Vedat Nisanoglu

Axillary Artery Perfusion in Acute Type A Aortic Dissection Repair

Abstract  Background: We evaluated our experience with axillary artery perfusion technique in acute type A aortic dissection repair. Methods: Between September 2000 and July 2006, 41 consecutive patients with acute type A aortic dissection underwent surgical repair. In 35 of 41 patients (85.4%), arterial perfusion was performed through right axillary artery and in the remaining six patients (14.6%), arterial perfusion site was femoral artery. Indication for femoral artery perfusion was cardiac arrest and ongoing cardiopulmonary resuscitation in one and pulslessness of right upper limb in five patients. Mean age was 54.9 ± 15.3 (16 to 90 years) and 28 were male. Unilateral antegrade cerebral perfusion (perfusate temperature 22 to 25 °C) through axillary artery was performed in all axillary artery perfused patients and in three patients who had femoral artery perfusion. Results: Five patients died postoperatively (hospital mortality 12.2%). All of them had evidence of single or multiple organ malperfusion preoperatively. We did not experience any new transient or permanent neurologic deficit after the procedure in the unilateral antegrade cerebral perfusion patients. Complications related to axillary artery cannulation were observed in two patients (5.3%). One patient with femoral artery cannulation experienced femoral arterial thrombosis, postoperatively. Conclusions: Right axillary artery cannulation for repair of acute type A aortic dissection is a simple and safe procedure. In the case of pulslessness of right upper limb, femoral artery is still the choice of cannulation site.

On-pump Coronary Artery Bypass Surgery in High-risk Patients Aged Over 65 Years (EuroSCORE 6 or More): Impact on Early Outcomes

The results of on-pump coronary artery bypass graft (CABG) surgery in 166 high-risk elderly patients (EuroSCORE 6 or more; over age 65 years [mean 71.8 years]) were compared with 176 low-risk elderly patients (EuroSCORE below 6; over age 65 years [mean 68.8 years]). There was no significant difference in hospital mortality or number of grafts between the two groups. Rates of inotropic agent use, intra-aortic balloon pump insertion and atrial fibrillation, and the duration of intensive care unit and hospital stay were significantly higher in high-risk than low-risk patients. There were no significant differences in the incidence of major complications between the two groups. The results suggest that, in selected patients, on-pump CABG can be safely performed in high-risk patients over 65 years old with no effect on mortality.

Effectiveness of Posterior Pericardiotomy After Valve Replacement

Dear Editor, Cardiac tamponade, especially posterior tamponade, is one of the most serious and potentially lethal complications occurring in a minority of patients after open heart surgery and yet most potentially correctable of all postoperative problems. A small amount of pericardial effusion placed posterior pericardium may compromise the left atrium and ventricle, and might lead to tamponade.1,2 The effectiveness of the posterior pericardiotomy (PP) in reducing the incidence of pericardial effusions and related complications was well-established in recent prospective studies after coronary artery surgery.3,4 Pericardial effusion is significantly more common after valve replacement than after coronary artery bypass grafting or other types of heart surgery. We have previously postulated that PP was beneficial for reducing the incidence of early and late pericardial effusions in patients who underwent a valve replacement.5 After this observation, we have been routinely performing a PP during valve surgery. It was surprising for us to find that PP was still open and effective three years after valve replacement. A 45-year-old female patient with the symptoms of palpitation and dyspnea was admitted to our hospital three years ago. Echocardiographic examinations revealed a severe mitral stenosis. We had performed mitral valve replacement with a 29-no. CarboMedics mechanical prosthesis. Additionally, a PP was performed by a longitudinal incision made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm. Postoperative period was uneventful and the patient was discharged from the hospital on the 6th postoperative day with INR = 2.3.

Cardiopulmonary bypass before general anesthesia in prosthetic valve thrombosis.

Valve obstruction is a lifethreatening complication of mechanical valve prostheses. Emergency operation is mandatory for patients who subsequently develop cardiogenic shock and severe pulmonary edema. In this severely compromised hemodynamic condition, cardiac arrest develops in most of the patients before surgery and just after general anesthesia induction. In one such case, we performed femorofemoral cardiopulmonary bypass with local anesthesia before general anesthesia induction and successfully replaced the thrombosed prosthetic valve, thus avoiding a catastrophic outcome.

Partial Dehiscence of Mechanical Aortic Valve Due to Infective Endocarditis

A 32-year-old man underwent aortic valve replacement with a mechanical St. Jude prosthesis (St. Jude Medical, St. Paul, MN, USA). He had progressive congestive heart failure combined with traumatic hemolytic anemia and a high-grade fever suggestive of prosthetic valve endocarditis in the 3rd month after surgery. Transthoracic echocardiography revealed partial valve dehiscence resulting from infective endocarditis (Figure 1). During urgent operation, dehiscence of three-quarters of the annulus was observed (Figure 2), and the prosthesis was replaced. Figure 1. Apical 5-chamber 2-dimensional transthoracic echocardiogram showing vegetations on a prosthetic aortic valve. Even more importantly, a perivalvular leak and partial dehiscence are also apparent.

Right Coronary Artery Origin in Stenosed Left Anterior Descending Artery

A very rare coronary artery anomaly of right coronary artery originating from the middle portion of the left anterior descending artery was discovered in a 58-year-old woman with unstable angina pectoris. Double coronary artery bypass grafting was performed successfully.