In selective patients with T4 non-small cell lung cancer with the primary tumor invading the mediastinal organs, extended lung resection may contribute to long-term survival. Adequate patients should be given a chance for surgery if complete resection and required reconstruction can be achieved. In this article, we report a 63-year-old male patient with T4 non-small cell lung cancer invading the left atrium. In the patient, we performed an extended left pneumonectomy with en bloc partial resection of the left atrium wall (4×2.5 cm) where the defect was repaired with pericardial patch via cardiopulmonary bypass. No severe complication developed postoperatively. The patient who was given adjuvant chemotherapy has been living for more than 10 years without disease.

Background: This study aims to evaluate the clinical results of off-pump coronary artery bypass graft surgery (CABG) in patients with renal dysfunction and coronary artery disease (CAD).Methods: Between January 2007 and July 2011, data of 30 patients (24 males, 6 females; mean age 64.7 +/- 8.3 years; range 43 to 83 years) with renal dysfunction who did not require hemodialysis and underwent coronary artery revascularization in our clinic were prospectively collected. Demographic data of the patients and preoperative and postoperative data were evaluated together with the clinical results.Results: One vessel in 12 patients (40%) two vessels in 15 patients (50%), three vessels in two patients (6.6%) and four vessels in one patient (3.3%) were revascularized. The mean postoperative length of stay in the intensive care unit was 1.1 +/- 0.4 days, while the mean length of hospital stay was 7 +/- 3.2 days. The preoperative plasma creatinine and urea levels were 2.6 +/- 1.2 mg/dL and 70.9 +/- 28.7 mg/dL, respectively. The postoperative plasma creatinine and urea levels were 2.7 +/- 1.6 mg/dL and 73.7 +/- 38.7 mg/dL, respectively. There was no statistically significant difference between pre- and postoperative plasma creatinine levels. Hemodialysis was required in one patient (3.3%) in the early postoperative period. Four patients (13.3%) developed atrial fibrillation, while one patient (3.3%) had sternal detachment and mediastinitis. One patient (3.3%) died in the postoperative period.Conclusion: The off-pump CABG can be safely done in patients with renal dysfunction requiring coronary artery revascularization with a lower mortality and morbidity rate.

Background: Off-pump coronary surgery is an established method of less invasive cardiac surgery. We compared our early results in patents with 1-vessel disease who underwent surgery with full sternotomy with off-pump coronary artery bypass (OPCAB) or a left anterior minithoracotomy with minimally invasive direct coronary artery bypass grafting (MIDCAB) without cardiopulmonary bypass.Methods: From July 2003 to June 2006, 54 patients with single-vessel disease of the left anterior descending artery who underwent surgery performed by the same surgical team were included in this prospective study. Of these patients, 27 underwent MIDCAB through an anterolateral minithoracotomy, and 27 had OPCAB through a full sternotomy. Patients were selected for the surgical groups on the basis of general condition, anatomical aspects, type of coronary lesions, comorbidities, and patient preferences. Demographic, operative, and postoperative data were collected prospectively.Results: Demographic data, Canadian Cardiovascular Society Classification, and comorbidities were identical for both groups. There were no cases of operative mortality, early graft insufficiency, myocardial infarction, cerebrovascular accident, or conversion to cardiopulmonary bypass in either group. Durations of mechanical ventilation and total hospital stay were shorter in the MIDCAB group, 6.8 +/- 3.0 hours vs 8.3 +/- 1.6 hours and 4.5 +/- 0.7 days vs 5.2 +/- 1.4 days (P=.03 and P=.03), respectively. Atrial fibrillation was seen in 2 patients in each group; all were returned to sinus rhythm by medical therapy.Conclusion: Although MIDCAB grafting is a challenging technique, it may be safely performed on selected patients with low postoperative mortality and morbidity.

Hydatid disease rarely involves the aortic wall. We report a case of hydatidosis involving the ascending aorta and the left atrium. The patient underwent replacement of the ascending aorta with a prosthetic Dacron graft and left atrial cystectomy. At the 6-month follow-up, she was leading a normal life.

BACKGROUND Sternal wound complication is a major concern in bilateral internal thoracic artery grafting. The purpose of this study was to assess whether avoiding cardiopulmonary bypass has beneficial effects with fewer wound complications in patients receiving bilateral internal thoracic artery grafting. METHODS Retrospective review was performed using prospectively gathered data of 69 patients who had undergone elective coronary artery bypass grafting and received conventional pedicled bilateral internal thoracic artery grafting from December 2002 through April 2004 by the same surgical team. The patients were divided into 2 groups: those who underwent coronary artery bypass grafting without cardiopulmonary bypass (off-pump group, n = 41), and those who underwent coronary artery bypass grafting with cardiopulmonary bypass (CPB group, n = 28). Chart review and 3-month follow-up were obtained for all patients. These 2 groups were compared for sternal wound complications and preoperative, intraoperative, and postoperative variables. RESULTS Deep sternal wound infection (SWI) was seen in 1 patient (2.4%), superficial SWI in 2 patients (4.8%), and sternal dehiscence in 1 patient (2.4%) in the off-pump group. Deep SWI was seen in no patients, superficial SWI in 2 patients (7.1%) and sternal dehiscence in 2 patients (7.1%) in the CPB group. No statistically significant difference in the frequency of occurrence of sternal complications was detected between the 2 study groups. CONCLUSIONS The results suggest that the avoidance of CPB has no beneficial effect on the number of sternal wound complications in patients receiving bilateral internal thoracic artery grafting. However, further prospective, randomized studies on large patient groups are required to assess this finding.

