Muzaffer Bahcivan

Idiopathic true brachial artery aneurysm in a nine-month infant

Upper extremity peripheral artery aneurysms are a rarely encountered arterial disorder. Brachial artery aneurysms seen in the pediatric age group are generally trauma resultant. A nine-month-old male infant patient presented with complaints of an asymptomatic mass in the arm. Following Doppler ultrasonography and magnetic resonance imaging (MRI) examinations, saccular aneurysm, originating from the left brachial artery was diagnosed in the patient without history of trauma. The aneurysm was resected by surgical intervention, and primary repair of the brachial artery was performed by end-to-end anastomosis. No complication was observed during the follow-up. Surgical intervention for upper extremity aneurysms should be initiated without delay in order to prevent extremity ischemia and amputation.

Inhibition of vein graft intimal hyperplasia by periadventitial application of hyaluronic acid–carboxymethyl cellulose: An experimental study

Objective. Placement of an external support has been reported to prevent intimal hyperplasia of vein grafts. In this study, we investigated the effect of HA/CMC on intimal hyperplasia in a rabbit model. Design. Right jugular vein to common carotid artery bypass grafting was performed in 24 female New Zealand white rabbits (2.5–3.0 kg). Animals were divided into two groups: control group (n=12) and HA/CMC group (n=12). Absorbable membrane barrier was wrapped around vein grafts in HA/CMC group. In control group, no material was applied following venous graft bypass. Results. At 1 month, in the vein grafts supported with the HA/CMC membrane neointimal thickening was significantly less (109 µm [IQR, 78–166]) compared to the unsupported control grafts (220 µm [IQR; 101–312]; p<0.001). Medial thickening in the HA/CMC group (128 µm [IQR, 101–181]) compared to unsheathed control grafts (182 µm [IQR, 131–255] p<0.001) was also significantly less. Conclusion. Periadventitial placement of HA/CMC as an absorbable membrane inhibits intimal hyperplasia of vein bypass grafts in a rabbit model.

Endothoracic Papaverine Application for Internal Thoracic Artery Harvest

This study compared the effects of different methods of papaverine application on free blood flow and harvesting time of the internal thoracic artery for coronary bypass grafting. Patients were randomly divided into 3 groups of 25 each: group 1 had papaverine injected into the endothoracic tissue around the internal thoracic artery before dissection, group 2 had papaverine injected into the periarterial tissues of the internal thoracic artery pedicle, and group 3 had intraluminal papaverine applied retrogradely into the internal thoracic artery. Mean blood flow was 56.3 ± 21.3, 21.1 ± 13.2, and 20.9 ± 9.1 mL · min−1 in groups 1, 2, and 3, respectively, immediately after harvesting. Flow in group 1 was significantly better than that in groups 2 and 3. Immediately before anastomosis, mean flow was 89.8 ± 19.1, 97.6 ± 35.4, and 95.9 ± 19.9 mL · min−1 in groups 1, 2, and 3, respectively, with no significant difference among groups. Internal thoracic artery harvesting times were shorter in group 1 than in groups 2 and 3. Administering papaverine into the endothoracic fascia of the internal thoracic artery bed prior to dissection is a reliable method that facilitates rapid harvesting of the graft without causing trauma and consequent spasm.

A Rare Cause of Pulmonary Emboli in a Patient with Deep Vein Thrombosis: Doppler Ultrasonographic Compressibility Maneuver

Deep vein thrombosis (DVT) often begins in the calf veins or around the venous valves in the solar plexus in the lower extremities. Thrombus formation does not organize before 5–10 days and the risk of proximal progress and pulmonary thromboembolus (PTE) is high in an unorganized thrombus [1]. PTE develops in about 20% of untreated proximal venous thromboses and these follow a fatal course at a rate of 10%–20%. The mortality rate might be reduced by 5–10 times with aggressive anticoagulants [2].

Left Subclavian Artery Aneurysm Rupture in Association with Aortic Coarctation

Aneurysms occurring in association with aortic coarctation are generally seen during the postoperative period and occur in a true or pseudoaneurysm form. Presumably, the stiff patch transmits additional tension to the adjacent elastic aortic wall, which thus bears the total burden of the pulse wave and dilates [1]. However, several cases have been reported in which an aneurysm developed in the absence of coarctation repair; these aneurysms are generally located in the ascending aorta [2]. Subclavian artery aneurysms (SAAs) are rare peripheral aneurysms and most are caused by atherosclerosis. They are rarely seen as complications of aortic coarctation and rarely result in aneurysm rupture [3, 4]. In the present issue, we have reported the clinical, operative, and imaging findings of a patient with left SAA rupture secondary to aortic isthmic coarctation.

