ObjectiveEndovenous laser treatment (EVLA) is fast gaining acceptance as an alternative to open surgery for the treatment of saphenous vein incompetence. The method of action of these techniques is based on heat, making tumescence anaesthesia necessity. Heat-induced complications may occur with inadequate application of tumescent anaesthesia. Our hypothesis was, local cooling effect of tumescent anaesthesia on tunica adventitia might be kept undamaged from disruption due to the thermal injury. MethodsWe experimented with two popular laser wavelengths (980 and 1470 nm) and with two different thermal media (+4 and +24°C) in vitro for perforation. Twenty different 12 cm length vein pieces were numbered randomly to set up four groups of the experiment. Endovenous laser procedures were applied in same manner in a unique design test tube with same energy density per pieces on same duration (10 W/second) (linear endovenous energy density 60 J/cm). Procedure video was recorded for macroscopic perforations. All postprocedure vein segments were examined microscopically. ResultsActivities of both wavelengths were much better in cold medium (P < 0.05). Cold tumescent anaesthesia reduces the bleeding complication rate. But the performance of 1470 nm laser was better than that of 980 nm in cold environment (P = 0.0136). ConclusionsIt can be commented that reducing the ambient temperature is more beneficial than modifying the laser wavelength on perforation rates. Therefore we suppose tumescent anaesthesia temperature is effective on perforation independently from the wavelengths or type of the laser fibre.

Objective: To evaluate the feasibility, efficacy and safety of ultrasound-accelerated catheter-directed thrombolysis (UACDT) in the delayed treatment of lower extremity deep venous thrombosis (DVT).Design: Twelve patients with unilateral iliofemoral or femoropopliteal DVT (mean symptom duration 92 +/- 44 days) were prospectively investigated.Method: UACDT was performed using recombinant human tissue plasminogen activator delivered using the EKOS EkoSonic system. Stents were deployed if indicated by post-procedure venography. Follow-up comprised weekly duplex ultrasound for 1 month and monthly thereafter.Results: Successful thrombolysis occurred in 11/12 limbs (92%; complete 6/12, partial 5/12) after a mean infusion time of 26 +/- 7 hours. 2/12 patients required angioplasty and stent insertion. At a mean follow-up of 9 (6-15) months, 10/11 (91%) veins were patent whereas 1/11 re-occluded at 2 months (patient with protein-C deficiency). 2/11 limbs developed symptoms/signs of post-thrombotic syndrome and 3/11 had developed deep vein reflux (duplex ultrasound). 2/12 patients experienced pen-catheter bleeding but no major hemorrhage or symptomatic pulmonary embolism occurred.Conclusions: This preliminary evidence suggests that UACDT may be a safe and effective option for the delayed treatment of lower limb DVT. (C) 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Objective: Mechanical valvular prostheses have the advantage of longevity but carry a risk of thrombosis, which is dependent from valve design, materials and host-related interface. Anticoagulation is known as essential for mechanical heart valves to prevent lethal complications such as valve thrombosis and systemic embolism. Method: A 47-year-old man had an aortic valve replacement in 1985. His native valve was incompetent from infective endocarditis. He discontinued warfarin a few months after the surgery and presented 26 years later with palpitations and dyspnea on exertion for one month. On auscultation, mechanical valve sounds were absent. Transthoracic echocardiography and angiography revealed that the mechanical aortic valve was dysfunctional. Furthermore, echocardiography showed tilting disc of the prosthetic valve was entirely immobile with a mobile soft tissue mass, 5 mm in diameter, was detected at the obstructed leaflet. The patient was re-operated for to replace the dysfunctional valve. Results: At the time of surgery, tilting disc aortic valve, which was implanted at an anatomical orientation, was obstructed at the open position with fresh thrombi. We decided upon replacement with a 23 mm St Jude Medical prosthetic aortic valve. Postoperative period was uneventful and medication consisted of warfarin plus low molecule weight heparine. Conclusion: It is unusual that a functioning mechanic aortic valve is present without anticoagulation for over twenty-five years. The potential factors underlying in the normal valvular mechanics in our patient remains unclear. Prompt diagnosis and emergency surgical intervention are essential for a successful outcome.

