Münevver Yüksel

Primary spontaneous coronary artery dissections in atherosclerotic patients. Report of nine cases with review of the pertinent literature

Primary spontaneous coronary artery dissection is one of the rare causes of acute myocardial infarction. Previous studies reports that it is mostly seen in middle aged women in the last trimester of pregnancy and early postpartum period. Clinical presentation of the disease is variable in pattern and severity related to extent and development rate of dissection. In the last 2 years, nine non-pregnant primary spontaneous coronary artery dissection cases were found in coronary angiography among 3750 patients prediagnosed as coronary artery disease. The cases were presented and discussed with review of the pertinent literature.

Perioperative Risk Factors for Mortality in Patients With Acute Type A Aortic Dissection

BACKGROUND This study was undertaken to identify the perioperative risk factors for death in patients with acute type A aortic dissection (AADA). METHODS Between 1993 and 2001, 108 consecutive patients (86 men; mean age, 53 years) underwent emergent operations for AADA. All patients but 2 underwent replacement of the ascending aorta with an open distal anastomosis during a period of hypothermic circulatory arrest. In addition, 22 patients had hemiarch and 5 had total arch replacement. Aortic root was replaced in 20 and repaired with gelatin-resorcinol-formaldehyde glue in 39 patients; aortic valve was separately replaced in 3, resuspended in 24, and remained untouched in 22 patients. RESULTS Overall in-hospital mortality was 25%. Mortality rate was significantly higher in patients with preoperative dissection complications than in those without (21/36 [58%] vs 6/72 [8%], p < 0.001). In multivariate analysis, predictors of mortality were presence of rupture, renal failure, and intestinal malperfusion, duration of cardiopulmonary bypass > or = 200 minutes, blood loss > or = 500 mL, and transfusion of blood > or = 4 units. Location of the intimal tear, extent of the replacement, type of the aortic root repair, and duration of hypothermic circulatory arrest did not emerge as predictors of mortality. CONCLUSIONS Major determinants of surgical mortality in patients with AADA are preoperative complications. Earlier diagnosis remains essential to improve the survival rate.

Superior Mesenteric Artery Aneurysm

A 38-year old woman with mid-epigastric pain, diarrhea, and weight loss, underwent resection of a superior mesenteric artery aneurysm and primary repair of the artery. Pathological examination showed degenerative atherosclerotic changes, marked medial and intimal thickening, and vegetations. Microbiological studies demon-strated Streptococcus viridans as the infecting organism of this mycotic aneurysm. The patient made a good recovery and remained well after 3 years.

The side-effects of cardiopulmonary bypass on the lungs: changes in bronchoalveolar lavage fluids:

Although technical refinements have improved the safety of cardiac operations, postoperative dysfunction of lung and other organs occurs frequently after cardiopulmonary bypass (CPB). The aim of the present study was to search the aetiopathogenesis of pulmonary complications due to CBP. Ten patients with stable coronary artery disease, undergoing coronary artery bypass grafting (CABG) surgery, were included in the study. Forty bronchoalveolar lavage (BAL) fluid samplings were performed in the 10 patients. Samples were obtained at the following time periods: (1) preoperatively; (2) at the end of the first hour after anaesthetic induction; (3) at the conclusion of 30 min of crossclamp on CPB; and (4) at the conclusion of 20 h after the end of CPB, postoperatively. Cell contents of bronchoalveolar lavage fluid, alveolar macrophage viability, eosinophil cationic protein (ECP) levels and myeloperoxidase (MPO) concentrations were analysed in each bronchoalveolar lavage fluids. While the percentage of preoperative macrophages was 85.90% and the percentage of preoperative neutrophils was 2.40%, they were 77.00% and 11.30% in the postoperative samples, respectively. Mean alveolar macrophage viability was 96.20% preoperatively and 90.40% in the postoperative period. Preoperative eosinophil cationic protein mean concentration was < 2 μg/l and mean response value (RV) was 28.80. Pre-operative mean myeloperoxidase concentration was 7.66 ng/ml. Postoperative eosinophil cationic protein mean response value was 63.40 and mean myeloperoxidase concentration was 59.25 ng/ml. There were significant differences between third and final samples with regard to both neutrophil percentages (p = 0.028) and MPO levels (p = 0.005). While the preoperative mean PaO2 value was 89.39 mmHg and mean SaO2 value was 97.12%, they were calculated in the postoperative arterial blood specimens of patients, without inhaling O2, as 65.31 mmHg and 93.84%. These changes between blood gas analyses reflect the impairment of the lungs (p = 0.009 and p = 0.007, respectively). Neither alveolar macrophage viability nor ECP levels changed significantly between consecutive periods. However, when the results of the first and fourth samples were compared, we saw the cumulative effects of CPB, in that alveolar macrophages lost their viability and ECP mean RVs rose. These changes were statistically significant (p = 0.027 and p = 0.013, respectively). However, postoperative ECP levels were not like those found in a patient with asthma. Also, changes between alveolar macrophage percentages (p = 0.028), between neutrophil percentages (p = 0.036) and between MPO concentrations (p = 0.005) were statistically significant. Again, changes in neutrophil percentages between first and final samples correlated with changes in MPO levels between same periods (r = 0.657, p = 0.039).