Coexistence of pulmonary embolism, aortic dissection, and persistent left superior vena cava in the same patient.

We report a patient with pulmonary embolism, dissection in the descending and abdominal aorta, and persistent left superior vena cava. To our knowledge, coexistence of these three clinical entities has never been described before in the same patient.

Double giant thrombi in the left atrium in a patient with rheumatic mitral valve stenosis and atrial fibrillation.

After a presyncopal attack, echocardiography of a 79-year old man with atrial fibrillation and rheumatic mitral valve stenosis revealed a giant mobile ball thrombus transiently obstructing the mitral valve orifice, with another giant immobile thrombus filling the left atrial appendage (Supplementary Videos 1 and 2). Both thrombi, with dimensions of 40 × 30 and 60 × 30 mm, were removed successfully with the implantation of a prosthetic mitral valve (Figs 1 and 2). Supplementary material (Videos 1 and 2) is available at EJCTS online. Video 1: Echocardiographic apical four-chamber view of the free-floating giant ball thrombus transiently obstructing stenotic mitral valve orifice during diastole. Video 2: Echocardiographic parasternal short-axis view of the two thrombi in the left atrium.

Migration of a foreign body to the right ventricle following traumatic penetration to the right subclavian vein.

Severe calcific aortic stenosis (AS) is the most common valvular disease in older population, which affects 2-7% of the population over the age of 65 years. In Turkey, the total population is 72.5 million and 7% of them were over 65 years of age according to official data (TUIK) in 2010. Surgery is still a gold standard approach, but surgical risk rises with age and the mean STS (Society of Thoracic Surgeons) score is approximately 15% in older age groups due to severe comorbidities leading to denial of surgery in 30-40% of these patients (1). Transcatheter aortic valve implantation (TAVI) is a novel technique, initiated by Alain Cribier in 2002 (2). So far, two available systems, Edwards SAPIEN (Edwards Life Sciences, Irvine, CA, USA) (Fig. 1) and Corevalve ReValving System (Medronic Inc, Minneapolis, MN, USA) have been widely used in Europe and USA. TAVI procedure is not only a novel interventional therapy, but also an excellent example for a hybrid procedure, which is successfully being performed with collaboration of cardiovascular surgeons and cardiologists. From 2002 to 2012, besides the experience gained, improvements in devices and technique resulted in an increase in procedural success rate from 75% to 98.5%. TAVI procedure was started in Turkey in early 2009 (3), and then followed by another center with a procedural success reaching up to 100% (4). These first two attempts were followed by other private and public training and research hospitals. In 2010, Turkish Ministry of Health finally began to support TAVI procedure in a particular group of training hospitals with a special budget making a pivotal financial plan. After the initial success rate and experience, Turkish Ministry of Health has decided to generalize TAVI to whole country by selecting university hospitals, which may be capable to do this procedure in 2011. Within the framework of this plan, TAVI procedure was began in Erzurum in November 2011 and will start in Trabzon in January 2012. So far, TAVI procedure was performed totally in 116 cases; 8 in 2009, 28 in 2010 and 80 cases in 2011, and continues to advance rapidly. One must be very careful and retain the property of acting ethically, because the excitement created by the interventional therapy may increase the unethical behaviors that had been experienced in the early period of widespread use of drug eluting stents. On the other hand, operator training is a crucial component of TAVI procedure, and it is also essential for the candidate center to have experience on coronary, endovascular and structural heart interventions; sufficient infrastructure (hybrid operation theater), and surgical support. The cost is important issue for national economy in our country, so the candidates for TAVI should be carefully selected among high-risk patients refused by surgeon to operate, because TAVI still has many life-threatening complications (5) and high stroke rate. Finally, in November 2011 the US Food and Drug Administration has approved the TAVI for inoperable AS, the Sapien (Edwards-Life sciences). TAVI is a promising intervention and will probably be offered to a wider group of patients in the future. However, the heart team consisting of surgeons and cardiologists must be fully aware of the clinical concept and rationality of TAVI bearing the economic reality of Turkey in mind. We must not be hasty and impatient to perform TAVI in an unrealistically liberal way. A national health policy must be established with collaboration of Turkish Cardiovascular Societies and Ministry of Health. New technologies and interventions must inevitably and constantly be brought to clinical practice by experienced training centers with a team approach.

Successful combination of interventional and surgical treatment of left atrium perforation

Percutaneous interventions are increasingly used in the treatment of cardiac diseases which are resistant to medical treatment. However, the complications caused by these interventions can lead to serious results. In this article, we present a case of a successful combination of interventional and surgical treatment methods, following the development of left atrial perforation during radiofrequency catheter ablation (RFA), in a patient with atrial fibrillation resistant to medical treatment.