Popliteal venous aneurysms are uncommon but potentially fatal abnormalities, since they can cause pulmonary emboli. Here, we report a case of a popliteal venous aneurysm of the right popliteal fossa. In a 32-year-old healthy male complaining of a localised swelling and pain in his right popliteal fossa, duplex ultrasonography and angio-computed tomography revealed a giant popliteal vein aneurysm. The popliteal fossa was surgically explored and aneurysm was resected partially and sutured through posterior approach. Recovery was uneventful and patient still remains asymptomatic. Further duplex ultrasonography follow-ups revealed patency of popliteal vein without thrombotic changes in 1st, 6th, 12th and 15th months. Additionally, no dilatation of the operated vein segment has been observed in the follow-up ultrasound studies. Surgical repair of popliteal venous aneurysms can be performed safely. Partial aneurysm resection together with lateral venorrhaphy is preferred. Due to pulmonary thrombo-embolic complication risks, we recommend surgery in early stages.

Dextrocardia is a rarely seen cardiac malposition, often associated with multiple and complex congenital cardiac anomalies. Valve surgery for acquired valvular lesions in dextrocardia with situs inversus is also rare. Surgeons require a prospective strategy for handling problems such as poor exposure of the cannulation site and diseased valve. The case is described of a patient with dextrocardia with situs inversus, illustrating the anatomic issues and operative considerations particular to aortic and mitral valve surgery in patients with this condition. Approaching the aortic and mitral valve through a left sided left atrial incision seems to provide excellent exposure for valve surgery.

Mean SD Age (years) 67.7 6.7 Left ventricular ejection fraction (%) 47.6 16.1 Number of distal anastomosis 2.3 0.9 FEV1 (% predicted) 53.3 6.5 MEF 50 (% predicted) 28.3 8.4 FEV1 5 1 second forced expiratory volume; MEF 50 5 maximal expiratory flow in the middle of expiration. Results: The perioperative course of all patients was uneventful. There was no respiration block and no patient received general anaesthesia with intubation. Contact with the patients could be established immediately after their transfer to ITU, and their pulmonary and general rehabilitation could be started. Discussion: The experience with TEA without intubation in cardiac surgery was first published in 2000 [1]. Our report shows that the method may even benefit patients with severe obstructive pulmonary impairment. No bronchospasm or bronchial hyperreactivity was observed, perhaps because there was sympathetic blockade. We believe this type of anaesthesia is another step in the development of ‘minimally invasive’ techniques in cardiac surgery. However, the new technique raises some questions such as the real gain, the exact criteria for using the technique and the safety of the procedure. Reference: 1 Karagoz I-IY, Sönmez B, Bakkaloglu B, et al. Coronary artery bypass grafting in the conscious patient without endotracheal anesthesia. Ann Thorac Surg 2000; 70: 91–6.

There has always been a debate about groin incisions for preparation of femoral arteries. Commonly, two types of surgical incisions are being used. We classified the patients who have been operated in our center during last 10 year according to their surgical procedures such as IABP insertion and femoral surgical procedures. We compared 440 IABP patients in their own group according to their insertion technique as percutaneous and two surgical incision types. We compared 343 patients underwent a peripheral bypass operation whose femoral arteries were used, according to incision type as longitudinal and oblique we evaluated the incidence of lymphorrhage, wound infections and early vascular complications. In cases of IABP, oblique surgical approach should be preferred less vascular event rate due to direct exposure versus blind percutaneous technique. In peripheral vascular procedures, oblique approach is preferable to longitudinal since it serves an excellent exposure as comfortable as longitudinal approach.

Aortic hypoplasia, aortic root, and valvular involvement associate with homozygous form of Familial Hypercholesterolem (FH) less commonly. We describe a 32 year old female patient with a previous dacron patch aortoplasty. The echocardiographic supra-aortic gradient was maximally 120 mmHg. Angiographicy revealed 40% left and 50% right ostial stenosis. Annular and supra annular stenosis was revealed by using the Manouguian type aortic root enlargement procedure with a unique oval shaped dacron patch. Before closing the patch completely, a supracoronary positioned mechanical aortic valve was implanted. Two saphenous bypasses for left anterior descending and right coronary arteries were added because of the ostial stenosis. The postoperative period was uneventfull. We suggest that all patients with FH should be evaluated in detail with CT or MRI for possible hypoplastic aortic root. Therapy of this kind of FH is still under debate. We evaluated the therapy modalities and small aortic root problems in this report.

