Umit Duman

Noncompaction of Ventricular Myocardium in a Patient with Congenitally Corrected Transposition of the Great Arteries Treated Surgically: Case Report

Noncompaction of the ventricular myocardium is a rare disorder that represents numerous prominent trabeculations and intratrabecular recesses in the ventricles. It is believed to represent not only an arrest in endomyocardial morphogenesis but also an unclassified cardiomyopathy. The pathology has been almost invariably associated with other congenital cardiac malformations. A female patient with noncompaction of the myocardium of both ventricles and congenitally corrected transposition of the great arteries (cTGA), situs inversus totalis, and atrial and ventricular septal defects is described. When she was 7 days old a permanent pacemaker was implanted because of complete heart block. Prazosin (Minipress), an alpha-receptor blocker, was administered, and the cardiac ejection fraction showed a striking increase from 20% to 42%. Despite careful and regular follow-up evaluations, the general condition of the patient slowly worsened. Five months after surgery she died of hepatorenal failure and low cardiac output. This case report is thought to be the first description of congenital complete heart block, cTGA, and situs inversus totalis with noncompaction of the myocardium of both ventricles.

Coronary Artery Bypass Grafting Is Associated with a Significant Worsening of QT Dynamicity and Heart Rate Variability

Background: Imbalance in autonomic nervous system and impaired myocardial repolarization has been shown to increase the risk for arrhythmias in patients with coronary artery disease. This study evaluated the effects of coronary artery bypass grafting (CABG) on heart rate variability and QT interval dynamicity in subjects with coronary artery disease undergoing elective CABG surgery. Methods: The study group consisted of 68 consecutive patients (mean age ±SD: 61 ± 9 years) with coronary artery disease who underwent elective CABG. Twenty-four-hour Holter monitoring was performed 2–5 days before cardiac surgery and was repeated 10 days after CABG. ELATEC holter software was used to calculate heart rate variability and QT dynamicity parameters. All subjects had a complete history, laboratory examination and transthoracic echocardiography. Results: All patients had beta-blocking agent medication pre- and postoperatively. Standard deviation of all NN intervals for a selected time period, square root of the mean of the sum of the squares of differences between adjacent RR intervals, the proportion of differences in successive NN intervals greater than 50 ms, normalized low-frequency power, and normalized high-frequency power were significantly decreased after CABG surgery, whereas low-frequency/high-frequency ratio was significantly increased after CABG. QT/RR slopes over 24 h were significantly increased after CABG surgery for QT end and QT apex (QTapex/RR: 0.16 ± 0.13 vs. 0.28 ± 0.19, p < 0.001; QTend/RR: 0.18 ± 0.13 vs. 0.36 ± 0.23, p < 0.001). Conclusion: This prospective study showed for the first time that CABG was associated with a significant worsening of heart rate variability and QT dynamicity parameters in the postoperative period.

Assessment of the Radial Artery and Hand Circulation by Computed Tomography Angiography: A Pilot Study

OBJECTIVES The radial artery (RA) is increasingly being used as a coronary bypass graft. Results of a previous study using Doppler ultrasound and histopathologic examinations indicated that the RA has a higher incidence of preexisting intimal hyperplasia, medial calcification, and atherosclerosis than the internal thoracic artery. The aims of this study were to evaluate the use of computed tomographic angiography (CTA) to display hand collateral circulation, to define the criteria for an abnormal CTA test result, and to demonstrate usefulness of CTA as an alternative to conventional angiography for evaluation of the radial artery. MATERIALS AND METHODS Sixteen patients scheduled for coronary artery bypass grafting entered this study. We performed 32 examinations of forearm and hand arterial anatomy in these patients. CTA was performed in patients with a normal Allen test result, except 1 patient who had a persistent median artery. Soft tissue density forehand roentgenography was performed in all patients before the CTA evaluation. There was no selection of patients in relation to patient characteristics. As a risk factor for radial artery calcification, 6 of the patients had diabetes mellitus, 6 had aortofemoral occlusive disease, and 4 had a history of smoking. RESULTS Bilateral forearm arteries were visualized in all patients. Severe RA calcification was found in 1 patient, and distal occlusion was found in another patient. Focal RA calcification was noted in 2 patients. In the remaining patients no radial artery calcification or occlusion was noted. Anatomic variation of the upper limb arteries was shown in 2 patients; these variations were persistent median artery with absence of the radial and ulnar arteries and high bifurcation of the radial artery from the brachial artery. CONCLUSION CTA is useful and safe for detection of radial artery calcific disease and assessment of the forehand circulation and its anatomic variations. Preoperative imaging of the RA is a means to avoid unnecessary forearm exploration or inadvertent use of a diseased conduit in coronary artery bypass candidates with multiple risk factors such as diabetes mellitus.

