Patent foramen ovale is not a benign pathology in patients undergoing off-pump coronary artery bypass: A word of caution

WOS: 000380575500087PubMed ID: 27423847We thank Bozinovski and Caton1 for their valuable article entitled ‘‘A Benign PFO in OPCAB Can Suddenly Take a Right Turn, but Maybe It Can’t Tolerate It.’’ They present a case with desaturation due to right-to-left shunt through a patent foramen ovale (PFO) during off-pump coronary artery bypass (OPCAB). Although rare, this is an extremely important problem in the OPCAB procedure. PFO is a frequent pathology with an estimated prevalence of 25%. 2 However, in cases without a known PFO, intermittent intra-atrial shunting due to an elevated right atrial pressure may be an important problem during OPCAB. Because most patients undergoing off-pump revascularization are high risk in terms of chronic obstructive pulmonary disease and elevated pulmonary artery pressures, opening of a PFO is not infrequent when the right atrial pressure increases. This is particularly evident in cases with left and posterior wall revascularization due to positioning of the heart leading to right atrial compression. These patients are not always capable of tolerating decreases in systemic oxygenation and cyanosis due to right-to-left shuntin

EComment. Efforts to further enhance the safety of sternal re-opening in the paediatric age group

WOS: 000320858900069PubMed ID: 23785095We thank Gandolfo et al. for their effective and easy reproducible technique for managing major vessel injuries during chest re-entry in children [1]. As diagnostic and therapeutic interventions in congenital heart diseases advance progressively, cardiac surgeons have begun to deal with chest re-opening more frequently. Although major venous damages like innominate vein can be managed by a Fogarty catheter, cardiac surgeons are still facing challenging problems, such as damage of cardiac chambers, retrosternal right ventricle to pulmonary artery conduits and ascending aortic aneurysms during the re-sternotomy procedures performed in children. In such cases, we believe that the inflation of Fogarty catheters may even enlarge the defect and make it more uncontrollable in an incomplete sternotomy. In our practice, patients with a sternotomy history are carefully evaluated before the operation. Although the best option in imaging work-up is computed tomography, its routine usage is avoided so as not to increase the exposure of ionizing radiation in the paediatric age group. In most of the patients with redo cardiac surgery, magnetic resonance angiography or lateral projection of cardiac cineangiography studies demonstrate the potential adhesions of the anatomic structures to the posterior part of the sternum. At the operation, we regularly mark the femoral vessels with Doppler ultrasonography and prepare a cardiopulmonary bypass (CPB) set-up before initiating the incision

Fibula allograft sandwich technique for the reconstruction of sternal nonunion after cardiac surgery

Sternal dehiscence is an untoward complication of cardiac surgery that leads to increased morbidity as well as length of hospital stay and costs. Although many different conventional and creative techniques have been described using both synthetic and biologic materials, the ideal method of sternal reconstruction is still controversial. In this case, we describe a simple and reproducible "fibula allograft sandwich technique" for the reconstruction of sternal nonunion in a cardiac surgery patient. This technique also facilitates the conventional wiring by creating bilateral landing zones for the wires at both sides of the sternum

Aort Koarktasyonu Tanısıyla Cerrahi Düzeltme Uygulanan Hastalarda Rekoarktasyon Gelişimi Üzerine Etki Eden Faktörler