We present a 47 year old male patient with dextrocardia and situs inversus who underwent successful coronary artery bypass with cardiopulmonary bypass. Vessels revascularized included the left internal mammary artery to the left anterior descending artery, the right internal mammary artery to the circumflex obtuse 2 branch and the radial artery to the right coronary artery posterior descending branch. The patient was discharged to his home after an uneventful recovery. Only a few similar cases of myocardial revascularization in patients with dextrocardia have been reported so far, and this is the first procedure, in patients with dextrocardia, performed with all arterial revascularization. A 47 years old male patient admitted hospital with chest paint. He had anginal complaints before. The electocardiography revaled inferior acute myocardial injury. The patient was hospitalised. With the antiischemic medication his angina revealed. ST segment elevations in the inferior leads returned to the baseline level. The patient had a history of situs inversus with dextrocardia. The past medical history was significant for cigarette smoking, hyperlipidemia and hypertension. On the second day a coronary angiography was performed. On the coronary angiogram the patient was found to have 90% stenosis of the left anterior descending (LAD), 80% of the second obtuse marginal (OM2) branch of the left circumflex coronary artery and 80% stenosis of right coronary artery. There were no associated congenital cardiac abnormalities. Elective coronary artery bypass surgery planned. Under general anestesia a midline sternotomy was performed (figure 1). Figure 1 Figure 1: Intra-operative view LIMA,RIMA and a left radial artery were harvested. Standart aortic and right atrial (left sided) canulation was done. Myocardial protection was obtained with systemic hypotermia 28 C and blood cardioplegia. The radial artery was anastomosed end-to-side to the right corornary artery posterior descending branch and the right internal mammarian artery was anastomosed with an end-to-side fashion to the obtuse 2 branch of the circumflex artery. Llastly, the left internal mammarain artery was anastomosed with an end-to-side fashion to the left anterior descending coronary artery. Under the same cross clamp period proximal anastomose of the radial artery was done to the Coronary Artery Bypass Grafting In A Patient With Dextrocardia With Situs Inversus: A Case Report 2 of 3 aorta. The operation was uneventful. Cross clamp period was 35 minutes. Cardiopulmonary bypass time was 45 minutes. The patient was transfered to intensive care unit. Post operative period was uneventfull. Patient was discharged from the hospital on the sixth day.

Background. There are no standard criteria for the timing of drain removal. The objective of this study was to determine whether the macroscopic appearance of chest tube drainage fluid to serosanguineous may be used as a criteria for drain removal. Methods: 2,359 patients were assessed retrospectively and 80 randomized patients were followed prospectively who underwent cardiac surgery. In both parts of the study, patients were divided into two groups according to the timing of drain removal. Group I consisted of patients whose chest tubes were removed as soon as the macroscopic appearance of the drainage fluid turned to serosanguineous. Group II consisted of patients whose chest tubes were removed at the second postoperative day when the drainage output declined to less than 50 mL in a five-hour period. In the retrospective part, cases of hemodynamically significant pericardial effusion observed within seven days postoperatively were reviewed. In the prospective part, just before the drain removal, the fluid sample hematocrit obtained from the drain lines and patients' blood hematocrit were measured and recorded. Patients were evaluated with echocardiography for pericardial effusion. Results: No statistically significant difference was detected in the frequency of hemodynamically significant pericardial effusion and incidence or amount of pericardial effusion between the two study groups. The drain hematocrit to blood hematocrit ratios before drain removal showed a significant correlation with pericardial effusion. The strength of correlation between the drain hematocrit to blood hematocrit ratios before drain removal and pericardial effusion was also studied using receiver operating characteristic curve, which suggests that a drain hematocrit to blood hematocrit ratio of less than or equal to0.3 is strongly predictive that pericardial effusion would be absent or mild between the fifth and seventh postoperative days. Conclusions: It is safe to remove the chest tubes as soon as the macroscopic appearance of the drainage fluid turns to serosanguineous since this practically indicates cessation of active bleeding.

