Ertan Onursal

A complication of pectus excavatum operation: endomyocardial steel strut.

An 18-year-old patient who had correction of pectus excavatum deformity in our department 4 years earlier was admitted because of stabbing chest pain. He had not attended to postoperative controls and had not come for extraction of the steel strut, although he had been contacted. He was diagnosed to have a broken steel strut, and the strut was noted to be embedded in the myocardium. This unreported complication of pectus excavatum operation forced us to review sternal support techniques.

The benefits of continuous ultrafiltration in pediatric cardiac surgery

Background—Systemic inflammatory response and capillary leak syndrome, caused by extracorporeal circulation, have negative effects on the function of vital organs during the postoperative period. Modified ultrafiltration (MUF) has been developed as an alternative method to reduce the detrimental effects of cardiopulmonary bypass. The aim of this prospective, randomized study is to analyze the effects of MUF in a pediatric population undergoing congenital cardiac surgery. Methods—Twenty‐seven patients who underwent open‐heart surgery at our institution were included in this prospective study. They were randomized into two groups as follows: Group I (n=14) of conventional ultrafiltration during bypass and Group II (n=13) receiving both conventional and modified ultrafiltration during and after the cessation of the bypass, respectively. The amount of prime volume, postoperative chest drain loss, transfusion requirements, hemodynamical parameters, duration of mechanical ventilatory support, and length of intensive care unit stay were compared between the two groups. During the postoperative period, the concentrations of hematological, biochemical and inflammatory parameters were also compared by analyzing the blood samples obtained at various time points. Results—MUF resulted in a significant increase in hemoglobin, hematocrit and platelet levels, and significantly reduced the amount of chest tube output and transfused blood and blood products. MUF also shortened the duration of postoperative mechanical ventilatory support, length of the intensive care unit stay and improved postoperative hemodynamical parameters. During the early postoperative hours, IL‐8 is significantly reduced in patients undergoing MUF, however, the concentrations of IL‐8 were similar in both groups at the end of 24 h. Conclusions—MUF decreases the duration of mechanical ventilatory support, the length of intensive care unit stay, the need for blood transfusion and improves postoperative hemodynamics. It is associated with increased levels of hemoglobin, hematocrit and platelets. We can conclude that MUF attenuates the inflammatory response by decreasing the levels of inflammatory mediators.

Surgical Treatment of Cardiac Echinococcosis: Report of Eight Cases

Abstract Cardiac involvement of hydatid disease is uncommon, and establishing a diagnosis is difficult because the presenting symptoms are variable. Between 1985 and 1997, eight patients ranging in age from 8 to 56 years underwent surgical excision of cardiac hydatid cysts, located in the interventricular septum in two, the right atrium in one, and the intrapericardium in five. There was one hospital death due to septic shock, but the other seven patients recovered uneventfully.

Peri-operative comparison of different transient external shunt techniques in bidirectional cavo-pulmonary shunt

OBJECTIVE In patients with functional single ventricular physiology, the avoidance of cardiopulmonary bypass offers many advantages including earlier extubation, decreased necessity of inotropic support, improved hemodynamical status and reduced likelihood of post-operative prolonged pleural effusion. We believe that the bidirectional cavopulmonary anastomosis operations may be performed with transient external shunt techniques. The purpose of this prospective study is the peri- and post-operative comparison of different transient external shunt methods used in bidirectional cavopulmonary shunt operations. METHODS Between years 1997 and 2000, 30 patients have undergone bidirectional cavo-pulmonary shunt operation by using three different types of external shunt. The mean patient age was 13 months (range, 3 months-3 years). Previous operations had been performed in ten patients (33%). All patients were divided into three groups according to type of external shunt used. In group A (ten patients), the transient external shunt was constructed between superior vena cava and right atrium by uniting two standard venous cannulas with a Y-connector. In group B (ten patients), the external shunt was performed with a single short venous cannula constructed between superior vena cava and right atrium. In group C (ten patients), the external shunt was constructed between superior vena cava and left pulmonary artery by using a single short venous cannula. During operation, central venous pressure (CVP), arterial O(2) saturation and mean arterial blood pressure were recorded continuously. RESULTS All operations are completed without the establishment of cardiopulmonary bypass. Hospital mortality was 3.3%. One patient in group A died because of low cardiac output at the end of postoperative day 2. All patients were extubated within 4h. In groups A-C mean superior vena caval pressures were measured 28, 24 and 21 mmHg, respectively during superior vena cava-right pulmonary artery anastomosis. In both groups A and B patients, arterial O(2) saturation decreased to a minimum 53+/-2 and 53+/-2%, respectively during the operation. In the group C, minimum arterial O(2) saturation was measured 82+/-2%. Although mean arterial pressure decreased in all groups during clampage; in group C patients, this drop is not significant. CONCLUSION Based on the study presented here, bidirectional cavo-pulmonary anastomosis can be carried out by using different types of transient external shunt. The best hemodynamical condition and arterial O(2) levels were achieved with the shunt constructed between superior vena cava and left pulmonary artery.

Aneurysm of the kinked extracranial internal carotid artery case report and review of the literature.

Aneurysms at the extracranial portion of the internal carotid artery are rare disorders. In the largest series, McCollum reported only 37 cases over a 21 year period (1) and Moreau reported 35 cases over a 24 year period (2). This uncommon but interesting vascular disorder usually presents as a parapharyngeal pulsatile mass. It can be partially or completely thrombosed and can thereby cause embolization or compression of neuronal vasculature. Ruptures and ischaemic events are other complications. Therefore the mortality rate in nonoperated patients is very high. The major etiologic factor is atherosclerosis. Sometimes, trauma may be another cause. Surgery is recommended for symptomatic aneurysms in patients at all ages. The aim of this paper is to report the symptoms and clinical findings of a patient with a kinked extracranial internal carotid artery with aneurysm and to review the literature.

