Background The tricuspid valve is usually ignored and tricuspid interventions are mostly done in the context of other planned cardiac surgery. Isolated tricuspid reoperative procedure, especially tricuspid valve replacement (TVR) is very rare and carries a very high mortality rate. In this prospective study, clinical results of isolated TVR either through a median re-sternotomy or an antero-lateral thoracotomy with conventional cardiopulmonary bypass (CPB) have been evaluated.Methods Thirty patients with previous open heart surgery through median sternotomy had isolated TVR between 2004 and 2011. Operative approaches were through a median re-sternotomy in 13 patients and a right antero-lateral thoracotomy in 17 patients.Results Follow-up period is complete with a mean duration of 19.77 +/- 17.08 months. The hospital mortality rates were 46.2% (six patients) in the Median Re-sternotomy Group and 5.9% (one patient) in the Thoracotomy Group (p= 0.025). The surgical procedures lasted shorter and the postoperative drainage amounts were lower in the Thoracotomy Group (298.08 +/- 76.64 min vs 246.76 +/- 47.40 min, p= 0.032 and 1787.50 +/- 1399.53 mL vs 903.33 +/- 692.43 mL, p= 0.03 respectively). Presence of ascites in the preoperative period (p= 0.007), operative technique (median re-sternotomy) (p= 0.025), use of cross-clamp (p= 0.048), and need for inotropic support during the operation (p= 0.002) were statistically significant factors affecting the hospital mortality. The mean estimated life period was better for the Thoracotomy Group (16.7 +/- 5.03 versus 35.9 +/- 5.01 months, p= 0.044). Presence of ascites in the preoperative period was a significant risk factor for overall mortality according to Cox regression analysis.Conclusion Thoracotomy for TVR in patients with previous median sternotomy is a practical and safe technique with lower mortality rates.

BACKGROUNDChronic mesenteric ischemia and carotid stenosis frequently have coexistent coronary artery disease. Myocardial ischemia is the most common cause of morbidity and mortality following revascularization of the peripheral arteries. The optimal treatment of concurrent mesenteric, carotid, and coronary disease is unknown.CASE REPORTWe report a case of a 75-year-old man who required revascularization of the left anterior descending coronary and superior mesenteric arteries and carotid endarterectomy. After concomitant surgical revascularization, the patient remained asymptomatic during the 3-year follow-up.CONCLUSIONA good result in this case encourages us for one-stage combined surgical intervention in patients who require multisystem revascularization.

Introduction: Popliteal artery entrapment syndrome (PAES) is the rare congenital abnormality. It is a threat to the lower extremity due to ischemia in young adults.Case Report: A 32-year-old health worker (medical doctor) applied to our clinic with a complaint of lower extremity pain, paleness, and coldness, post-exercise. He did not have any complaint to make him think as ischemia. Peripheral arterial angiography was applied, but the main diagnosis was given by magnetic resonance imaging angiography. Medical thrombolytic treatment, femoral embolectomy and then tendon resection, approached posteriorly, were applied to the popliteal region.Discussion: Repeated exterior microtraumas cause thickening in the arterial wall, early atherosclerosis, thrombus and ischemia. To diagnose this entity is difficult. Treatment should be surgical, oriented to abolish the compression.Conclusion: In this case, we wanted to emphasize how quiet the progression of the PAES may be, and effacement of the compression is essential in the treatment. Femoral embolectomy does not have any aid to treatment.

Left ventricular pseudoaneurysm is a rare, but life-threatening complication occurring after acute myocardial infarction. Early diagnosis and surgery are critical for the patients' recovery. An 80-year-old man was admitted to hospital with severe dyspnea. Coronary angiography and ventriculography showed a giant left ventricular pseudoaneurysm. Surgical approach to pseudoaneurysm was made through the mitral valve and directly from the aneurysmal sac. Defect was closed by Dacron patch. Postoperative period was uneventful and patient was discharged from hospital seven days after surgery.

Background: This study aims to investigate genetic polymorphisms in patients with mechanical heart valve dysfunction.Methods: Between January 1994 and December 2004, a total of 83 patients including 18 patients who were reoperated due to mechanical heart valve dysfunction (group 1), 15 patients with normal functions with lower international normalized ratio (INR) levels who underwent mechanical valve replacement (group 2), and 50 healthy individuals (group 3) were included. Factor V Leiden, prothrombin, interleukin (IL-6), and tumor necrosis factor alpha (TNF-alpha) polymorphisms were investigated for possible relationships between these factors and mechanical heart valve dysfunction.Results: A significant difference in IL-6 polymorphism was found between group 1 and group 3 (p<0.05). Other polymorphisms were not significantly associated with mechanical heart valve dysfunction among the groups. The IL-6 G-174C polymorphism was found to be significantly associated with mechanical heart valve dysfunction.Conclusion: Interleukin-6, the key inflammatory response cytokine, may play an effective role in mechanical heart valve dysfunction possibly through ongoing chronic inflammatory processes.

