Harun Arbatli

A fatal complication due to radiofrequency ablation for atrial fibrillation: atrio-esophageal fistula

Treatment of chronic atrial fibrillation with intraoperative radiofrequency ablation is gaining more acceptance in patients with rheumatic valve disease. This article reports a case of fatal atrio-esophageal fistula after radiofrequency ablation in a patient with rheumatic mitral and aortic valve disease with chronic atrial fibrillation.

Ventral cardiac denervation reduces the incidence of atrial fibrillation after coronary artery bypass grafting

OBJECTIVES Because the autonomic nervous system is an important determinant in the appearance of atrial fibrillation, we have assessed the role of ventral cardiac denervation for its prevention. METHODS Patients undergoing low-risk coronary artery surgery were enrolled. No routine antiarrhythmic drugs were administered before or after the operation. Ventral cardiac denervation was performed in 207 patients, and 219 patients were used as control subjects. Denervation was performed before cardiopulmonary bypass. The groups were comparable regarding demographic, clinical, and operative variables. RESULTS The additional time for the denervation was 5 +/- 2 minutes, and there were no associated complications. Postoperative atrial fibrillation was present in 15 (7%) patients undergoing ventral cardiac denervation (95% confidence interval, 4%-12%) and in 56 (27%) control subjects (95% confidence interval, 18%-35%). Patients submitted to ventral cardiac denervation had fewer and less severe episodes of atrial fibrillation, and no patient had atrial fibrillation after discharge. Ventral cardiac denervation was the most significant predictor of postoperative atrial fibrillation (odds ratio, 0.42; confidence interval, 0.23-0.78; P =.006). Age of greater than 65 years (odds ratio, 1.67; confidence interval, 0.96-2.9; P =.067) was a highly suggestive predictor. The analysis of the effect of ventral cardiac denervation correlated with the patients age showed a more pronounced effect in patients younger than 70 years (odds ratio, 0.43; confidence interval, 0.22-0.86; P =.022) CONCLUSIONS Ventral cardiac denervation is a fast and low-risk procedure. Its use significantly reduces the incidence and severity of atrial fibrillation after routine coronary artery bypass surgery. Patients younger than 70 years of age are expected to have a higher success rate than those older than 70 years.

Total endovascular aortic arch reconstruction via fenestration in situ with cerebral circulatory support: an acute experimental study

The aim of this experimental study is to evaluate the feasibility of endovascular repair of the complete aortic arch by using novel fenestration devices with simultaneous support of the cerebral circulation. Two fresh human cadavers and five Yorkshire pigs were used for the experiments. In human cadavers the thoracic aorta was pressurized using a roller pump to simulate the circulation. In animal experiments right femoral artery to right distal carotid artery bypass circuit was achieved in order to support the cerebral circulation during the stent graft deployment, fenestration and conduit fixation procedures. Commercially available Valiant Thoracic Stent Grafts, covered stents, steerable guiding catheters and dilatation balloons were used. Stent grafts were deployed successfully and two fenestrations and one conduit implantation were achieved in each cadaver. All animals survived the stent graft implantation, fenestration and conduit implantation procedures. Cadaver dissection and necropsy of the animals revealed good fixation of the conduits into the fenestrated segments of the stent graft. Endovascular repair of the total aortic arch via in situ fenestration of the stent graft using cerebral circulatory support seems to be feasible and safe. Further studies are required before clinical adoption of this procedure.

Coronary bypass grafting via minithoracotomy on the beating heart

BACKGROUND Recently the availability and the superiority of less invasive coronary artery bypass grafting on some selected groups of patients in the meaning of patient comfort and short hospital stay has been shown by some authors. We present here the clinical results of 40 patients operated on by minithoracotomy incision on the beating heart without using cardiopulmonary bypass mostly harvesting the left internal thoracic artery by videothoracoscopic assistance. METHODS Between March 1996 and September 1996, 40 patients were operated on by harvesting the left internal thoracic artery mostly by video-assisted thoracoscopy and performing bypass through a minitoracotomy incision. Two patients in whom the procedure was switched to conventional technique were not included in this series. Nine of the patients were female and the rest were male. The mean age was 43.2 +/- 7. RESULTS Left internal thoracic arteries were harvested by video-assisted thoracoscopy completely in 11 patients, incompletely in 24 patients (the harvesting was completed by direct vision afterwards), and under direct vision in 5 through a mini-anterior thoracotomy incision. Thirty-six patients received a bypass graft to left anterior descending coronary artery only, whereas 4 received a diagonal branch graft also. Left internal thoracic arteries were used to bypass the left anterior descending coronary artery directly in 38 patients. The left internal thoracic artery was injured in the middle portion during harvesting in 1 of the remaining 2 patients. The length was not enough in the other. A short saphenous vein graft was interposed between the left internal thoracic artery and the left anterior descending coronary artery in these 2 patients. There was no mortality. One patient had perioperative myocardial infarction. We did not see serious morbidity except one lung injury due to the trochar. CONCLUSIONS The results obtained from our experience suggest that coronary artery bypass grafting by minithoracotomy could be applied effectively and safely without overwhelming additional risk to the patient. Furthermore, it has some advantages in reducing operative trauma and cost and also improving patient comfort.

