Harmonic scalpel has acute beneficial effects during radial artery harvesting.
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Coronary Artery Bypass↗
Biomedical subjects
Hakan Posacioglu
Publications and source records attributed to Hakan Posacioglu.
Surgical approaches to the aberrant right subclavian artery.
Aberrant subclavian artery (arteria lusoria) is a rare congenital anomaly that usually does not produce symptoms. Symptomatic patients require surgical intervention. The operative approach to correct this condition has been controversial. Herein, we describe surgical approaches to the aberrant right subclavian artery. From 2000 through 2004, 3 children and 1 adult with aberrant right subclavian artery underwent operation. Our surgical approach varied according to the age of the patient. A muscle-sparing right thoracotomy was used in the pediatric patients, and a supraclavicular approach was used in the adult. Patients were treated successfully by division of the aberrant right subclavian artery and translocation to the right common carotid artery, without graft interposition. There was no operative or late morbidity or death. Symptoms were completely relieved in all patients. Although an extrathoracic approach is applicable and reliable for adult patients, we believe that adequate exposure for the described procedure is best accomplished through a right thoracotomy in pediatric patients. This approach enables optimal mobilization of the distal right subclavian artery without leaving a long stump and enables direct anastomosis to the ipsilateral carotid artery.
Adult↗
Large pseudoaneurysm of the carotid artery in Behçet's disease.
Behçet's disease is a multisystem inflammatory disease of unknown cause. Its major pathologic feature is vasculitis. We report the occurrence of a large pseudoaneurysm of the carotid artery in a patient who had Behçet's disease. The patient underwent surgery and was discharged on the 7th postoperative day. Ours is only the 4th such case reported in the English-language medical literature. Endovascular and surgical options are discussed herein.
Adult↗
Aortic root infection destroying the left fibrous trigone.
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Adult↗
Management of vascular infection in the groin.
We performed this retrospective study in order to evaluate the effectiveness of different surgical methods in the treatment of inguinal vascular infections. Fourteen consecutive patients underwent surgical treatment of such infections from 1996 through 2004 in our clinic. The mean age was 52 +/- 16 years. Seven of the 14 patients underwent emergency operation due to bleeding or acute ischemia. The events that caused inguinal infection were synthetic graft implantation in 8 patients, gunshot injury in 1, arterial catheterization in 2, femoropopliteal saphenous vein bypass operation in 1, and motor vehicle accident with abdominal wall laceration in 2. The most common infecting pathogen was Staphylococcus aureus (7 patients). Sixteen operations were performed in 14 patients. These operations included lateral femoral bypass (5), obturator bypass (5), revascularization with homograft (5), and femorofemoral bypass (1). All inguinal infections were completely cured after surgery. Early complications included poor wound healing (4 patients), minor amputation (1 patient), and extension of infection to the distal anastomosis of the obturator bypass and false aneurysm formation (1 patient). Late complications were acute homograft occlusion of a femorofemoral bypass and thrombosis of a below-knee lateral femoral bypass. There was no operative or late mortality. All patients were followed up for a mean of 48.1 +/- 21.9 months. We did not encounter any aneurysmal degeneration, rupture, or reinfection in homograft patients during follow-up. We conclude that vascular infections of the groin can be cured by proper selection and application of one of the above techniques.
Adult↗
Composite graft endocarditis: repair with a mechanical prosthesis.
We report the case of a 64-year-old man who developed a mediastinal pseudoaneurysm due to severe endocarditis, 2 years after aortic root replacement with a prosthetic composite graft containing a mechanical valve. After a short period of stabilization and antibiotic therapy, the patient underwent surgery. The coronary buttons and the sewing ring of the composite graft were found to be detached from the graft and the annulus, respectively. Re-replacement with a prosthetic composite graft (Dacron graft with a mechanical valve) by the Cabrol procedure was performed. Although the homograft is considered by many surgeons to be the best graft for aortic root replacement, the synthetic composite graft can also be used to treat composite graft endocarditis successfully. The technical aspects of homograft versus synthetic aortic root replacement in patients with endocarditis are discussed briefly.
Aorta, Thoracic↗
Pseudoaneurysm and aortobronchial fistula after aortic coarctation repair by patch aortoplasty.
Pseudoaneurysm and aortobronchial fistula are very rare complications of aortic coarctation repair by means of patch aortoplasty, and are usually fatal if not treated surgically. A 26-year-old man with recent-onset massive hemoptysis had undergone aortic coarctation repair by means of Dacron patch aortoplasty at the age of 10 in our hospital. Computed tomography of the chest showed a descending aortic pseudoaneurysm. Left heart bypass was used for distal perfusion while the patient underwent graft interposition. Lung parenchyma around the fistula was repaired, and the patient was discharged after an uneventful postoperative course. When hemoptysis occurs in a patient with a history of thoracic aortic surgery, aortobronchial fistula should be suspected. Close follow-up is mandatory for patients who have undergone coarctation repair.