Results of surgical treatment for infective endocarditis in children

OBJECTIVE Infective endocarditis is uncommon condition, with a high degree of morbidity and mortality. It is less common in children, albeit tending to be associated with congenital cardiac malformations. We describe our experience of the need for surgical treatment in children with infective endocarditis. PATIENTS AND METHODS We analyzed retrospectively the records of 9 children aged below 16 years seen between May 2003 and March 2005 with infective endocarditis, reviewing the demographic details, clinical presentation, microbiological and echocardiographic data, operative findings, and outcome. RESULTS Apart from pre-existing renal insufficiency in 1 patient, congenital cardiac malformations were the predisposing factors. Blood cultures were positive in 3, but remained negative in the other 6 patients. The indications for surgical treatment included uncontrolled sepsis, congestive heart failure, recurrent endocarditis, patch or graft dehiscence, and pseudoaneursymal formation. Death due to uncontrolled sepsis resulting in multiorgan failure occurred in 1 patient, who had tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries. Another patient died late postoperatively due to cardiac failure after relapse of the endocarditis in the setting of negative blood cultures. CONCLUSION Despite advances in antimicrobial therapy, diagnosis, and measures of treatment for infective endocarditis, complications continue to be responsible for substantial morbidity and mortality. Since blood cultures are frequently negative, clinical and echocardiographic findings should be the major determinants of strategies used for treatment. We believe that our small series of patients seen over the past two years in which surgical treatment was performed will be helpful in guiding the clinical perspectives for children with infective endocarditis.

Influence of methylprednisolone on levels of neuron-specific enolase in cardiac surgery: a corticosteroid derivative to decrease possible neuronal damage.

Abstract  Background: Cerebral injury is a well‐known complication after cardiac surgery with cardiopulmonary bypass (CPB), especially in adult patients. Specific biochemical markers like neuron‐specific enolase (NSE) and S‐100β protein were developed previously for early detecting neuronal damage after CPB. Corticosteroids are shown to reduce multisystemic deleterious effects of cardiopulmonary bypass due to their anti‐inflammatory characteristics. The aim of this study is to demonstrate the decrease of serum neuron‐specific enolase levels in patients who received corticosteroids before CPB. Methods: Thirty patients scheduled for elective coronary bypass surgery were included in the study. Patients were divided randomly into two groups as the control group (n = 15) who underwent a standard coronary bypass surgery without any additional medication and the study group (n = 15) who received 1 gm of methylprednisolone before CPB. Blood samples for analysis of serum NSE, interleukin‐6 (IL‐6), and IL‐10 were drawn before CPB, 4 and 24 hours after the end of extracorporeal circulation. Results: Serum cytokine and NSE levels were significantly increased after CPB above their normal range in both groups. In the study group, IL‐6 and NSE levels were significantly reduced while IL‐10 levels were much higher after CPB. High NSE levels significantly correlated with IL‐6 levels in the control group. Conclusion: The lower levels of NSE in patients who received methylprednisolone may suggest that corticosteroids might be useful in decreasing possible neuronal damage during heart surgery. However, we were not able to demonstrate an adverse neurological outcome.

Results of surgical treatment for nonthymomatous myasthenia gravis.

AbstractPurpose. To clarify the factors that influence improvement and remission after thymectomy for patients with nonthymomatous myasthenia gravis (MG). Methods. We retrospectively reviewed 204 patients with nonthymomatous MG who underwent thymectomy and anterior mediastinal dissection through a partial median sternotomy, between 1980 and 2001, and examined whether age, sex, preoperative classification, and duration of symptoms influenced their prognosis. Results. There was no perioperative or hospital mortality. The mean follow-up period was 7.2 ± 1.2 years, with early and late postoperative remission rates of 44.6% and 73%, respectively. Seven patients died; two from pneumonia and five from causes unrelated to MG. Preoperative treatment and classification, duration of symptoms, age, and sex did not seem to have a significant influence on remission, but the response to thymectomy was greater in patients with thymic hyperplasia. Remission and improvement rates were significantly better at the end of the first year, with the same status found at the last follow-up. Conclusion. Thymectomy is an effective and highly curative method of treatment for patients. with MG. It provides excellent symptomatic improvement, which is enhanced over the long term.

Unusual complication of femoro-popliteal saphenous vein bypass—Aneurysm formation

An aneurysm as an unusual complication of saphenous vein bypass for femoro-popliteal occlusive disease is reported. The aneurysm developed 1 year following the bypass procedure. A diagnosis of Behçets disease based on microscopic immunological examination and the clinical picture was suspected following successful aneurysmectomy.

Over 14 years of experience with cardiac myxomas

Atrial myxomas are the most commonly encountered tumours of the heart and can present at different ages with different clinical symptoms. They are one of the curable tumours of the heart. Appropriate surgical treatment and surgery must be performed with great precautions in order to prevent fatal systemic embolizations. In this retrospective study we will present our experience of 14∞∞years, between 1990 and 2004, in 27∞∞patients who had been operated for cardiac myxomas. Diagnosis of the myxomas were made by echocardiography in all cases. Surgical approach to the tumour was biatrial in nine, left atrial in 11, and transseptal in seven patients.Associated procedures included coronary artery bypass grafting in one, mitral valve repair with tricuspid annuloplasty in two patients, mitral valve replacement in one and bilateral femoral embolectomy in one patient. One hospital mortality occurred as a result of multiorgan failure in a patient with peripheral embolization. None of the patients required recurrent operation, however, mitral valve insufficiency was surgically corrected in one patient.