Structural bioprosthetic valve degeneration is the most prominent drawback of these valves. The durability of bioprosthetic valve is less with mitral than aortic ones. Herein we present a case who had undergone a bioprosthetic mitral valve replacement 21 years ago when he was 31 years old. Echocardiography showed 3 degree mitral regurgitation with gradient 23/12 mmgh, systolic pulmonary artery pressure (SPAP) 48mmgh, left atrium diameter was 8 cm and 3 degree tricuspid regurgitation. The bioprosthetic valve in mitral position was replaced with No.29 st Jude mechanical valve and Tricuspid valve Devege annuloplasty was performed. The postoperative period was uneventful.

Conventionally, mitral valve replacement (MVR) is performed under cardioplegic arrest. A 69-years-old male patient was admitted to our clinic with severe dyspnea, orthopnea and palpitation. Transthoracic echocardiography revealed fibro-calcified mitral valve stenosis. Without cross-clamping the aorta, beating heart MVR under cardiopulmonary bypass (CPB) was performed. Since no dissection of the ascending aorta is performed, the risks of injury and embolic complications are minimized. Porcelain aorta with the mitral valve disease is a new indication for beating heart MVR under CPB.

BACKGROUND:Postoperative pulmonary dysfunction following cardiopulmonary bypass (CPB) usually develops secondary to the inflammatory process with contact activation, hypothermia, operative trauma, general anesthesia, atelectasis, pain, and pulmonary ischemia/reperfusion due to cross-clamping. The aim of the present study was to evaluate the effects of an on-pump, normothermic, and beating-heart technique and of low-volume ventilation on lung injury.METHODS:We compared the results for 20 patients who underwent operations with an on-pump, normothermic, and beating-heart technique of mitral valve surgery with low-volume ventilation (group 1) with the results for 23 patients who underwent their operations with an on-pump, hypothermic cardiac-arrest technique (group 2). In both groups, blood samples were collected from the right superior pulmonary vein, and inflammation and oxidative stress markers (malondialdehyde, lactic acid, platelet-activating factor, and myeloperoxidase) were studied.RESULTS:Malondialdehyde, myeloperoxidase, and lactate values were significantly lower in group 1 than in group 2 just before the termination of CPB (P < .05). We observed no differences between the 2 groups with regard to values for platelet-activating factor.CONCLUSIONS:Inflammation and oxidative stress markers were lower in the group of patients who underwent beating-heart valve surgery with low-volume ventilation. These results reflect less of an ischemic insult and lower inflammation compared with the results for the patients who underwent conventional operations.

BACKGROUND:The aim of this study was to compare the postoperative long-term neurocognitive functions of patients who under-went beating-heart mitral valve replacement on cardiopulmonary bypass (CPB) without aorta cross-clamping with those of patients who underwent mitral valve replacement via the classic method.METHODS:The study group included 25 randomly selected patients who underwent beating-heart mitral valve surgery. During the same period, 25 patients were randomly selected as controls to undergo mitral valve replacement procedures via the standard ascending aorta-cannulation technique. The clinical and postoperative (2 months) neurocognitive functional data of both groups were compared.RESULTS:Neurologic deficit was observed in neither group during the postoperative period. There were no statistically significant differences between the control and the study groups with respect to Hospital Anxiety and Depression Scale (HADS) results (HADS: anxiety, P = .653; HADS: depression, P = .225), in the right hemispheric cognitive function test results (Raven's Standard Progressive Matrices [RSPM] and Line Orientation Test [LOT] tests: RSPM, P = .189), and in the left hemispheric cognitive function test results (the Ray Auditory Verbal Learning [RAVL] and Stroop Color-Word Test [SCWT] tests: SCWT 1 time, P = .300; SCWT 2 time, P = .679; SCWT 3 time, P = .336; SCWT 4 time, P = .852; SCWT 5 time, P = .416; RAVL total verbal learning, P = .167; RAVL immediate recall, P = .791; RAVL distraction trial, P = .199; RAVL retention, P = .174; RAVL delayed recall, P = .111; RAVL recognition, P = .282; SCWT 4 mistake, P = .306; SCWT 4 reform, P = .066; SCWT 5 mistake, P = .236; SCWT 5 reform, P = .301).CONCLUSIONS:The technique of mitral valve replacement with normothermic CPB without cross-clamping of the aorta may be safely used for the majority of patients requiring mitral valve replacement without causing deterioration in neurocognitive functions.