Adult↗
Supravalvular aortic stenosis: repair with the Yacoub procedure.
Preservation and restoration of the aortic valve and root, as well as relief of the stenosis, is of paramount importance during surgical treatment of supravalvular aortic stenosis. A 23-year-old woman with a history of medically treated endocarditis presented with progressive fatigue and dyspnea on exertion. A diagnostic work-up revealed multiple stenoses and a small saccular aneurysm involving the diffusely hypoplastic ascending aorta, in addition to severe mitral regurgitation. The aortic root and ascending aorta were replaced using the Yacoub remodeling technique. Hemiarch replacement was performed under hypothermic circulatory arrest, and the mitral valve replaced. By using a remodeling technique, it was possible to augment the left sinus of Valsalva, to obtain the largest diameter at the sinotubular junction, and to adjust the spatial relationship of commissures that renders good leaflet coaptation. Although extended aortoplasty has been used widely for supravalvular aortic stenosis, the Yacoub procedure is a good option in diffuse type hypoplasia with multiple stenosis of the ascending aorta.
Adult↗
Surgical treatment of acute arch dissection.
OBJECTIVES: Acute type A arch dissections are rare and no consensus has been reached on their surgical treatment. We studied perioperative risk factors for mortality in arch dissection patients. METHODS: Between October 1995 and October 2001, 108 patients with acute type A dissection were operated on, of whom 16 had acute arch dissections. Their mean age was 58 +/- 9 (44-77). Surgery involved total arch replacement in 4, hemiarch replacement in 10, and intimal tear repair with pledgeted sutures and ascending aortic replacement in 2. RESULTS: One patient who underwent total arch replacement died intraoperatively due to bleeding. Both patients who underwent ascending aortic replacement and primary repair of arch tears died 2 days postoperatively, 1 due to bleeding, and the other due to multiorgan failure. In-hospital mortality was thus 18.75%, or 3 of 16. All 3 had cardiac tamponade preoperatively. The 13 survivors were discharged after a mean hospital stay of 11 +/- 6 days. Mean follow-up was 38 +/- 25 months, from 3 months to 6 years. One patient died due to graft infection 3 months postoperatively, but the remaining 12 remain in good condition. Univariate predictors of in-hospital mortality were the type of surgery (primary intimal tear repair) (p = 0.027) and preoperative cardiac tamponade (p = 0.007). CONCLUSION: Surgical treatment of acute type A-arch dissections can be done with reasonable mortality and mid-term survival comparable with those of other subgroups with acute type A dissection. As with series of arch dissections, our patient population is too small to draw specific conclusions, but our experience leads us to conclude that the sites of intimal tears should be resected in acute type A arch dissection.
Acute Disease↗
A practical tool to control bleeding during sternal reentry for pseudoaneurysm of the ascending aorta.
Big pseudoaneurysms of the ascending aorta after a previous thoracic operation are rare and represent a surgical challenge. Because the rupture during sternal reentry occurs before the clamp-control of the distal ascending aorta, it is essential to control the bleeding until the adhesions are released in order to place the sternal retractor. We report the use of Foley catheter with a malleable guidewire to control the bleeding from the defect in the ascending aorta causing a pseudoaneurysm in case of a limited access.
Aneurysm, False↗
Prophylactic dialysis in patients with renal dysfunction undergoing on-pump coronary artery bypass surgery.
BACKGROUND: Preoperative creatinine values higher than 2.5 mg/dL are associated with markedly increased risk for both mortality and morbidity in patients undergoing coronary artery bypass surgery. We aimed to determine the effects of prophylactic perioperative hemodialysis on operative outcome in patients with nondialysis-dependent moderate renal dysfunction. METHODS: Forty-four adult patients with creatinine levels greater than 2.5 mg/dL but not requiring dialysis underwent coronary artery bypass surgery with cardiopulmonary bypass. The patients were randomly divided into two groups. In group 1 (dialysis group, 21 patients), perioperative prophylactic hemodialysis was performed in all patients. Group 2 (23 patients) was taken as a control group and hemodialysis was performed only if postoperative acute renal failure was diagnosed. RESULTS: The hospital mortality was 4.8% (1 patient) in the dialysis group, and 30.4% (7 patients) in the control group (p = 0.048). Postoperative acute renal failure requiring hemodialysis was seen in 1 patient (4.8%) in the dialysis group and in 8 patients (34.8%) in the control group (p = 0.023). Thirty-three postoperative complications were observed in the control group for an early morbidity of 52.2% (12 patients) and 13 complications occurred in 8 patients in the dialysis group (38.1%). The average length of the intensive care unit and postoperative hospital stay were shorter in the dialysis group than in the control group (p = 0.005 and p = 0.023, respectively). CONCLUSIONS: Preoperative creatinine levels higher than 2.5 mg/dL, increase the risk of mortality and the development of acute renal failure and prolong the length of hospital stay after on-pump coronary artery bypass surgery. Perioperative prophylactic hemodialysis decreases both operative mortality and morbidity in these high-risk patients.