Amaç: Çalışmamızda, aort koarktasyonu (AK) tanısıyla opere edilmiş hastalarda rekoarktasyon gelişimi üzerine etki eden faktörler araştırılmış ve elde edilen sonuçlar ışığında, rekoarktasyon oranlarının azaltılmasına katkıda bulunulması hedeflenmiştir. Gereç ve Yöntem: Bu retrospektif çalşmaya, Hacettepe Üniversitesi Tıp Fakültesi Kalp ve Damar Cerrahisi Kliniği’nde 1977-2010 arasında AK tanısıyla cerrahi düzeltme yapılan 358 hastadan, verilerine tam olarak ulaşılabilen ve düzenli olarak takiplerine gelmiş olan 217 hasta dahil edildi. Rekoarktasyon gelişen olgularda cerrahi düzeltme esnasındaki yaş, vücut ağırlığı ve kullanılan cerrahi tekniklerin sonuçları karşılaştırıldı. Veriler istatistiksel olarak değerlendirildi. Kategorik değişkenler için tanımlayıcı istatistikler sayı (n) ve yüzde (%) olarak belirtildi. Sonuçlar ortalama±standart sapma ve/veya yüzde (frekans) cinsinden sunuldu. Alfa anlamlılık değeri <0,05 olarak kabul edildi. Bulgular: Hastaların 147’si (%67,7) erkek, 70’i (%32,3) kadındı. Doksan (%41,4) hasta basit koarktasyon, 127 (%58,6) hasta ise koarktasyon ve eşlik eden kompleks intrakardiyak anomaliler tanıları ile opere edildi. Otuz altı hastada (%16,5) rekoarktasyon tespit edildi. Rekoarktasyon tespit edilen 36 hastadan 21’i (%58,3) balon anjiyoplasti, 10’u (%27,7) cerrahi, 5’i stent implantasyonu (%13,8) ile tedavi edildi. Sonuç: Çalışmamızda vücut ağırlığı <3 kg ve yaşı <1 yaş olan hasta grubunda rekoarktasyon gelişimi istatistiksel olarak anlamlı bulunmuştur. Kullanılan cerrahi teknikler arasındaysa istatistiksel bir anlam tespit edilmemiştir. AK nedeni ile opere edilecek hasta gruplarında vücut ağırlığı <3 kg ve yaşı <1 yaş olan hasta gruplarının post operatif takiplerinde rekoarktasyon gelişimi açısından daha dikkatli olunması gerekmektedir

Are perioperative near-infrared spectroscopy values correlated with clinical and biochemical parameters in cyanotic and acyanotic infants following corrective cardiac surgery?

WOS: 000371172200007PubMed ID: 26034194Background: Near-infrared spectroscopy (NIRS) is a useful non-invasive tool for monitoring infants undergoing cardiac surgery. In this study, we aimed to determine the NIRS values in cyanotic and acyanotic patients who underwent corrective cardiac surgery for congenital heart diseases. Methods: Thirty consecutive infants who were operated on with the diagnosis of ventricular septal defect (n=15) and tetralogy of Fallot (n=15) were evaluated retrospectively. A definitive repair of the underlying cardiac pathology was achieved in all cases. A total of six measurements of cerebral and renal NIRS were performed at different stages of the perioperative period. The laboratory data, mean urine output and serum lactate levels were evaluated along with NIRS values in each group. Results: The NIRS values differ in both groups, even after the corrective surgical procedure is performed. The recovery of renal NIRS values is delayed in the cyanotic patients. Conclusion: Even though definitive surgical repair is performed in cyanotic infants, recovery of the renal vasculature may be delayed by up to two days, which is suggestive of a vulnerable period for renal dysfunction

Çocuklarda ve Genç Erişkinlerde Subaksiller Sağ Torakotomi Yaklaşımıyla (Bikini İnsizyonu) Minimal İnvaziv Atriyal Septal Defekt Onarımı

Aim: The minimally invasive techniques in the treatment of congenital heart diseases have widely expanded recently both in terms of cosmetic results and patient comfort. In this report, we aimed to present our results of patients with the diagnosis of atrial septal defect and associated intracardiac pathologies who were operated through subaxillary mini thoracotomy.Materials and Methods: Seven patients who underwent subaxillary mini thoracotomy out of 53 patients with atrial septal defect that were operated with minimally invasive techniques in our clinic between 2009 and 2020 were identified. Six of the patients (85%) were girls and one was a boy (15%) and the mean age at operation was 8. 1 15.8 years.Results: Three patients had secundum atrial septal defect with a deficient septal rim; two patients had primum atrial septal defect, mitral cleft and mild mitral regurgitation and two patients had atrial septal defect, partial pulmonary venous return of the right pulmonary veins. All of the intracardiac pathologies were treated through right subaxillary mini thoracotomy. The mean cardiopulmonary bypass times and aortic cross clamp times were 71.5 19.2 and 44.4 22.1 minutes, respectively. Our patients were uneventfully discharged in 5.2 0.4 days. We did not encounter and morbidity or mortality in a mean follow up period of 4.4 3.1 years.Conclusion: The postoperative wound healing is faster and wound related complications are less frequently seen in patients undergoing cardiac surgery performed with minimally invasive techniques. The selection of subaxillary thoracotomy provides advantages both in terms of cosmetic aspects and breast development not being affected negatively

eComment. Complex and novel versus simple and traditional approaches for sternal closure

WOS: 000376402700023PubMed ID: 27114395I congratulate Grabert and colleagues for presenting their experience with a novel sternal closure system [1]. Mechanical sternal stabilization devices (MSSD) have significantly developed in the last decade. Although many theoretical advantages have been proposed, the clinical results may be controversial [2]. The plates usually include large holes and the screws occupy significant space in the sternum, which may become a nidus for bacterial growth and invasion. Herein, I would like to emphasize some major advantages of the traditional wiring originally described by Robicsek et al. [3]

eComment. Evidence, experience or novelty for achieving the best outcome in surgery?