Background. Tricuspid valve replacement is one of the most challenging operations in cardiac surgery. Selection of the suitable prosthesis is still debatable.Methods. In our institution, between January 1980 and December 2000, 129 tricuspid valve replacements were performed in 122 patients (14.7%). Bioprosthetic valves were used in 32 patients, whereas 97 patients had mechanical valve implantation. Twenty-two percent of replacements were done on men. Mean age was 35.27 +/- 11.56 years. In all patients, initially an annuloplasty technique was tried. Tricuspid valve replacement was performed when annuloplasty was not sufficient. In most of the cases, tricuspid valve interventions were done under cardiopulmonary bypass and on a beating heart.Results. Early mortality was 24.5%. Patients were followed for 2 to 228 months. Seven patients underwent reoperation because of tricuspid valve dysfunction (7.6%). Nine patients died during the follow-up period. Late mortality was 9.7%. Actuarial estimates of survival in 20 years of follow-up for all tricuspid prosthetic valves, mechanical valves, and bioprosthetic valves were 65.1% +/- 9.3%, 68.3% +/- 10.6%, and 54.8% +/- 12.1%, respectively. For the bioprosthetic valve group, freedom from structural valve degeneration was 90% +/- 5.5%; for the mechanical valve group, freedom from deterioration, endocarditis, and leakage was 97.8% +/- 4.2%, and freedom from thromboembolism was 92.6% +/- 6.9%.Conclusions. We found that there was no statistically significant difference between the two groups in terms of early mortality, re-replacement, and midterm mortality (p > 0.05). Nevertheless, we recommend low profile modern bileaflet mechanical valves for prosthetic replacement of the tricuspid valve, due to their favorable hemodynamic characteristics and durability. (C) 2002 by The Society of Thoracic Surgeons.

BACKGROUND To determine the differences in the operative findings between the two groups of patients who had undergone either minithoracotomy or conventional sternotomy. METHODS We compared 12 valve operations that were performed in our clinic with minithoracotomy (group I) between January 1997 and November 1999 with 13 valve operations that were performed with conventional median sternotomy (group II) in the same period in regard to preoperative, perioperative and postoperative variables, retrospectively. Preoperative variables were age, sex, bleeding time, clotting time, platelet count, and additional diseases like diabetes mellitus, hypertension, etc. Perioperative variables were extracorporeal circulation (ECC) time, cross-clamp (CC) time, and operation time. Postoperative variables were mechanical ventilation period, stay in the postoperative intensive care unit and hospital, mediastinal drainage amount, the amount of blood and blood products for transfusions, and costs. Group I consist of six mitral valve replacements (MVRs), three aortic valve replacements (AVRs), one aortic valve replacement combined with mitral valvuloplasty, and two tricuspid valve replacements (TVRs). Group II consist of nine MVRs and four AVRs. RESULTS Statistical results are given with mean standard error (SEM) deviations. There were significant differences between the two groups in respect to operation time (in group I, mean operation time was 328 +/- SEM 22 minutes in group II, 271 +/- SEM 14 minutes (p < 0.04)); mediastinal drainage (in group I, mean drainage time was 283 +/- SEM 57 cc/m2, in group II, 490 +/- SEM 74 cc/m2 (p < 0.04)); and amounts of transfused blood and blood products (in group I, mean transfused blood products amount was 375 +/- SEM 115 cc/m2, in group II, 874 +/- SEM 184 cc/m2 (p < 0.03)). CONCLUSION The operation times are apparently longer in the minithoracotomy group. On the other hand, less mediastinal drainage occurred and less blood and blood products transfusion needs were determined to exist in the minithoracotomy group.

Yapici, N.; Unal, O.; Yapici, F.; Coruh, T.; Tarhan, A.; Serbetcioglu, A.; Ozler, A.; Aykac, Z. Author Information

Background. Hydatid cyst disease is a significant health problem for undeveloped and developing countries. Although cardiac involvement is rare, early diagnosis and treatment of this situation is important.Methods. To investigate the long-term outcome of patients who underwent operation for cardiac hydatid cysts with intracavitary expansion, we reviewed 8 patients who had cardiac hydatidosis and who underwent operation in our institution between January 1988 and November 1999. All patients presented with intracavitary protrusion of the cysts. Seven patients were women. The mean age was 33 +/- 14.3 years with a range of 17 to 55 years. The cysts were located on the right ventricular outflow tract (2 patients), right midventricular part of the muscular septum, left atrial free wall and apical portions of the right (2), or left (2 patients) ventricle. Standard cardiopulmonary bypass and crystalloid antegrade cardioplegia with aortic cross-clamping were used in all patients. In one, with right ventricular hydatid cyst, we used cardiopulmonary bypass with femoral cannulation and total circulatory arrest at less than 18 degreesC systemic hypothermia. This patient, who was arrested because of pulmonary emboli could not be weaned from cardiopulmonary bypass and died.Results. The cystic cavity was cleaned and closed with multiple pursestring sutures in 4 patients. In 2, cardiac and cystic cavities were united by partially resecting part of the cyst facing the cavity. In another patient, a left ventricular patch plasty was performed after removal of the cystic material in the left ventricle. Mebendazole was used postoperatively in all patients. Except for 1 patient who died, all were discharged without postoperative complications. The mean follow-up was 7.5 +/- 5 years. There was no late cardiac mortality or recurrence.Conclusions. Cardiac hydatid cysts with intracavitary expansion should be treated surgically without delay. Gentle handling of the heart during cardiopulmonary bypass minimizes operative risk. All patients should be investigated for systemic cysts. (Ann Thorac Surg 2001;71:1587-90) (C) 2001 by The Society of Thoracic Surgeons.

