Results Ages of 21 patients with pregnancies ranged between 22-53. Outcomes of 30 pregnancies were as follows: 7 live births (6 healthy and one with warfarin embriopathy), 20 abortus in first trimester (16 medical and 4 spontaneous), 3 stillbirths. Two patients, both on LMWH, during their 2nd trimester required urgent operation with mechanical valve thrombosis, survived but ended-up with stillbirths. Among the patients who had healthy births, 3 had LMWH throughout the pregnancy, 3 had LMWH in the first trimester, warfarin between 12 and 36 weeks, then LMWH until delivery. Warfarin embriopathy occurred in one case where mother was using >5 mg during first trimester. Conclusion This pilot study demonstrates surprisingly high rates of gestation among MHVP bearing women. Medical abortus seems to be the most frequent approach to pregnant women with MHVP. For women wishing to continue their pregnancy, anticoagulation regiment and outcomes are divers and inconclusive to suggest the superiority of one among others.

The purpose of this study was to investigate the risk of perioperative major cerebrovascular events (MCVEs) in patients undergoing coronary artery bypass grafting (CABG) and to develop preventive therapy. After excluding the patients with marked ascending aortic atheromas and those with combined intracardiac procedures such as valve replacement and aneurysmectomy, 722 consecutive patients who had carotid artery duplex scanning (CADS) and CABG were studied. The results of the study showed the correlation of advanced age, smoking, previous major cerebrovascular event (MCVE), and severe coronary artery disease with high grade carotid artery stenosis of 80-99% (p < 0.05). A total of 13 patients had perioperative MCVE and an analysis of risk factors showed that the MCVE correlated with carotid stenosis of > 60% and reduced cardiac output requiring inotropic support (p < 0.01). Prophylactic carotid endarterectomy (CEA) in patients with 80% to 99% carotid stenosis notably decreased the incidence of MCVE (p < 0.01), and the use of the "pump off" technique instead of standard cardiopulmonary bypass decreased MCVE (p = 0.056). On the basis of these data, prophylactic carotid endarterectomy is effective in averting perioperative MCVE in subjects with carotid stenosis of 80% to 99%, and for those with 60% to 79% carotid stenosis, the pump off technique decreases MCVE.

Background: Although the overall complication rates have been decreased significantly in recent years, stroke rates still remain high in patients undergoing coronary bypass operations. This study is designed to evaluate the risk factors for stroke in patients who had undergone coronary artery bypass surgery in an 8-year period in our clinic. Methods: Between 1995 and 2003, 8547 coronary artery operations under cardiopulmonary bypass were performed. Retrospective analysis of the patient files revealed that 75 (0.9%) patients had stroke in the early postoperative period. Results: Mean age of these patients was 62.3 +/- 9.5 years, and 54 (72%) were males. Stroke rate was 1.2% between 1995 and 1998 and this was significantly higher from the stroke rate (0.7%) of the period 1998 to 2003 (p = 0.03). Major technical differences between these two periods were the routine application of preoperative carotid arteries Doppler evaluation and intraoperative epiaortic echocardiography after 1998. Higher age (p = 0.000), female sex (p = 0.005), smoking (p = 0.03), presence of diabetes mellitus (p = 0.01), hypertension (p = 0.008), and left main coronary artery disease (p = 0.001), carotid surgery (p = 0.000), and peripheral vascular disease (p = 0.049) were identified as important risk factors in univariate analysis for stroke development. Higher age (p = 0.000; OR = 21.38), left main coronary artery disease (p = 0.007; OR = 7.26), peripheral vascular disease (p = 0.050; OR = 3.08), and operation date before 1998 (p = 0.012; OR = 6.33) were identified as important risk factors in logistic regression analysis. According to intraoperative epiaortic ultrasonography, operative strategy was changed in 9% of patients. Thirty-seven (49.3%) of the stroke patients died. Female sex (p = 0.023; OR = 5.18) and preoperative hypertension (p = 0.045; OR = 4.03) were observed as significant risk factors for mortality after stroke. Conclusion: Development of stroke is one of the major reasons of mortality after coronary artery bypass operations. It is essential to take all the measures to prevent this complication, especially in patients with known risk factors. Evaluation of carotid arteries prior to operation and application of routine intraoperative epiaortic echocardiography may in part eliminate stroke.

