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

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

EComment. Interpretation of the data together with the management of cardiac surgery patients with diabetes mellitus

WOS: 000327456100026PubMed ID: 24243950We have read with interest the analysis by Tennyson et al. of the role of HbA1c in predicting the mortality and morbidity outcomes in patients undergoing coronary artery bypass surgery (CABG) [1]. In such patients, higher fasting blood glucose (FPG) levels are associated with a higher incidence of arrhythmia, atelectasis and prolonged mechanical ventilation, whereas higher HbA1c levels are associated with a higher incidence of intra-aortic balloon counterpulsation, massive bleeding and multi-organ failure [2]. Although diabetes mellitus (DM) is traditionally known to be associated with an increased risk for CABG, there are also adverse outcomes reported in the literature indicating similar hospital mortality rates for diabetic and non-diabetic patient groups [3]. In fact, delaying the surgical procedure seems to be the safest measure when quadrupled mortality for CABG is noted with HbA1c values of over 8.6% [1]. Since the lifespan of red blood cells is around three months, any effective change in HbA1c levels will be assumed to take place within 10-12 weeks. So, the question is about which parameters we are able to manipulate in a patient with altered FBG levels who are candidates for a CABG procedure and how we can interpret and evaluate the HbA1c and FPG levels in these patients. In our clinical practice we put all DM patients who are on oral hypoglycaemic drugs onto dual insulin treatment in the preoperative period without taking HbA1c levels into account

Motorsiklet kazası sonrası triküspit kapağında korda rüptürü

WOS: 000380166800008PubMed ID: 27372618Cardiac valve injury, a condition that can follow blunt thoracic trauma, has a wide range of clinical presentations, depending on the structures involved. Post-traumatic tricuspid regurgitation is relatively rare, caused by increase in intrathoracic pressure when the tricuspid valve leaflets close, leading to rupture of the chordae tendineae. A case of severe tricuspid regurgitation due to chordal rupture presenting with atrial flutter following a motorbike accident is described in the present report.Özet– Künt toraks travmaları sonrası gelişen kalp travması olguları, etkilenen yapılara bağlı olarak çeşitli klinik sunumlar göstermektedir. Travma sonrası triküspit yetersizliği literatürde nadirdir, triküspit kapak yapraklarının kapalı olduğu sırada travmaya sekonder toraks içi basıncı artışı sonucu triküspit kapak kordalarının rüptürüne bağlı olarak geliştiği düşünülmektedir. Bu yazıda, motorsiklet kazası sonrası atriyum flutteri ve ileri triküspit yetersizliği ile karşımıza çıkan hastanın triküspit kapaktaki korda rüptürü olgusu tartışıldı

Progressive supra-aortic stenosis in a young adult with the findings of Singleton Merten Syndrome

Singleton Merten Syndrome is an autosomal dominant disorder of unknown origin. Patients often present with muscular weakness, failure to thrive, abnormal dentition, glaucoma, psoriatic skin lesions, aortic calcifi cation and musculoskeletal abnormalities. In this case, we present a young girl with a history of aortic root replacement, who had an unusual progressive supra-aortic stenosis managed with urgent surgery during the course of the syndrome. Cardiovascular involvement needs special attention, since it is the major cause of mortality along with rhythm disturbances in the course of Singleton Merten Syndrome

eComment. Prompt decision making on the site of surgical approach in patients with chest trauma-a brief communication

WOS: 000332033800024PubMed ID: 24443401We read with great interest the article by Chen et al. [1]. Haemothorax is an important finding in trauma patients, which may either be a self-limited condition or the evidence of a life-threatening injury to the thoracic or abdominal organs. We have encountered an extremely rare case of type B dissection in which the first finding was a right-sided haemothorax [2]. Considering the case presented by Chen et al., we would like to figure out the importance of the type and site of the surgical incision. In our experience, if the echocardiography does not reveal any significant cardiac injury or pericardial effusion in such a trauma patient, the easiest and safest approach is a lateral thoracotomy at the fifth intercostal space. This approach helps discriminate intra- and extra-thoracic etiologies of bleeding in such a patient. In case of a cardiac laceration or cardiopulmonary arrest, access to the heart or cannulation of the aorta and right atrium for the utilization of cardiopulmonary bypass is easy with or without a hemi-clamshell extension of the incision. The presented case could be a major pulmonary vessel branch or intercostal artery injury leading to massive right haemothorax in which the subxiphoid pericardial window or a full sternotomy will have a limited use, but a waste of time during an active bleeding. Even the cause of the right haemothorax is a cardiac injury; an uncontrolled subxiphoid access may lead to acute decompression and cardiopulmonary arrest as presented in this case. In this patient, considering the negative echocardiographic findings for a significant pericardial effusion, the mentioned surgical algorithm does not target the most frequent causes of a massive right haemothorax. In such cases we prefer a lateral thoracotomy with a hemi-clamshell extension towards midline when necessary. Such patients require prompt evaluation and surgical intervention is lifesaving in most of the cases

eComment. Combined surgical strategies for anomalous connection of coronary artery to pulmonary artery in adults