Cases of ventilator-associated pneumonia (VAP) were investigated in a cardiothoracic surgery postoperative intensive care unit between 1 January 1999 and 31 December 1999. A total of 1716 patients who had undergone cardiothoracic operations and admitted to the intensive care unit (ICU) were included in the study. Patient- and laboratory-based prospective surveillance of VAP was done along with otherhospital-acquired infections. During the study period a total of 26 585 patient-days with 2708 ventilator-days were recorded. Forty-six cases of VAP occurred in 36 of 1716 patients who had undergone cardiothoracic operations (2.09%, 1.3 episodes of pneumonia per patient). The ventilator utilization rate at our institution was 0.10. There were 16.4 VAPs per 1000 ventilation days. Thirty-eight percent of VAP were caused by Gram-negative enteric rods, 34% byPseudomonas aeruginosa , and 17% by Staphylococcus aureus. VAP was polymicrobial in 9% of cases. No causative micro-organism was identified in 2% of cases. The same bacteria were isolated in both blood and endotracheal aspirate cultures in 10 of 46 pneumonia cases (22%). The crude mortality rate of VAP was calculated as 30%

The purpose of the study: We analyzed 14 patients with menbranous septal aneurysms presenting with a left-to-right communication, by comparing the angiographic, operative and pathological findings. We decided to use medical treatment on two patients and operated on the rest (12 cases),Basic methods: The mean age of the patients was 19 +/- 9 yr; nine were female, five were male. Cine-angiography of all patients revealed a saccular abnormality protruding into the right ventricle at the uppermost part of the interventricular septum, just below the aortic valve. The sac had the appearance of a glove finger, a cauliflower, a diverticulum, or it was dome-shaped on angiography,Principal findings: Perioperative exploration revealed a perforated true aneurysmal sac in seven patients. In three patients, the perimembranous tissues were severely fibrotic, thickened or had more than one perforation. Two patients had a defect under the septal leaflet of the tricuspid valve at the postero-inferior part of the septum, hidden between the chordae of the valve.Conclusions: Defining the membranous septal abnormalities clearly is not always possible by cine-angiography, Echocardiography provides additional information, Pathological examination of the resected specimens showed almost total loss of elastic fibers and extensive accumulation of mucopolysaccharides. (C) 2000 The International Society for Cardiovascular Surgery, Published by Elsevier Science Ltd. All rights reserved.

Abstract Background and Aim: Swan‐Ganz catheterization is an important technique for monitoring perioperative and postoperative cardiac pressures during open heart surgery. However, although a rare condition, resistance may be encountered while removing the catheter postoperatively and its removal must be accomplished through surgery. Methods: Between May 1988 and February 2000, we observed Swan‐Ganz catheter entrapment complications in 10 cases subjected to open heart surgery. All the cases had valve replacement. Five cases were male, while five were female. The Swan‐Ganz catheter was retained in the vena cava cannulation suture in four cases, in the right atriotomy in three cases, in a left atriotomy suture in one case, and looped around the right ventricular papillary muscle in one case. In the last case, it was looped around chordae tendinea between the tricuspid valve conal papillary muscle and septal leaflet. Although cardiopulmonary bypass equipment was prepared, it was not utilized in any of the cases. The catheter was released and removed by placing a pursestring suture on the vena cava cannulation site in four cases, by placing a matrix suture on the proximal and distal part of the left or right atrial suture line and a pursestring suture on the site of the entrapment in four cases, and by digital palpation from the right atrial appendage in two cases. Results: All patients were taken to the intensive care unit postoperatively and to the wards the next day without complications. Conclusions: When performing open heart surgery, the surgeon should not leave the Swan‐Ganz catheter in the suture while closing the right or left atriotomy or during venous cannulation. In addition, the catheter should be moved after suturing to ensure that there is no entrapment.