Real-time patency control with thermal coronary angiography in 1401 coronary artery bypass grafting patients

OBJECTIVE Intraoperative coronary angiography has always been favoured by cardiac surgeons. Thermal coronary angiography (TCA) is a useful method for intraoperative control of graft patency. It detects heat differences between tissues, provides easy-to-interpret angiographic images and even measures the flow of the grafts quantitatively. METHODS Between January 2000 and January 2002, TCA has been used in scheduled coronary bypass operations. Upon completion of each distal anastomosis, the perfusion of the distal arterial tree from the graft was evaluated with a thermal camera. RESULTS TCA was applied to 1401 patients, mean age 60.97+/-9.61 years, who underwent simple coronary artery bypass grafting (CABG) procedures. A total of 4105 thermal images were obtained including 2161 venous, 1355 single internal thoracic artery (ITA), 56 bilateral ITA and 477 radial artery grafts. Image quality was not sufficient in 34 grafts (1.57%) due to either deep intramyocardial vessels or excessive epicardial fat tissue. Technical failures in three ITA anastomoses were detected and revised before the cross-clamp was removed. Flow-restricting lesions distal to the anastomosis on the left anterior descending artery (LAD) in nine patients were managed with a secondary distal bypass graft (five patients) or plaque splitting and anastomotic revision (four patients). Endarterectomy was combined in seven patients since the graft flow and the distal visualization was not satisfactory, although the anastomoses were performed on a good lumen. Angiographically undetected diagonal arteries were revascularized in 11 patients with totally occluded LAD vessels. CONCLUSION Thermal imaging provides decisive coronary angiographies, and detects the perfusion area and flow of the implanted graft. It allows real-time detection of technical failures, reveals unexpected occluding plaques or any kind of flow-restricting lesions, and gives the chance of refinement of the anastomosis during the arrest period. We believe that the thermal imaging technique is a safe, noninvasive and feasible method to document the quality of the myocardial revascularization intraoperatively.

Management of Infected Grafts and Mycotic Aneurysms of the Aorta Using Cryopreserved Homografts

OBJECTIVE To evaluate the efficacy of the treatment of infected prosthetic grafts and mycotic aneurysms of the aorta with cryopreserved homografts. MATERIALS AND METHODS Between April 1994 and May 2002, 15 cryopreserved aortic homografts were used in 13 patients in the thoracic and abdominal aortic position with supplementary omental or pectoral muscle wrapping for infected grafts (n=11), and mycotic aneurysms (n=2) (mean age: 57.5). RESULTS One patient died due to multiorgan failure and the other due to postoperative cerebral hemorrhage (15.38%). Another patient died four months after the operation due to septic arthritis, and coronary heart disease. Ten patients are still alive without evidence of infection (76.92%) during a follow up of 44+/-23.03 (range 4-71) months. CONCLUSION The use of cryopreserved homografts with supplementary omentum and/or muscle flap coverage, assures an anatomical reconstruction with good results in this difficult group of patients.

Dynamic human cadaver model for testing the feasibility of new endovascular techniques and tools

Endovascular device specifications and technical improvements are strongly required, especially in particular anatomical locations such as the aortic arch and the thoracoabdominal aorta. We present a new technique for total endovascular repair of the aortic arch and an experimental design of a circulation model in the human cadaver in order to evaluate the feasibility of this technique.

Endovascular Treatment of an Aortobronchial Fistula

A 67-year-old man operated on 8 years previously for type B aortic dissection presented with two episodes of massive hemoptysis. An aortobronchial fistula was suspected with spiral computed tomography angiography, and showed a small pseudoaneurysm corresponding to the distal anastomotic site. The patient underwent endovascular stent-graft implantation and is asymptomatic 8 months after the procedure.

Deep venous thromboembolism and pulmonary embolization as a rare complication of diagnostic femoral catheterization and prevention of recurrence with inferior vena cava filter prior to cardiac surgery

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are rare complications after diagnostic femoral catheterization. A few clinical cases have been reported, especially in the setting of venous compression with an enlarging haematoma, mechanical groin compression or prolonged procedures. Similarly, clinically evident PE after cardiac surgery is also very rare, but may be catastrophic. In this article, we present a case of PE after silent (symptomless) DVT due to femoral catheterization. The patient had critical coronary artery disease and was a candidate of coronary artery bypass grafting. A inferior vena cava filter was implanted prior to cardiac surgery for prevention of a potential pulmonary embolus.

Repair of Recurrent Patent Ductus Arteriosus in an Adult with Cardiopulmonary Bypass

Abstract Recurrence of ductal patency is a rarely encountered complication in surgical repair of patent ductus arteriosus (PDA). An adult patient with ductal recurrency underwent closure of ductus by using cardiopulmonary bypass via transpulmonary approach. She had significant improvement of symptoms and no residual shunt or pseudoneurysm seven months after surgery. (J Card Surg 2003; 18:17‐19)