WOS: 000350199500030PubMed ID: 25605826We read with great interest the article by Gurbuz et al. [1]. We congratulate them on their successful effort in the surgical treatment of such a rare case, presenting with both carotid artery stenosis and coronary artery disease accompanied by an anomalous origin of the left coronary artery from pulmonary artery (ALCAPA). In fact, the traditionally-named ALCAPA leads to a left-to-right shunting into pulmonary arteries, resulting in ventricular ischaemia [2]. Although the terminology defines an origin of left anterior descending artery (LAD) from pulmonary artery, the actual flow direction of the blood is from the coronary circulation to main pulmonary artery. This reversed coronary flow leads to a coronary steal phenomenon. In general, in such cases, re-establishment of a dual coronary circulation is the preferred treatment modality [2]. However, we would like to discuss some points about the surgical treatment strategy for the case presented by Gurbuz and colleagues. Coronary artery bypass grafting (CABG) for the revascularization of LAD with the left internal thoracic artery (LITA) will provide the antegrade flow to the distal segment of LAD; however the proximal part will still have the reversed flow pattern. The coronary steal phenomenon will possibly affect the septal or diagonal branches originating proximally to the lesion at the LAD. We would prefer the addition of a pulmonary arteriotomy to the CABG procedure in this case, in order to close the origin of the LAD simply with a pericardial patch, as reported by Tseng and colleagues [3]. In our opinion, this surgical strategy will provide both anatomical and physiological correction of the underlying pathology with prevention of the reversed flow from LAD to pulmonary artery as well as the distal perfusion by means of LITA-LAD anastomosis. In conclusion, in such congenital abnormalities related to the origin of the coronary arteries, the surgical strategy might be determined depending on both the anatomical and physiological effects of the disease

eComment. Evidence-based selection of conduits in coronary artery bypass grafting

WOS: 000350199500027PubMed ID: 25605825We read with great interest the article by Gaudino et al. [1]. They have performed coronary artery bypass grafting (CABG) with both internal thoracic arteries (ITA) in a 68-year old patient with a surgical history of aortic coarctation repair. However, there Figure 2: Postoperative angiographic control showing normal functioning left (A) and right (B) ITA grafts. CASE REPORT M. Gaudino et al. / Interactive CardioVascular and Thoracic Surgery 279 Downloaded from https://academic.oup.com/icvts/article-abstract/20/2/279/734665 by guest on 09 April 2020 are some issues we would like to discuss regarding the surgical strategy of the graft selection in this patient. The patient was reported to be hypertensive, both at admission and during the postoperative period. The authors performed a histopathological evaluation of the discarded ITA segments and markedly thickened endothelium was encountered. We wondered how they had decided that the discarded distal segment of the ITA with markedly thickened endothelium guaranteed an intact proximal arterial wall. The atherosclerotic involvement of the ITA may be segmental, hence distal ITA sampling may not accurately predict the degree of atherosclerosis at the proximal part of the graft [2]. Moreover, the same authors had published a review on the use of ITAs in patients with aortic coarctation recently [3]. In that paper, they reviewed 13 reports related to this topic and only one of them included an angiographic control at the long-term follow-up. The authors concluded that, ’a careful evaluation of the conduit is obviously paramount in the context that preoperative transthoracic Doppler ultrasound and selective LITA and RITA catheterization at the time of cardiac catheterization will provide with optimal preoperative planning’

Changes in aortic pulse wave velocity and the predictors of improvement in arterial stiffness following aortic valve replacement

Background: The interaction between valvular aortic stenosis (AS) and arterial stiffness, as well as the impact of aortic valve replacement (AVR) on arterial stiffness, remains unclear. In this study, we aimed to evaluate the degree of AS severity on non-invasive pulse wave velocity (PWV) measurements. We also searched whether the AVR procedure favorably affects PWV. Methods: In all, 38 patients undergoing AVR for chronic AS were included. The degree of aortic stiffness was measured with PWV at both baseline and 6 months after AVR. Improvement in aortic stiffness was defined as the absolute decrease in PWV at 6 months compared to the baseline value. Results: The study population had a mean age of 59 ± 16 years, mean aortic gradient of 47.1 ± 6.4 mmHg, and mean aortic valve area (AVA) index of 0.45 ± 0.11 cm²/m². Baseline PWV values correlated positively with the mean aortic gradient (r = 0.350, p = 0.031) and negatively with the AVA index (r = -0.512, p = 0.001). The mean PWV improved in 20 patients (53%) and worsened in 18 patients (47%). The baseline New York Heart Association (NYHA) class (odds ratio [OR] = 1.023, 95% confidence interval [CI] = 1.005–1.041, p = 0.041) and AVA index (OR = 1.040, 96% CI = 1.023–1.057, p = 0.028) emerged as the independent predictors of improvement in PWV following AVR. Conclusion: The severity of AS was significantly associated with baseline PWV. In general, the mean PWV did not change with AVR. Baseline NYHA class and the AVA index independently predicted PWV improvement following AVR. Since the change in PWV after AVR was polarized based on the patients’ characteristics, such as preoperative NYHA functional class or AVA index, further studies are needed to confirm clinical significance of PWV change following AVR in severe AS patients