Iatrogenic brachial and femoral artery complications following venipuncture in children.

INTRODUCTION Catheter- or noncatheter-related peripheral arterial complications such as arterial pseudoaneurysm, embolus, or arteriovenous fistula may be seen in the pediatric age group. The most common etiologies defined for arterial complications are peripheral arterial puncture performed for a routine arterial blood gas analysis, arterial catheters placed for invasive monitorization of children, or catheterization performed for diagnostic purposes through the peripheral arterial system, most commonly the femoral artery. MATERIALS AND METHODS Nine children with peripheral arterial complications, whose ages varied between 2 months and 2.5 years, were enrolled in this study. All patients were treated surgically. Following physical examination, Doppler ultrasonography, computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography were used as diagnostic tools. We studied thrombophilic panels preoperatively. Six patients had brachial artery pseudoaneurysms that developed accidentally during venipuncture, I had a brachial arteriovenous fistula that developed after an accidental brachial artery puncture during routine peripheral blood analysis. In the remaining 2 patients, peripheral arterial embolic events were detected. One had a left brachial arterial embolus and the other had a sudden onset right femoral artery embolus that was detected via diagnostic interventions. RESULTS No morbidity such as amputation, extremity loss, or mortality occurred due to the arterial events or surgery. All patients were discharged from the hospital in good clinical condition. In all patients, follow-up at 3 or 6 months revealed palpable peripheral artery pulsations of the ulnar and radial arteries at wrist level. CONCLUSION Because the incidence of peripheral arterial complications is relatively low in children compared to adults, the diagnostic and therapeutic approaches are extrapolated from the adult guidelines. We proposed that early diagnosis and surgical approach prevented the complications from further developing in the affected extremity in these particular cases.

The changes and effects of the plasma levels of tumor necrosis factor after coronary artery bypass surgery with cardiopulmonary bypass.

BACKGROUND Systemic inflammatory response after cardiopulmonary bypass (CPB) is thought to result from contact of cellular and humoral blood components with the synthetic material of the extracorporeal circulation system, leukocyte and endothelial activation caused by ischemia and reperfusion or endotoxins, or by surgical trauma. Proinflammatory cytokines, such as tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and IL-8, play an important role in the inflammatory processes after CPB and may induce cardiac and lung dysfunction. This study examined the association of the increased release of TNF-alpha with increased myocardial and lung injury after CPB and its effect on postoperative morbidity. METHODS Twenty patients undergoing elective coronary artery bypass grafting (CABG) were included in the study. Four intervals of blood samples were obtaind and assayed for TNF-alpha, white blood cells, C-reactive protein, and erythrocyte sedimentation rate. RESULTS All patients were similar with regards to preoperative and intraoperative characteristics, and clinical outcomes were comparable. Plasma levels of TNF-alpha rose more than 20 pg/mL during and after standard CPB in 13 patients (group 1), whereas the plasma levels were less than 20 pg/mL in the remaining 7 patients (group 2) after CPB. The patients of the first group had increased mediastinal bleeding and prolonged intubation time compared to the other group. CONCLUSION Cardiac surgery and CPB stimulate systemic inflammatory processes characterized clinically by changes in cardiovascular and pulmonary function. Significant morbidity is rare, but most patients undergoing CPB exhibit some degree of organ dysfunction due to activation of the inflammatory response. This study showed that there were no major clinical results of TNF-alpha and white blood cell level, C-reactive protein, and erythrocyte sedimentation rate after the operation, but in patients with a high level of TNF-alpha (more than 20 pg/mL), increased mediastinal bleeding and longer orotracheal intubation time was observed. A number of studies have shown the increase of TNF-alpha after open heart surgery; however, the specific level of TNF-alpha was first described as 20 pg/mL in this study.