Objectives: The present study aimed to compare the results of beating heart technique and conventional mitral valve surgery (MVS). Methods: Three hundred and nineteen patients who underwent MVS between April 2005 and December 2006 were enrolled in the study. While 125 patients underwent beating heart MVS (group 1), the conventional approach was used for 194 patients (group 2). Of those patients who underwent beating heart MVS, 75 underwent MVS without cross-clamping the aorta. Coronary sinus retroperfusion was used during surgery in the remaining 50 patients. The right anterolateral thoracotomy was performed in nine out of the 29 patients requiring re-operation, while resternotomy was performed in 20. Results: No significant differences were shown between the groups in the preoperative period in terms of the Parsonnet mortality score, Ontario mortality score, and length of intensive care stay. However, there were significant differences with respect to EuroSCORE risk score, EuroSCORE mortality, and Parsonnet risk score, and length of hospital stay according to Ontario risk scoring. It was established that the patients in group 1 had a shorter length of hospital stay [group 1: six days (range, 4-37 days); group 2: 10 days (range, 4-62 days)]. Group 1 was observed to have shorter time periods when the groups were compared regarding operative time [group 1: 130 min (range, 100-270 min); group 2: 240 min (range, 100-360 min)], cross-clamping (XCL) time [group 1: 27.5 min (range, 3-99 min); group 2: 60.5 min (range, 30-163 min)], and cardiopulmonary bypass time [group 1: 57 min (range, 22-150 min); group 2: 90 min (range, 39-388 min)]. There were also significant differences in favor of group 1 in terms of postoperative need for inotropic support wgroup 1: 26 patients (16%); group 2: 68 patients (35%) x. Although there were no statistically significant differences in the groups in terms of mortality rates according to the Parsonnet scoring system, with the exception of the moderate risk group, it was noted that the mortality rates in the beating heart group were lower. Conclusions: This study concluded that beating heart MVS can be performed successfully, particularly for patients at higher risk which will lead to increased morbidity and mortality in postoperative period. (C) 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Traditionally, reoperations for mitral valve replacement are carried out under cardioplegic arrest with cross-clamping of the ascending aorta via a median sternotomy. In this case, the mitral valve replacement operation was performed with an on-pump beating heart technique without cross-clamping the aorta and via a right thoracotomy because of diffuse adhesions around the ascending aortic tube graft. A 44-year-old male patient had undergone a Bentall operation via a median sternotomy for annulo-aortic ectasia 3 years ago. He was admitted to the hospital complaining of palpitation and dyspnea. Transthoracic echocardiography revealed 4th degree mitral insufficiency. Mitral valve replacement was carried out through a right thoracotomy using an on-pump beating heart technique without cross clamping the aorta. In conclusion, mitral valve replacement with an on-pump beating heart technique via a right thoracotomy offers a safe approach when excessive dissection is required to place a cross-clamp to the ascending aorta.

Isolated tricuspid valve replacement is not a common operation and the choice between mechanical and biologic prostheses remains controversial. When mechanical prosthesis are used, anticoagulant therapy is mandatory. In this article, we report a 21-years-old female patient who survived 15-years without anticoagulation following tricuspid valve replacement with a Bjork-Shiley prosthesis. Ultimately the mechanical valve was stuck and we replaced the tricuspid valve with a St. Jude Medical trileaflet bioprosthesis.

OBJECTIVE:: Thrombosis of mechanical heart valve prosthesis is a rare fatal complication after heart valve replacement. Although surgical intervention is the suggested treatment in many series, fibrinolytic treatment offers a good alternative. We describe eight cases with mechanical aortic valve thrombosis and compare their results after fibrinolytic treatment or redo aortic valve replacement.METHODS:: Between February 2008 and March 2009, eight patients with previous mechanical prosthetic aortic valve replacement history were admitted to our center with mechanical aortic valve thrombosis. Four patients were operated, and the remaining four patients received low-dose fibrinolytic treatment. All patients' data were collected prospectively.RESULTS:: Two of the four operated patients died. In the fibrinolytic group, all patients totally recovered, and there was no mortality or morbidity during the follow-up period.CONCLUSIONS:: We thought that fibrinolytic treatment is a feasible and effective method for thrombosed mechanical aortic valve. However, much more populated patient groups are needed for the vigorous inference.