Objective: Several antegrade cerebral perfusion techniques with differing neurological outcomes are employed for aortic arch repair. This study demonstrates the clinical results of aortic arch repair with unilateral cerebral perfusion via the right brachial artery. Methods: Between January 1996 and March 2004, 181 patients underwent aortic arch repair via the right upper brachial artery with the use of low-flow (8-10 ml/kg per min) antegrade selective cerebral perfusion under moderate hypothermia (26 degrees C). Mean patient age was 58 12 years. Presenting pathologies were Stanford type A aortic dissection in 112, aneurysm of ascending and arch of aorta in 67, and isolated arch aneurysm in two patients. Ascending and/or partial arch replacement was performed in 90 patients and ascending and total arch replacement in 91 patients (including 27 with elephant trunk). In a subset of patients, renal and hepatic effects of ischemic insult were assessed. Free hemoglobin and lactate dehydrogenase levels were measured pre and postoperatively to identify hemolytic effects of brachial artery cannulation. Results: Mean antegrade cerebral perfusion time was 36 +/- 27 min. Three patients with acute proximal dissection died due to cerebral complications. One patient had transient right hemiparesis. Total major neurological event rate was 2.2%. Brachial artery was able to carry full cardiopulmonary bypass flow with mild hemolysis. Renal and hepatic tests showed no deleterious effects of limited ischemia at moderate hypothermia. Conclusions: Arch repair with antegrade cerebral perfusion through right brachial artery has excellent neurological results, provides technical simplicity and optimal repair without time restraints, does not necessitate deep hypothermia and requires shorter CPB and operation times. (c) 2005 Elsevier B.V. All rights reserved.

BACKGROUND:Statins improve patient survival and decrease rejection episodes in heart transplant recipients. We studied the effects of simvastatin treatment on myocardial tumor necrosis factor alpha (TNF-alpha) expression; TNF-alpha is a potent pro-inflammatory cytokine associated with hypertrophy and fibrosis in heart transplant recipients.METHODS:We randomized 10 consecutive heart transplant recipients to receive either 20 mg/day simvastatin (n = 5) or placebo (n = 5) for 6 months after cardiac transplantation. Routine surveillance endomyocardial biopsy specimens were obtained from all patients. We analyzed tissues for myocardial TNF-alpha content, total collagen content, and myocyte size using semiquantitative immunohistochemistry.RESULTS:Myocyte size and total collagen content of placebo and simvastatin groups did not show a statistically significant difference at any biopsy time point. Myocardium TNF-alpha content (% tissue area stained) at 1 week after transplantation was similar in the simvastatin and placebo groups. At the 24(th) week after transplantation, when compared with Week 1 values, we found a significant decrease in myocardium TNF-alpha content in the simvastatin group (15.0% +/- 2.3% vs 5.8% +/- 2.4%, p = 0.02) that was not observed in the placebo group (15.0% +/- 1.5% vs 12.0% +/- 2.6%, p = not significant).CONCLUSION:Simvastatin treatment in heart transplant recipients decreased myocardium TNF-alpha expression. This decrease did not translate into a difference in the markers of hypertrophy. However, decreased myocardial TNF-alpha may be a marker of a general statin-mediated decrease in inflammation in the transplanted heart that leads to improved graft and patient survival.

Background. Antegrade selective cerebral perfusion as a method of cerebral protection during the correction of aortic arch aneurysms and dissections is considered as a safe method for cerebral protection. There are still some questions remaining to be answered; such as whether cerebral perfusion through contralateral hemisphere is adequate.Method. Fifteen consecutive patients (mean age of 53 +/- 3.3 years) under-went surgical reconstruction of aortic arch with antegrade selective cerebral perfusion through the right brachial artery. We monitored maximum, minimum and mean blood flow velocities of bilateral middle cerebral arteries using the transcranial Doppler technique at four different time periods: after induction of anesthesia, during cardiopulmonary bypass, during antegrade selective cerebral perfusion, and after termination of cardiopulmonary bypass. We compared the results of brachial cnnulation group with aortic group.Results. Following induction, no significant differences were observed in the right and left middle cerebral artery blood flow velocity measurements in and between the groups. During cardiopulmonary bypass, V-max and V-mean decreased significantly in both groups. When two groups were compared there was a significant decrease in the left V-max values of brachial group (p = 0.048). In-group comparisons revealed that V-max values were lower in left middle cerebral artery than right middle cerebral artery in brachial group (p = 0.002). With the initiation of antegrade selective cerebral perfusion in brachial group, significant decrease occurred in V-max and V-mean when compared with cardiopulmonary bypass values. When left and right sides were compared, although V-min values remained similar, V-max and V-mean values decreased significantly in the left side (P = 0.001 and p = 0.003, respectively). After cardiopulmonary bypass, in both groups, all values restored to initial values and indicated no difference between left and right middle cerebral artery in the groups as well as between the groups. No neurologic deficit was observed in any patient postoperatively.Conclusions. Antegrade selective cerebral perfusion through the right brachial artery, as a method of cerebral protection for aortic arch repair, seems to provide adequate perfusion for both right and left cerebral hemispheres.