Acute Kidney Injury↗
Amiodarone reduces the incidence of atrial fibrillation after coronary artery bypass grafting.
OBJECTIVE: The purpose of this study was to evaluate the safety and efficacy of postoperative administration of prophylactic amiodarone in the prevention of new-onset postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting. METHODS: In this prospective study 157 patients were randomly divided into two groups: 77 patients (amiodarone group) received intravenous amiodarone in a dose of 10 mg/kg/d for postoperative 48 hours. On postoperative day 2 oral amiodarone was started with a dose of 600 mg/d for 5 days, 400 mg/d for the following 5 days, and 200 mg/d for 20 days, and 80 patients received placebo (control group). RESULTS: Preoperative patient characteristics and operative variables were similar in the two groups. Postoperative atrial fibrillation occurred in 8 patients (10.4%) receiving amiodarone and in 20 (25.0%) patients receiving placebo (P =.017). Duration of atrial fibrillation was 12.8 +/- 4.8 hours for the amiodarone group compared with 34.7 +/- 28.7 hours for the control group (P =.003). The maximum ventricular rate during atrial fibrillation was slower in the amiodarone group than in the control group (105.9 +/- 19.1 beats per minute and 126.0 +/- 18.5 beats per minute, respectively, P =.016). The two groups had a similar incidence of complication other than rhythm disturbances (20.8% vs 20.0%, P =.904). Amiodarone group patients had shorter hospital stays than that of control group patients (6.8 +/- 1.7 days vs 7.8 +/- 2.9 days, P =.014). The in-hospital mortality was not different between two groups (1.3% vs 3.8, P =.620). CONCLUSIONS: Postoperative intravenous amiodarone, followed by oral amiodarone, appears to be effective in the prevention of new-onset postoperative atrial fibrillation. It also reduces ventricular rate and duration of atrial fibrillation after coronary artery bypass grafting. It is well tolerated and decreases the length of hospital stay.
Administration, Oral↗
Cardiac hydatid cyst located in the interventricular septum.
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Adult↗
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.
Acute Disease↗
Analysis of perioperative risk factors in mortality and morbidity after modified Bentall operation.
The objective of the present study was to determine the risk factors for operative and short-term mortality, and morbidity after a Bentall operation. Between July 1994 and February 2001, 86 consecutive patients (70 males) underwent a modified Bentall operation at our hospital. The aortic pathology was acute aortic dissection in 12 (14%), chronic dissection in 9 (10.5%) and degenerative aneurysm in 65 (75.6%). Mean age was 48 +/- 15 years. Eleven preoperative, 8 intraoperative and 6 postoperative variables of these patients were retrospectively analyzed using univariate and multivariate logistic regression analysis. Six patients died in the hospital (6.9%) and 2 died within four months after being discharged from the hospital. Mean follow-up time was 33 +/- 23 months (2 months to 8 years). The survival rate among hospital survivors was 88% at 3 years and 77% at 6 years. Univariate predictors of in-hospital and short-term mortality were the presence of aortic valve calcification, stenotic aortic valves, renal failure, and cardiac failure after the operation. Multivariate analysis revealed no independent risk factors. Risk factors for morbidity were etiology of acute dissection, use of circulatory arrest, transfusion of blood and fresh frozen plasma more than 2 units each, cross clamp and cardiopulmonary bypass times (exceeding 90 and 140 minutes, respectively), and performing concomitant procedures. Modified Bentall procedures are safe in general. Meticulous dissection, careful handling and positioning of the coronary buttons are of paramount importance in patients with stiff aortic root since technical errors are more likely to occur.
Adolescent↗
Coronary artery bypass grafting in patients with poor left ventricular function.