Objectives: A possible role of some microorganisms has been proposed in the pathogenesis of atherosclerosis, but it is still an unresolved issue. We investigated the presence of Chlamydia pneumoniae and Helicobacter pylori DNA in carotid artery atherosclerotic plaques by using PCR.Methods: One hundred and four patients with atherosclerotic diseases were included. The study group consisted of 52 atherosclerotic plaque specimens obtained from the carotid arteries of patients who had carotid endarterectomy and the control group consisted of 52 specimens obtained from the macroscopically healthy regions of ascending aorta in patients who had undergone coronary artery bypass grafting. The presence of C. pneumoniae and H. pylori DNA in endarterectomy specimens were demonstrated by PCR.Results: C. pneumoniae DNA was detected in 16 of 52 (30.8%) atherosclerotic plaques and 1 of 52 (1.9%) macroscopically healthy ascending aorta wait specimens (P < 0.001). H. pylori DNA was detected in 9 of 52 (17.3%) atherosclerotic plaques and none of the controls (P = 0.003).Conclusions: The higher incidence of C. pneumoniae and H. pylori DNA in atherosclerotic plaques suggests that these microorganisms may play a rote in the pathogenesis of atherogenesis. (c) 2005 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

BACKGROUND:Endocarditis is a rare but life-threatening complication of brucellosis. Its mortality rate has recently been reduced with the use of combined medical and surgical treatment.METHODS:Between March 2002 and April 2004, 6 patients with Brucella endocarditis underwent surgery at the Siyami Ersek Cardiovascular Center in Istanbul, Turkey. The diagnosis of Brucellosis was based on the presence of clinical signs and symptoms compatible with brucellosis, serology and/or a positive blood culture. All patients with suspected Brucella endocarditis were studied by echocardiography. The diagnosis of Brucella endocarditis was made in accordance with Duke's criteria.RESULTS:The most commonly affected valve was the aortic valve (4 patients). Four patients had prosthetic valves because of a previous history of rheumatic fever. In 5 patients, elective surgery was performed. Five patients underwent valve replacement with prosthetic valves, but 1 patient underwent excision of the abscess cavity without valve replacement. There was no operative mortality. All patients continued antibiotic treatment for at least 3 months postoperatively. The median duration of follow-up after surgery was 12 months. During the follow-up period, 1 patient died, while the others remained alive with no recurrences.CONCLUSION:Prosthetic valve replacement is a safe procedure in patients with Brucella endocarditis. Surgical interventions combined with triple antibiotic therapy yield good results with no recurrence in the long-term follow-up.

Objective: Widespread application of on-pump revascularization procedures is increasing due to the thought of elimination of untoward effects of cardiopulmonary circuit. Thus, whether off-pump coronary artery surgery eliminates side effects especially related to respiratory functions is still controversial. Although many previous studies have evaluated these respiratory functions, daily comparison of 12 parameters was not included in any of the studies. The aim of our prospective study was to ascertain whether off-pump coronary operation improves pulmonary functions and postoperative recovery period when compared with on-pump technique and whether early discharge of patients with off-pump surgery is the result of respiratory improvement. Methods: Eighteen patients in each group were included: on-pump group underwent coronary revascularization with cardiopulmonary bypass and off-pump with stabilization. Respiratory function tests and arterial blood gas analyses were performed preoperatively and daily after operation function tests included forced expiratory volume (FEV) in 1 s, forced vital capacity (FVC), expiratory reserve volume, vital capacity, quotient of FEV in 1 s to FVC, maximal voluntary ventilation (MVV), tidal volume, and forced midexpiratory flow. Blood gas analyses included partial arterial oxygen and carbon dioxide pressure, arterial pH and hematocrit (Hct). Results: Preoperative pulmonary functions and arterial blood gases were not statistically significant between groups except MVV and partial arterial oxygen pressure. MVV was slightly higher in on-pump group and partial arterial oxygen pressure was slightly lower in on-pump group. During postoperative first day Hct (P=0.004) and FEV in 1 s (P=0.049) values and third day partial arterial oxygen pressure (P=0.011) and Hct (P=0.011) values were lower in on-pump group. Mean extubation, duration in postoperative suit and hospital discharge times, mean blood loss were not statistically significant between groups postoperatively. Conclusion: Pulmonary functions and arterial blood gases were not improved in off-pump patients when compared with on-pump patients. Patients going to be surgically revascularized should not be altered to off-pump surgery merely with the hope of improving respiratory functions with off-pump technique. As the postoperative stay times at surgical theatre and hospital is not different and the extubation times were similar, early discharge of patients with off-pump surgery cannot be related merely to better preservation of respiratory functions.