The use of suture anchors for sternal nonunion as a new technical approach (Demircin-Dogan technique).

OBJECTIVES Various comparative studies and techniques have been described for median sternotomy closure in the literature, previously. However, some patients are still under risk of sternal dehiscence, malunion or nonunion due to intrinsic or extrinsic factors after median sternotomy closure. Sternal nonunion described as sternal pain, with clicking, instability, or both for more than 3 months in the absence of infection, is an uncommon complication of midline sternotomy incision. To date, only a few studies have addressed the entity of sternal nonunion and its treatment. MATERIAL AND METHOD The suture anchor system has been described for the fixation of tendons or ligaments to the bone in the orthopedic, and then in cardiac surgery for closure of sternum. In the present study, we used different methods for correction and reduction of sternal nonunion with the use of suture anchors and it accompanied steel wires as an alternative technique in a male patient after coronary artery bypass grafting. RESULTS There was no complication due to suture anchors. Sternal stability, reduction, and fixation were achieved successfully. CONCLUSION Sternal nonunion and dehiscence may be the cause of prolonged hospitalization and increased mortality and morbidity if the patient is not treated surgically. This device may protect the wire from cutting into the sternal bone because the thoracal lateral enforcement may be decreased by the devices when the patient is breathing, and with upper extremity movement. This technique can be used easily, safely, and effectively in the repair of sternal nonunion.

Successful Surgical Management of a Double-Chambered Left Ventricle in a 13-Year-Old Girl: A Report of a Rare Case

BACKGROUND Double-chambered left ventricle (DCLV) is a rare congenital anomaly, and only a few cases in which a 2-chambered LV is separated by the interventricular septum or an abnormal muscle bundle have been reported in the literature. Frequently, such cases are diagnosed when a patient is admitted to hospital for the evaluation of a cardiac murmur, and most of these patients have isolated DCLV. MATERIALS AND METHODS We describe the case of a 13-year-old girl with DCLV who had twice undergone operation, including mitral valve replacement, in our institution. RESULT No gradient was found after surgical resection of the hypertrophic floating mass, and the patients symptoms disappeared. DISCUSSION Surgical resection can be carried out in patients with DCLV when done sufficiently early, and careful echocardiographic examination is important in a continuing follow-up. Surgeons should keep in mind the possibility of a recurrence of DCLV.

Diagnosis of a Coronary Artery Anomaly by 16-Channel Computed Tomography Coronary Angiography in an Infant

[3], and echocardiography [1] have been used for the detection of coronary artery anatomic variations in tetralogy of Fallot (TOF). To our knowledge, this is the first report of multidetector computed tomography (MDCT) angiography of the coronary arteries in a small infant with TOF [4]. MDCT was performed in a 3-year-old with TOF because of suspected coronary artery anomaly on cardiac catheterization. This study was performed by 16channel Somatom sensation MDCT (Siemens Medical Systems, Germany). Technical parameters were as follows: slice thickness, 1 mm; detector collimation, 0.75 mm; reconstruction index, 1 mm; table speed, 2.8– 3.4 mm/rotation; and gantry rotation time, 0.42 seconds, with a temporal resolution of 210 msec. Axial images were transferred to a separate workstation (Leonardo Siemens) with advanced volume-rendering software. After intravenous contrast injection (1 cc/kg) the entire heart was scanned during single breath hold (approximately 10–20 seconds). The MDCT data were reviewed on a workstation with interactive scrolling, multiplanar reconstruction, and maximum intensity projections. The coronary artery system and pulmonary artery branches were successfully visualized (Figs. 1 and 2). A large branch coronary artery arising from the left anterior descending artery was shown crossing the right ventricular outflow tract that was not visualized by cardiac catheterization. These findings were confirmed at surgery. Selective coronary angiography has been accepted as a gold standard for coronary imaging in TOF. Other imaging modalities include transthoracic and transesophageal echocardiography and magnetic resonance imaging. Even in surgery, an anomalous vessel crossing the right ventricular outflow track could be missed, especially when the coronary arteries are obscured by the overlying myocardium, epicardial fat, or scar tissue in patients who have undergone prior palliation. This report demonstrates that 16-channel MDCT coronary angiography can define the coronary artery course noninvasively with high-quality images in small infants using minimal amounts of contrast material and short examination times.