WOS: 000359699400022PubMed ID: 26203131I read with great interest the article by Cuttone and colleagues [1]. They reported a unique surgical treatment strategy for the management of circumflex coronary artery aneurysm (CAA) in an adult presenting with myocardial ischaemia. Coronary artery disease (CAD) is an important etiology for CAA formation in adults; however, connective tissue disorders and Kawasaki disease may lead to multiple giant CAAs in children [2]. Although rarely encountered, the cases with CAA present with technical challenges when interventional or surgical treatment modalities are concerned. Boyer and colleagues reviewed the literature and ACC/AHA acute coronary syndrome guidelines recently and the following indications were stated as the indications for surgical revascularization in CAA: (i) CAA involving the left main coronary artery, (ii) multivessel CAD, (iii) giant CAA (the diameter of CAA exceeding the reference vessel diameter by 4 times), (iv) CAA involving bifurcation of significant sidebranch vessel and (v) other separate indications for cardiothoracic surgery unrelated to CAA [3]. The surgical indication for this case is questionable in my opinion, unless the stenotic lesion at the right coronary artery deemed a surgical revascularization necessary. When the diameter and the location of the CAA is considered, this case seems to be manageable by percutaneous intervention with regard to the abovementioned criteria. Boyer et al. also mention that surgical revascularization is considered reasonable in cases where the PTFE-coated, bare metal or drug eluting stents cannot be delivered across the lesion [3]. In this case, the CAA was demonstrated to be thrombus free, which would provide safer circumstances for a covered, bare or drug eluting stent delivery

Creative solutions in order to treat sternal wound complications in cardiac surgery

WOS: 000372983300013PubMed ID: 26874004I read with great interest the article by Kalab and colleagues about their successful results with regard to the reconstruction of massive sternum defects following cardiac surgery [1]. They used allogenic bone transplantation in order to substitute tissue loss due to mediastinitis. Mechanical instability of the sternum is an untoward complication with significant morbidity in the field of cardiac surgery. The risk factors for sternal nonunion are broadly classified as preoperative, intraoperative, and postoperative [2]. Preoperative factors are related to the pre-existing factors in the patients, such as diabetes mellitus, obesity, chronic obstructive pulmonary disease, osteoporosis, and radiation to the chest. The intraoperative risk factors for sternal nonunion are mainly associated with technical errors, such as paramedian sternotomy, harvest of bilateral internal thoracic arteries for grafting, and mechanical failure. Postoperatively, prolonged mechanical ventilation, impaired cardiac output and infectious aetiologies are the most important risk factors associated with increased sternal complications. Several methods, devices and substitution material have been reported in literature. The biological substitution material as emphasized by Kalab et al. have the major advantage of optimal mechanical properties, biocompatibility, lower risk of infection as compared to synthetic materials and the ability for new tissue formation by osteoprogenitor cells in the allografts

Single stage substernal thyroidectomy and off-pump coronary artery bypass grafting: Is it worth using cardiopulmonary bypass unless absolutely necessary?

It is a rare entity to observe the coexistence of thyroid gland pathologies and coronary artery disease, whose surgical treatment may be performed simultaneously. In this case, we present a case of a patient with substernal thyroidectomy concurrent with off-pump coronary artery bypass grafting. A 57-year-old female patient was admitted to the hospital with exertional dyspnoea, intermittent coughing and stable angina pectoris. The substernal goitre measuring 5x5x4 cm was accompanied by a 95% in-stent restenosis at the left anterior descending artery. Thyroidectomy and off-pump coronary artery bypass grafting procedures were performed simultaneously. The postoperative period was uneventful and the patient was discharged 5 days after the operation. This case indicates that off-pump revascularisation seems to be a better option in cases where surgical interventions for thyroid and coronary artery diseases are necessary instead of on-pump revascularisation where the adverse effects of the cardiopulmonary bypass are considered