CONTINUOUS RETROGRADE CEREBRAL PERFUSION SUPPLIES SUBSTRATES FOR BRAIN METABOLISM DURING HYPOTHERMIC CIRCULATORY ARREST

Ten patients underwent replacement of ascending aorta and/or aortic arch with aneurysm or dissection, using hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP). RCP was administered through the superior vena cava cannula continuously during HCA (15°C to 20°C). Mean HCA time was 32 minutes (range, 18-45 minutes). To assess the metabolic changes during RCP, blood samples were taken from carotid arteries and the superior vena cava cannula simultaneously, five minutes after the onset and five minutes prior to termination of continuous retrograde cerebral perfusion (CRCP) for analysis of blood gas and glucose level. One patient died intraoperatively due to left ventricular failure. Nine patients survived their operations and all except one with stroke due to partial intimal flap obstruction of innominate artery awoke neurologically intact within four to six hours. One patient died on the postoperative fifth day due to septic shock following resection of ischaemic bowel due to dissection involving the mesenteric artery. Oxygen saturation, pH and glucose level were all found to be lower in blood back-bleeding from the carotid arteries than in blood perfused through the superior vena cava cannula at all sampling times during HCA and CRCP (p < 0.05). Although oxygen and glucose extraction is not only from brain tissue, these data demonstrate the efficacy of CRCP in supplying substrates for brain protection. CRCP is a reliable method as an adjunct to HCA for brain protection.

Effects of coronary artery bypass surgery on diastolic and systolic parameters of left ventricle in Type II diabetic patients

Diabetes mellitus itself can cause systolic and diastolic dysfunctions of the left ventricle in the absence of atherosclerotic coronary artery disease. Effects of coronary bypass surgery on the left ventricular functions of Type II diabetic patients having atherosclerotic coronary artery disease were investigated. Forty-eight Type II diabetic and 63 nondiabetic multivessel coronary artery disease patients who had no differences in age, sex, drugs used, number of revascularized arteries and aortic cross-clamp time were included in the study. Doppler echocardiographic examinations before and 6 months after operations were made, and early diastolic flow (E), atrial contraction (A), deceleration (DT) and isovolumetric relaxation time (IVRT), E/A ratio and systolic parameters like end-diastolic volume, end-systolic volume, stroke volume and left ventricular ejection fraction (LVEF) were measured in sequence. Preoperative and postoperative echocardiographic measurements were compared in the same group and between groups by paired t and Students t tests, respectively. P<.05 was accepted as statistically significant. E, A, E/A, DT, IVRT and LVEF were significantly improved after coronary bypass surgery in Groups I (P<.001, P<.01, P<.001, P<.01, P<.0001, P<.01) and II (P<.05, P<.05, P<.001, P<.001, P<.001, P<.001). Statistical comparison of values between groups showed better recovery in diastolic and systolic functions of diabetic and nondiabetic patients, respectively. It was concluded that Type II diabetic coronary patients by time could gain as much as the same benefit from coronary bypass surgery that nondiabetic patients had.

Left Ventricular Aneurysm Repair with Endoaneurysmorrhaphy Technique: An Assessment of Two Different Ventriculotomy Closure Methods.

BACKGROUND Left ventricular aneurysm is a serious mechanical complication of myocardial infarction and has an incidence of 10-35% after myocardial infarction. Ventricular aneurysm in patients with angina, heart failure, and ventricular arrhythmia should be surgically treated. Endoaneurysmorrhaphy is one of the repair techniques that results in better left ventricular geometry and function. After this surgical procedure the ventriculotomy is repaired either with Teflon felt strips or by direct suture of the epicardium. METHODS In this study, we described the postoperative early outcomes of two ventriculotomy closing techniques such as Teflon felt versus direct closure after aneurysm repair. This retrospective study included a total of 73 patients (mean age > 70 years) with left ventricular aneurysm, who underwent endoaneurysmorrhaphy repair between 1997 and 2009. All selected patients were divided into two groups according to the ventriculotomy closure technique either by Teflon felt or direct by epicardial closure. The pre-, intra-, and postoperative results of these patients were analyzed accordingly. RESULTS The postoperative early mortality rate and postoperative bleeding were not significantly different between the Teflon felt and primary closure groups (P = .246 and P = .371 respectively), but postoperative arrhythmias were significantly higher in the Teflon felt repair group (P = .049). CONCLUSION Endoaneurysmorrhaphy is a better surgical technique in left ventricle aneurysm to restore the internal contour and preserve the surface anatomy of the ventricle. The ventriculotomy closure can be performed with two different approaches, including Teflon felt strips or by direct suture of the epicardium. Based on this studys findings, two repair techniques have similar impact on the early outcomes. However, with overall outcomes with respect to Teflon felt repair, direct closure of the ventriculotomy after endoaneurysmorrhaphy was superior.

Intrapulmonary Hematoma and Hemothorax following Penetrating Chest Injury

Hemothorax and intrapulmonary hematoma were successfully treated in a 25-year-old male who suffered a penetrating chest injury. This very rare combination of clinical entities in the same patient is discussed in the light of pertinent literature.

Simple and Cost-Effective Gas Jet for Non-Pump Coronary Bypass Surgery

A gas jet is one method of achieving a bloodless surgical field. We describe a simple and cost-effective oxygen blower system for coronary artery bypass surgery performed without cardiopulmonary bypass.

Extracardiac Unruptured Sinus of Valsalva Aneurysm Presenting with Aortic Incompetence

We report a case of extracardiac unruptured aneurysm of the noncoronary sinus of Valsalva presenting with massive aortic regurgitation and high fever. The preoperative evaluation, echocardiographic and cardiac catheterization findings, and surgical management of this rare condition are discussed.