then repair of abdominal aorta aneurysm was carried out. Simultaneous surgery is believed to shorten cumulative intensive care unit and hospital stay and decrease total hospital costs. Concomitant coronary artery diseases (CAD) and peripheral arterial diseases are frequently seen.1 Combined surgical interventions for both diseases have been performed since 19802 using cardiopulmonary bypass (CPB), but serious mortalities and morbidities, such as massive hemorrhages, cerebral and pulmonary complications have been reported.3 Recently, off-pump cardiac surgery (OPCAB), which is devoid of these devastating side effects, is being performed safely and successfully.

Sequential Radial Artery Grafting Three-Vessel Coronary Artery Disease

Our objective was to compare the results of revascularization by sequential radial artery (RA) grafting with a left anterior descending left internal mammary artery (LIMA)-RA t-composite grafting technique. Patients were grouped as those with proximal anastomoses performed on the ascending aorta (Group A; n = 38), and those with proximal anastomoses performed on the LIMA as t-grafts (Group T; n = 13). Neither of the two groups revealed any mortality. The average number of grafts was lower in Group T (2.23 ± 0.43 in group T and 2.85 ± 0.69 in group A, p < 0.05). The results of the control coronary artery angiographies were superior in Group A. The patency rate of the RA grafts was 96.8% in Group A. Of the 20 distal anastomoses performed with RA grafts in 8 patients from Group T, nine (45%) were found to be patent. The patency rates of RA grafts with sequential distal anastomoses were found to be better when the proximal anastomosis was performed on the ascending aorta rather than on the LIMA. In conclusion, sequential distal anastomosis of RA grafts seem to be safe and effective when proximal anastomoses are performed on the ascending aorta.

Aorta-right atrial tunnel in an adult

Aorta-right atrial tunnel was diagnosed in a non-symptomatic 31-year old female patient. The Q p /Q s ratio was 2.5. Computed tomography and intraoperative views showed a posterior vascular tunnel with left aortic sinus and right atrium openings (Figs 1 and 2). The tunnel had no myocardial branches. We successfully closed both the openings. Figure 1: (A) A reconstructed computed tomographic view of the aorta-right atrial tunnel, which passed along the posterior aspect of the aorta (arrows indicate the tunnel). (B) The aortic origin of the aorta-right atrial tunnel (arrow indicates the origin of the tunnel where a surgical aspirator is situated)

Aortic Root Replacement

Abstract Aortic root replacement (ARR) is a fundamental surgical procedure for all cardiac surgeons and involves a broad spectrum of clinical use in aortic valve and ascending aortic and aortic arch pathologies. In unexpected situations such as urgent proximal aortic dissections, extremely small aortic annulus during elective aortic valve operation, endocarditis extending beyond the aortic annulus, or in elective situations such as aneurysms, poststenotic dilatation, heavily calcified aortic root, and reoperations, total or subtotal ARR is a lifesaving procedure for the patient. Conservative surgical approaches (subtotal) with excellent results should be used when appropriate, but radical aortic root resection may be the only option when the aortic root is totally destroyed. Despite the added complications of aortic valve–sparing procedures, which are chosen to avoid late complications related to prosthetic valves, this option is always preferred whenever possible during total ARR.

Thoracoabdominal aortic mural and floating thrombus extending into superior mesenteric artery

Thrombus in the thoracic aorta not related to aneurysm or atherosclerosis is a rare clinical entity with a limited number of cases reported. Floating thrombus is defined as non-adherent part of the thrombus floating within the aortic lumen. Herein, we present a 48-year-old woman who presented with progressive midline dull, aching abdominal pain of 2-day duration. Thoracoabdominal computed tomography revealed a free floating thrombus extending from the aortic arch into the superior mesenteric artery. Transesophageal echocardiography confirmed the findings of a thrombus extending through the aortic arch. Floating thrombus within the aortic lumen in a morphologically normal descending thoracic and abdominal aorta is a rare entity.