Coronary artery bypass grafting (CABG) in patients with poor left ventricular function remains a surgical challenge and is still controversial. The purposes of this study were to evaluate the effectiveness of CABG in such patients when performed without case selection on the basis of preoperative viability tests and to determine the predictors of postperative outcome. The preoperative, perioperative, and postoperative early and mid-term follow-up data of 273 patients with < or = 30% left ventricular ejection fraction (LVEF) who underwent isolated CABG between January 1995 and November 2000 were evaluated. Preoperative echocardiography and cardiac catheterization, and postoperative control echocardiography were performed in all patients. Follow-up was achieved via monthly periodical examinations in the first 6 months, and thereafter by either regular visits or phone contact. Preoperatively, 242 (88.65%) patients were in NYHA class III or IV, and the mean LVEF was 26.51 +/- 3.64%. The overall hospital mortality total was 14 (5.13%) patients. There were 44 (16.12%) late mortalities. Postoperative morbidities were observed in 74 (27.1%) patients. Two-hundred and two (93.95%) of the surviving 215 (78.75%) patients were in NYHA class I or II at 49.55 +/- 14.84 months of follow-up. Postoperative follow-up echocardiographic examinations revealed a mean LVEF of 39.66% +/- 5.43%. The improvements in functional capacity and LVEF were significant. Advanced age, diabetes, hypertension, cross-clamp time >60 min, bypass time>120 min, and severity of functional class (class III-IV of NYHA) were found to be the determinants of mortality. However, multivariate analyses revealed only older age and class III-IV of NYHA and CCS were predictors of mortality. The low mortality and morbidity rates as well as satisfactory postoperative improvements in functional capacity and LVEF measurements support the use of CABG without the need for any viability assessment in patients with left ventricular dysfunction.
Adult↗
Arch-first technique used with commercial T-graft to treat subacute type-A aortic dissection in patient with Marfan syndrome.
Staged repair of extensive thoracic aortic aneurysms puts certain patients at risk of rupture. We report the case of a patient with Marfan syndrome who presented with subacute type-A aortic dissection and a large descending aortic aneurysm. We used the arch-first technique with a commercially available Dacron T-graft. A clamshell incision was used for exposure. A button of arch vessels was anastomosed to the T-graft. Antegrade cerebral perfusion was established through the side branch. The distal end of the graft was anastomosed to the descending aorta and the proximal end to a composite graft. The duration of cerebral ischemia was 30 minutes; antegrade cerebral perfusion lasted 52 minutes. The patient experienced no neurologic dysfunction and was discharged with no major deficit. This technique shortens brain-ischemia time and is a good option if the risk of rupture of the descending component of an extensive thoracic aortic aneurysm is high. To the best of our knowledge, this is the 1st reported case in which the arch-first technique has been used with a commercially available T-graft to treat subacute type-A aortic dissection in a patient with Marfan syndrome.
Adult↗
Four years' experience with the Edwards-Tekna bileaflet valve prosthesis.
BACKGROUND AND AIM OF THE STUDY: Although over 20,000 Edwards-Duromedics valves were implanted worldwide between 1982 and May 1988, use of the valve was voluntarily suspended by the manufacturer in May 1988 on the basis of reported leaflet escapes. In 1990, a modified version was introduced to the market, the Edwards-Tekna. The study aim was to evaluate the short-term outcome with this revised valve. METHODS: Between 1994 and 1998, 137 patients (67 males, 70 females; mean age 36.3+/-9.1 years) underwent heart valve replacement with the Edwards-Tekna prosthesis. Among these patients, 72 had isolated mitral valve replacement, 59 isolated aortic valve replacement, and six double-valve replacement. RESULTS: Early hospital mortality was 0.72% (n = 1). Follow up was 95% complete (129/136 patients discharged from hospital). Mean follow up was 24.9+/-10.5 months (range: 2 to 48 months); total follow up was 282.9 patient-years (pt-yr). Actuarial freedom from complications at two-year follow up and linearized incidence (%/pt-yr) of these events were: late mortality 87.8+/-8.5% (1.77%/pt-yr); thromboembolism 89.8+/-4.9% (2.12%/pt-yr); anticoagulation-related bleeding 97.8+/-1.5% (0.71%/pt-yr); prosthetic valve endocarditis 99.1+/-0.9% (0.35%/pt-yr); valve-related mortality 98.2+/-1.2% (0.71%/pt-yr); and valve-related morbidity and mortality 85.0+/-5.0% (4.24%/pt-yr). There was no structural valve failure such as leaflet escape in this series. Clinically significant hemolysis was not encountered (mean postoperative plasma LDH level 345+/-124 IU/l). Preoperatively, 69% of patients were in NYHA classes III/IV; at two years postoperatively 90% of survivors were in classes I/II. CONCLUSION: The Edwards-Tekna mechanical valve prosthesis has shown excellent overall clinical performance in the short term, though long-term data are needed to confirm its durability.
Adult↗