The best management regimen for patients with coronary artery disease requiring surgery and bilateral total internal carotid artery occlusion remains controversial. A 61-year-old male patient presented with unstable angina pectoris. His medical history revealed that he had a cerebrovascular accident 11 years ago. On physical examination, he had dysarthria and monoparesis on the right upper extremity. Coronary and carotid angiography revealed critical coronary artery stenosis and total occlusion of bilateral internal carotid arteries, total occlusion of the right vertebral artery and 40% stenosis of the left proximal vertebral artery. After general intravenous fentanyl anesthesia, low dose heparin was administered, and coronary artery bypass grafting (CABG) was performed under off-pump beating heart condition. Systolic blood pressure was maintained above 120 mmHg to preserve cerebral blood flow during the operation. The postoperative course was uneventful and the patient was discharged in the 7(th) day postoperatively. If CABG is mandatory in patients having high cerebrovascular risk, off-pump CABG could be performed to reduce the stroke risk.

Background: The purpose of this study was to evaluate the safety and efficacy of amiodarone in the treatment of new-onset atrial fibrillation (AF) after coronary artery bypass grafting (CABG) surgery. Methods: The study included 20 patients (15 males, 5 females; mean age 64 9 years; range 43 to 79 years) who underwent CABG surgery for ischemic heart disease and received amiodarone treatment for AF that developed in the early postoperative period. Amiodarone was administered with an initial infusion of 150 mg/10 min, followed by infusions of 1 mg/min (first 0-6 hours) and 0.5 mg/min (6-24 hours). Following completion of 1,000-1,200 mg intravenous infusions, oral administration was continued with 400 mg (2x200 mg). Results: The mean time to AF development was 21.0 +/- 23.2 hours; the onset of AF was within the first eight hours in 10 patients, and between 13 to 70 hours in the remaining patients. Eight patients (40%) converted to sinus rhythm with amiodarone treatment within a mean of 25.4 +/- 22.0 hours, while 12 patients (60%) had persistent AF. Of these, three patients (15%) underwent electrical cardioversion on the seventh day of amiodarone treatment, and three patients were discharged with AF. Mortality occurred in seven patients (35%), of whom six had persistent AF. Following the development of AF, seven patients (35%) required inotropic support, and two patients (10%) required intraaortic balloon pump insertion. Bradycardia was seen in four patients (20%) following initiation of amiodarone. Patients with persistent AF showed significantly high rates of postoperative support (p<0.05) and, albeit not significant, higher rates of bradycardia (p=0.06) and mortality (p=0.08), and longer intubation time, intensive care unit stay, and hospital stay. Conclusion: Our findings showed that amiodarone was not effective in the treatment of new-onset AF following CABG surgery and unresponsive AF was associated with increased inotropic support and mortality.

Background and Aim: The incidence of residual opening after repair of postmyocardial infarction ventricular septal defect (VSD) was reported to be 10% to 25%. Redo surgery with remedian sternotomy is more complex than primary surgery and is consequently associated with higher mortality and morbidity due to the myocardial and patent coronary grafts injury during pericardial dissection. Methods: A 59-year-old female patient had coronary artery bypass grafting and closure of post myocardial infarction ventricular septal defect with patch 10 months earlier in a different cardiac center. She was admitted to the hospital for severe congestive heart failure. Results: She was operated because of the residual opening after repair of post myocardial infarction ventricular septal defect. Post myocardial infarction ventricular septal defect closure was performed through the right atrium by on-pump beating heart technique via the right thoracotomy. Conclusions: Closure of post myocardial infarction ventricular septal defect with this technique offers an alternative and safe approach to repair of the residual VSD when the coronary bypass grafts are patent.

Isolated tricuspid valve replacement, which is not a common operation, is associated with poor short-and long-term results, and the postoperative morbidity and mortality rates are high. The main reason for these adverse effects is the acute manifestation of chronic right heart failure. To treat right heart failure, we used levosimendan for its inotropic and vasodilatatory effects, and it does not increase the calcium overload in myocardial cells. We report two cases of tricuspid valve replacement operations performed using levosimendan. Both patients receiving levosimendan tolerated the operations well, and their postoperative courses were uneventful.