A 67-year-old woman who presented with chest and back pain was diagnosed with an aneurysm of the ascending aorta. Coronary angiography and aortography were performed via the right brachial artery, which was complicated by axillary artery dissection. At surgery, despite our clinical experience of using the right upper brachial artery for arterial cannulation, right femoral artery cannulation was performed to establish cardio-pulmonary bypass (CPB) as the dissection was extending to the brachiocephalic artery. The aortic crossclamp was placed on the arch of the aorta just after the origin of the brachiocephalic artery so that cerebral perfusion was performed via the left common carotid and left vertebral and basilar arteries through the left subclavian artery. No neurologic event was observed during the intensive care unit stay and follow-up period. To the best of our knowledge, the literature contains no other report of the use of only the left carotid and subclavian arteries to perfuse cerebral structures during CPB.

BACKGROUND:Although many reports demonstrate the hemodynamic benefits of left ventricular assist devices (LVAD) in right-sided circulation, it is not known whether the right ventricular myocardium goes through reverse remodeling after left ventricular mechanical circulatory support. Accordingly, the purposes of our studies were 1). to investigate the right ventricular changes that occur in fibrosis, in cellular hypertrophy, and in intra-myocardial tumor necrosis factor alpha (TNF-alpha) levels in patients receiving LVAD support; and 2). to determine whether the type of LVAD used influences right ventricular myocardial changes. METHODS AND RESULTS:We measured myocyte size, total collagen content, and TNF-alpha levels using semi-quantitative immunohistochemical analysis of myocardial samples from the right and left ventricles of control and failing myocardia, either supported by 1 of 2 distinct forms of LVADs or without support. We found that when compared with control, although myocyte size was not increased in the right ventricle of failing myocardia (p = not significant), total collagen content and myocardial TNF-alpha levels were decreased in the right ventricle compared with controls (p < 0.01 and p < 0.001, respectively). CONCLUSION:These data demonstrate that chronic left ventricular unloading with either pulsatile or continuous-flow devices decreases right ventricular total collagen and myocardial TNF-alpha content. We suggest that the decreased fibrosis and normalization of cytokine milieu observed may in part contribute to the recovery of right-sided cardiac function associated with chronic mechanical circulatory support.

In their report Galajda and colleagues1Galajda Z. Szentkirdyi I. Peterffy A. Brachial artery cannulation in type A aortic dissection operations.J Thorac Cardiovasc Surg. 2003; 125: 407-409Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar describe their technique of brachial artery cannulation for two patients with type A aortic dissection. One patient was cannulated through left brachial artery, and the authors mentioned that they performed the operation without circulatory arrest. Preferring the left brachial artery instead of right for cannulation site may limit the use of open distal repair technique when necessary. Our group has reported 104 cases of arch repair using right brachial artery where open distal repair was easily performed by reducing the flow and applying atraumatic vascular clamps to the innominate and left carotid arteries.2Tasdemir O. Saritas A. Kucuker S. Ozatik M.A. Sener E. Aortic arch repair with right brachial artery perfusion.Ann Thorac Surg. 2002; 73: 1837-1842Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar The authors have reported using 20F cannulas during their two operations. According to our experience, a 20F cannula is too large for the great majority of patients. We preferred using the Calmed non–wire reinforced venous return catheter (California Medical Laboratories, Irvine, Calif), the tip of which can be trimmed to 16F to 18F diameter according to the size of the patients’ brachial artery due to its conical shape. The authors suggest that the end of the inserted cannula should not extend beyond the origin of the subscapular artery to protect collateral circulation of the upper limb. We inserted the catheter into the brachial artery as its tip is positioned 5 to 7 cm proximal to the arteriotomy, which in most cases extended beyond the origin of the subscapular artery, but this did not cause upper limb ischemia in any of our patients. We are in complete agreement with the authors that the brachial artery is an easily accessible site for cannulation. In our current practice it is the standard for the repair of aneurysms and dissections of the aortic arch. Reply to the EditorThe Journal of Thoracic and Cardiovascular SurgeryVol. 139Issue 3PreviewWe have read the article by Dr Küçüker and his colleagues with great interest. They should be congratulated on their excellent clinical outcome of arch repair using right brachial artery cannulation.1 Their technique achieves the same goal as the axillary artery cannulation technique. Although the brachial artery might be easier to access, its size might occasionally prevent it from being used. Monitoring of the antegrade selective perfusion pressure, which we believe to be a critical component of assessment of the cerebral perfusion, might be easier with axillary cannulation with an arterial pressure line placed in the right radial artery. Full-Text PDF Reply to the editorThe Journal of Thoracic and Cardiovascular SurgeryVol. 126Issue 6Preview Full-Text PDF

