Ismihan Selen Onan

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.

Cerebral Perfusion During Cardiopulmonary Bypass in Children: Correlations Between Near‐Infrared Spectroscopy, Temperature, Lactate, Pump Flow, and Blood Pressure

Near-infrared spectroscopy (NIRS) is a noninvasive modality to monitor regional brain oxygenation (rSO(2) ). In this study, we aimed to investigate the correlation between cerebral rSO(2) and lactate, pump flow, hematocrit, pCO(2) , and mean blood pressure (MBP) during cardiopulmonary bypass (CPB). Between March and September 2011, 50 pediatric patients who underwent congenital heart surgery were enrolled into the study. Ages ranged from 6 days to 168 months (median 14 months). A NIRS sensor (Somanetics 5100B, Troy, MI, USA) was placed on the right forehead of patients. CPB period was divided into five stages: 1-at the beginning of CBP, 2-cooling at 32°C, 3-at final hypothermic temperature, 4-rewarming at 32°C, 5-before weaning from CPB. Data collection included measurements of each parameter at five stages of CPB. Data were analyzed using multivariate analysis within groups and Spearmans correlation to test association between parameters. Lactate levels increased significantly from stage 1 to stage 5 during CPB (P < 0.05). There was no significant correlation between cerebral rSO(2) and MBPs, pump flows, hematocrit, or pCO(2) during CPB. Cerebral rSO(2) levels showed changes between the stages; there was a significant increase during cooling period, compared to stage 1 (P < 0.05). Significant changes during cooling stage did not happen for other parameters. At stage 3, there was a negative correlation between lactate level and MBP. At stage 4, there was no significant change in cerebral rSO(2) levels despite decreased MBP. At the warming stage, low MBPs, but normal rSO(2) values, are observed despite increased pump flows. Increased rSO(2) levels despite insignificant changes at other parameters during the cooling stage of CPB may show that optimal pump flow with adequate intravascular volume may provide effective cerebral perfusion even without changes in MBP. Considering normal rSO(2) values during CPB in this study, it may be speculated that brain protection can be assessed by using NIRS and applying a standard bypass protocol.

Extracorporeal Life Support Experiences of a New Congenital Heart Center in Turkey

Extracorporeal life support (ECLS) provides mechanical support following cardiac surgery when respiratory and cardiac failure occurs. We retrospectively reviewed medical records of patients who needed ECLS at a new congenital heart center in Turkey. Between December 2009 and February 2012, 616 congenital heart operations were performed. A total of 13 patients (seven female) underwent ECLS. The ages of the patients ranged between 16 days and 33 years. There were two neonatal, seven infant, three pediatric, and one adult congenital cases. Medos DPII ECLS system was used in all patients. Mean duration of ECLS was 6.2 ± 5.8 days (ranged from 29 h to 24 days). While central vascular access with aorta and right atrial cannulation was used in 11 patients, neck vessels were used in the other patients. Four patients (30.7%) weaned successfully from ECLS (two infant, two pediatric cases). Three of them had ECLS intraoperatively. In all patients, two (15.4%) were discharged from the hospital. One of them had mild neurologic deficit. Bleeding from the surgical and cannulation sites was the most common complication. Thrombus was detected in pump head and changed uneventfully in three patients. Arterial pH and lactate levels at the beginning of ECLS were significantly lower in patients who were successfully weaned from ECLS than nonsurvivors (P = 0.04 and P = 0.02, respectively). ECLS can be a lifesaving modality in the perioperative period. It may be more beneficial if ECLS is used before the development of severe acidosis and high lactate levels.

Peroneal Nerve Palsy Caused by Popliteal Pseudoaneurysm in A Child with Hereditary Multiple Exostosis

A 12-year-old boy with a family history of hereditary multiple exostosis presented with a 3-week history of progressive knee swelling. The clinical examination revealed drop foot and a loss of extension in his right knee. Evaluation with color duplex ultrasonography, computed tomography angiography, and magnetic resonance imaging revealed a popliteal artery pseudoaneurysm associated with exostosis from the distal femur. This patient was diagnosed as having peroneal neuropathy caused by popliteal artery pseudoaneurysm compressing the nerve in the right popliteal fossa. The pseudoaneurysm was repaired primarily, and the exostosis was excised during the operation. Pain and knee contracture resolved after surgery. The patient was then referred to physical therapy for the management of drop foot.

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.

Coronary Artery Bypass Grafting in Cold-Induced Urticaria

Cold-induced urticaria is an unusual systemic disorder that develops in response to exposures to cold temperatures in susceptible individuals. Patients with cold urticaria are potentially at risk of severe systemic anaphylactic shock-like reactions. This disorder is of unique clinical importance in cardiac surgery, considering the use of cardiopulmonary bypass and hypothermia. Contact of blood with hypothermia and subsequent warming can be associated with hemodynamic instability, hypotension, and cardiovascular collapse, mainly during the period of rewarming. We report the case of a 41-year-old woman with chronic cold-induced urticaria, who underwent a successful coronary bypass grafting, and describe perioperative management of this rare disorder.

Clinical Outcome of Patients in a Start-Up Congenital Heart Surgery Program in Turkey

This study summarizes the clinical outcome data of a start-up congenital heart surgery program in Turkey. Between December 2009 and February 2012, 616 operations have been performed in 132 newborns (22%), 260 infants (42%), and 224 children/adolescents (36%). Risk adjustment analysis was performed using the risk adjustment in congenital heart surgery (RACHS-1) risk assessment model. There were 66 mortalities (10.7%). According to the RACHS-1 categories, there were 51 cases in level I (8.2%) with no mortality (0%), 250 in level II (40.6%) with 11 (4.4%) mortalities, 199 in level III (32.3%) with 33 (16.5%) mortalities, 53 in level IV (8.6%) with 10 (18.8%) mortalities, 14 in level V and VI (2.2%) with 11 (78.5%) mortalities, and 49 cases (7.9%) out of the RACHS-1 categories with one (2.0%) mortality. Mortality was higher in neonates compared to infants, and in infants compared to children/adolescents. Mortality was higher in palliative procedures compared to corrective procedures. The data demonstrate that a start-up program with a relatively loaded surgical volume may achieve acceptable clinical results with a good teamwork. Collaboration of anesthesiologists, perfusionists, pediatric cardiologists, intensivists, and cardiovascular surgeons is necessary to provide a better outcome in congenital heart surgery.

Factors affecting perioperative mortality in tetralogy of Fallot

We evaluated the preoperative, operative and postoperative risk factors affecting early mortality in patients who underwent total correction of tetralogy of Fallot (TOF).

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.

Robotically enhanced coronary artery bypass grafting: the feasibility and clinical outcome of 196 procedures.

The aim of this study was to assess the feasibility of robotically enhanced myocardial revascularization and to present the clinical outcome of 196 patients.