Diagnosis of perigraft seroma by use of different techniques in infants with respiratory distress after modified Blalock-Taussig shunt.

commonly used material in modified Blalock–Taussig shunts in infants. Perigraft seroma is a collection of a nonsecretory fibrous pseudomembrane surrounding a vascular graft containing clear, sterile fluid. This pathology can be life threatening in some infants due to the mass effect on adjacent mediastinal structures ranging from airway compression to pericardial tamponade. A-10-month-old female was diagnosed with tetralogy of Fallot and pulmonary atresia and underwent a left modified Blalock–Taussig shunt with a 4-mm PTFE graft. Respiratory distress and hypoxia developed requiring intubation several days after the operation. Chest x-ray showed a large and welldemarcated left superior mediastinal mass and pleural effusion (Fig. 1). There was marked tracheal displacement. Echocardiography with color Doppler showed a patent shunt and a large cystic formation encircling the functioning PTFE graft (Fig. 2). On reexamination, a large left pleural effusion due to fluid leakage along the PTFE graft was found and the shunt was surrounded by a fibrous pseudomembrane. Fluid was aspirated and the seroma was evacuated, leading to an increase in oxygen saturation from 40 to 90%. The echocardiographic examination confirmed the disappearance of the fluid collection and patency of the shunt. The postoperative course was uneventful, and the patient was discharged from hospital 5 days later. A second patient was found to have a left mediastinal mass on the second day postoperatively after a left Blalock–Taussig shunt without clinical sequelae. Transthoracic echocardiography showed suspicion of perigraft seroma formation. Computed chest tomography was performed and showed a cystic mediastinal mass surrounding the shunt (Fig. 3). The patient did not require surgical reintervention. Complications of modified Blalock–Taussig shunts include thrombosis, aneurysm formation, hematoma, O.F. Dogan (&) Æ U. Duman Æ U. Ersoy Department of Cardiovascular Surgery, Hacettepe University Medical Faculty, Sihhiye, Ankara, Turkey E-mail: ofdogan@hacettepe.edu.tr

20. ICD: Primary Prevention, Utilization & Costs

Objectives Coronary Artery Bypass Grafting (CABG) surgery is the method of choice for treating patients with multivessel coronary disease. Heart rate turbulence (HRT) is a new method for risk stratification based on a simple expression of ventriculophasic sinus arrhythmia, after a single ventricular premature beat (VPB). HRT also reflects baroreceptor sensitivity. The aim of this study was to evaluate the influence of CABG surgery on HRT parameters assessed 10 days after operation. Methods Ninety-five consecutive patients with coronary artery disease presenting with sinus rhythm were enrolled in this study (mean age 53±13, range: 39 –82). Forty patients having no VPB on holter recordings were excluded from study. In each patient, a 24 h Holter recording was obtained during a stable phase of coronary artery disease. An ELATEC Holter system was used to process the Holter recordings. All subjects had a complete history, laboratory examination and transthorasic echocardiography. Results All patients analyzed did not have symptoms or signs of myocardial ischemia during 24 hours holter recording period. Mean value of left ventricular ejection fraction was 52.1±5.6. HRT onset showed an increase after CABG, whereas HRT slope was found to be lower (TO: −0.66±1.77, 0.22±1.3, p = 0.028; TS: 6.97±4.97, 2.81±4.47, p = 0.002). Conclusions This study showed that HRT parameters were impaired after CABG. It may be related to the perioperative autonomic nerve damage and impairment of baroreceptor sensitivity, caused by clamping of the aorta.