Background. Cardiac and pericardial echinococcosis as a life-threatening disease may present with a clear picture most of the time, however it may also become a clinical puzzle.Methods. In the period between 1977 and 1998, 14 patients were operated on with the diagnosis of cardiac and pericardial echinococcosis. Nine patients were operated on with standard cardiopulmonary bypass (CPB) techniques, and the remaining 5 patients were operated on without CPB. Transesophageal echocardiography (TEE) or intraoperative surface echocardiography were used to plan and perform the operation for the late cases.Results. One patient died during the postoperative period due to the rupture of interventricular septum. All other patients survived the perioperative period, received mebendazole treatment, and exhibited no recurrence during the follow-up.Conclusions. The definitive treatment is the surgical extraction of the cyst. Because the clinical picture may vary according to the number, size, and location of cysts, as well as complications, cardiac echinococcosis should be remembered and included in the differential diagnosis to achieve the treatment. Intraoperative surface echocardiography is of paramount value for diagnosis and planning the management of a successful surgery. (C) 1999 by The Society of Thoracic Surgeons.

BACKGROUND:Rheumatic mitral valve stenosis is still an endemic disease in some parts of the world and may complicate pregnancy and perinatal period. During the 10-year period between January 1988 and December 1997, 10 pregnant women with mitral stenosis were operated on.METHODS:Combined cesarean delivery and closed mitral valvulotomy (CMV) were performed on 6 patients, combined cesarean delivery and Mitral Valve Replacement (MVR) were performed on 1 patient, and 3 patients had CMV during their third trimester.RESULTS:There was 1 stillbirth. All other patients and delivered babies were healthy. MVR was necessary for mitral restenosis in one patient 5 years after her CMV. Three of the remaining patients had some degree of restenosis but did not require reoperation.CONCLUSION:CMV when indicated during pregnancy can be performed with low risk. For symptomatic patients responding to medical therapy, a combined approach of cesarean section and CMV will prevent possible complications that may arise on perinatal period due to hemodynamic fluctuation.

Background. This study was performed to assess the functional capacity of the survivors of septal myectomy for the treatment of hypertrophic obstructive cardiomyopathy in long-term follow-up as assessed by dobutamine stress echocardiography.Methods. Sixty-nine patients with hypertrophic obstructive cardiomyopathy underwent septal myectomy between 1975 and 1996. The mean age was 25.4 +/- 13.6 years (range, 6-58 years), and 10 of the patients were women. The early mortality was 4.3%. Hospital survivors (95.7%) were followed up for a mean of 43.8 +/- 28.7 months (range, 6-114 months).Results. The postoperative mean functional capacity of the group was 1.47 +/- 0.56. No late deaths were reported. Forty-nine patients (74.2%) were evaluated with standard echocardiographic techniques, and 29 (43.9%) patients underwent dobutamine stress echocardiography. There was a significant decrease in the thickness of the interventricular septum after surgery. The mean preoperative and postoperative septal thickness was 1.99 +/- 0.59 cm (range, 1.3-3.8 cm) and 1.55 +/- 0.41 cm (range, 0.96-2.8 cm), respectively (p < 0.004). The mean posterior wall thickness was significantly less than the preoperative value (p = 0.008) and the left ventricular end-diastolic diameter was slightly greater in the postoperative measurements, but the difference was not significant (p = 0.162). Postoperative left ventricular outflow systolic gradients were reduced significantly when compared with preoperative values (preoperative mean, 78.4 +/- 33.6 mm Hg, range, 50-212 mm Hg versus postoperative mean, 17.9 +/- 15.9 mm Hg: range, 0-40 mm Hg: p < 0.0001).Conclusion. Septal myectomy for patients with hypertrophic obstructive cardiomyopathy is a safe procedure with excellent clinical and functional results in the longterm follow-up. (C) 1997 by The Society of Thoracic Surgeons.