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.

OBJECTIVES:The endotoxemia associated with cardiac surgery is thought to be dominantly influenced by the use of cardiopulmonary bypass. The objectives of this study were to assess the relative contribution of cardiopulmonary bypass on endotoxemia apart from cardiac surgical access and to improve our understanding of the potential benefits of off-pump procedures.METHODS:Thirty patients undergoing coronary artery bypass grafting were followed up prospectively. The patients were divided into 2 equal groups: those who underwent bypass grafting through a sternotomy incision without cardiopulmonary bypass (off-pump group) and those who underwent bypass grafting through a sternotomy incision with cardiopulmonary bypass (CPB group). Blood sampling for endotoxin, lactate, and cardiac index measurements were performed during the following time points: (1) after sternotomy; (2) during the coronary occlusion period in the off-pump group and during aortic clamping in the CPB group; (3) after removal of the coronary occlusion sutures in the off-pump group and after removal of the aortic clamp in the CPB group; (4) 30 minutes after the completion of all distal anastomoses in the off-pump group and immediately after weaning from cardiopulmonary bypass in the CPB group; (5) 1 hour postoperatively; and (6) 12 hours postoperatively.RESULTS:Endotoxin and lactate levels were significantly (P <.05) lower in the off-pump group at all sampling time points, except after sternotomy.CONCLUSIONS:In conclusion, this study has shown that endotoxemia during coronary artery bypass surgery seems mainly to be associated with cardiopulmonary bypass procedure. The relatively lower endotoxin levels observed in off-pump surgery might contribute to improved postoperative recovery.

Objectives: This study sought to evaluate the long-term prognostic significance of stress–redistribution–reinjection Tl-201 imaging in patients with severe left ventricular (LV) dysfunction and coronary artery bypass surgery. Background: Preoperative stress–redistribution–reinjection Tl-201 imaging detects viable but asynergic segments which show functional improvement postoperatively and is considered as a valuable noninvasive method in selection of patients with severe LV dysfunction for revascularization. The long-term prognostic value of the reinjection technique remains unclear. Methods: Fifty-two patients with severe LV dysfunction (mean ejection fraction (EF) 0.32 ± 0.03) who underwent coronary artery bypass surgery in 1993–1994 were included in the study. Patients had follow-up 49 ± 12 months. LV function was assessed by two-dimensional echocardiography. Perfusion was assessed by Tl-201 SPECT imaging and was graded on a four-point scale (0 = normal, 3 = absent uptake) using the 20 segment model. Perfusion index was derived by adding the score of all segments and dividing these by 20. Patients were divided into two groups. Group A comprised patients with seven and more dysfunctional viable myocardial segments. Group B included patients with less than seven dysfunctional but viable segments. Results: Mean EF increased from 0.32 ± 0.03 to 0.46 ± 0.04. Mean perfusion index did not show a significant difference as a whole during follow-up compared to the early postoperative values (0.9 ± 0.4 and 1.1 ± 0.4, p = NS). When adequacy of revascularization was considered, the predictive value of a positive preoperative viability test for functional improvement was 82%. Nineteen cardiac events occurred in group B patients and six in group A patients: six deaths (four from cardiac and two from noncardiac causes), 13 myocardial infarctions (MI). Multivariate Cox survival analysis identified the number of viable segments detected preoperatively (χ2 = 7.2, p = 0.002), postoperative improvement in Tl-uptake (χ2 = 6.6, p = 0.01) and functional improvement (χ2 = 5.3, p = 0.03) postoperatively as independent predictors of cardiac events. Preoperative EF and functional capacity were not associated with cardiac events in long-term prognosis. Conclusion: These data suggest that preoperative stress–redistribution–reinjection Tl-201 imaging, specifically the number of viable segments detected preoperatively and postoperative improvement in Tl-201 uptake provide important long-term prognostic information in patients with severe LV dysfunction who had coronary artery bypass surgery.

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.

Between 1988 and 1998, 7 patients with coronary arteriovenous fistulas were treated surgically. Indications for surgery were congestive heart failure and marked left-to-right shunt in association with ischemic heart disease. Long-term follow-up (mean, 99 ± 37 months) was complete and mainly uneventful. Coronary arterio-venous fistulas can be successfully managed by surgery and patients should be treated without delay because complications of an untreated fistula may increase the complexity of the operation.