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Objective: Antegrade cardioplegia may cause maldistribution in patients with multivessel coronary artery disease. Surgically bypassing large epicardial vessels before the cross-clamp and then administering cardioplegia from both the aortic root and the anastomosed grafts significantly prevent maldistribution and provide better cardiac protection. Methods: This study included 80 patients, all older than 70 years with an ejection fraction between 25 and 35%. Patients were equally divided into two groups. Distal anastomoses to some of large epicardial coronary arteries were performed before the cross-clamp was placed. Grafted veins were attached to multi-perfusion set ports. Then, cross-clamping was performed, and the multi-perfusion set was disconnected from the aortic cannula and attached to the cardioplegia route. Antegrade cardioplegia was administered to both the aortic root and saphenous vein grafts. After all distal anastomoses were completed, the cross-clamp was removed, and the multi-perfusion set was connected to the aortic cannula again. Conventional coronary bypass techniques were used in group 2 patients. Results: Inotropic agents were administered in 12 patients in group 1 and 29 patients in group 2 (p < 0.001). The average troponin I value in coronary sinus blood was 1.05 ± 0.8 ng/mL in group 1 and 3.12 ± 0.7 ng/mL in group 2 (p < 0.001). The average lactate value in coronary sinus blood was 1.15 ± 0.55 mmol/L in group 1 and 3.7 ± 2.4 mmol/L in group 2 (p < 0.001). Six patients died in the early postoperative period in group 2 (p = 0.028). Conclusion: The current technique considerably reduces cross-clamping time and allows better distribution of the cardioplegic solution, preserving myocardium. Reduced coronary sinus lactate and troponin I levels also indicate better myocardial protection.

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Proximal circumflex coronary artery in the atrioventricular groove usually has large diameters. Arterial diameters in this region vary from 2.5 to 5 mm. Revascularization of this part of the circumflex artery allows good distal anastomosis configuration and better long-term patency rate.

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BACKGROUND: Right ventricle (RV) dysfunction after a coronary artery bypass grafting procedure is a challenge that adversely affects RV filling pressure and contraction. This study sought to determine whether additional bypass of an RV branch would lessen RV dysfunction. METHODS: Patients with severe right coronary artery (RCA) stenosis were divided into 2 groups. Group 1 patients (n = 50) had a single distal bypass on the RCA. Group 2 patients (n = 50) had both distal RCA and additional bypass on the RV branch of the RCA. Right ventricular function was examined by echocardiogram by measuring transannular plane systolic excursion, fractional area change, tissue Doppler S-wave velocity, and inferior vena cava diameter. RESULTS: Transannular plane systolic excursion and fractional area change measurements rapidly decreased below the cutoff in both groups, but group 2 patient values reached normal limits at 90 days. Tissue Doppler S-wave velocity reached the normal limit in 7 days. Inotropic agents were required in 11 patients in group 1 and 2 patients in group 2 (P = .013). The mean (SD) intensive care unit stay was 2.11 (1.12) days and 1.45 (0.71) days (P = .033), and the hospital stay was 7.32 (1.44) days and 6.22 (0.45) days in groups 1 and 2, respectively (P = .027). CONCLUSION: The data in this study suggest that an additional graft on the RV branch of the RCA (eg, conus, marginal, any good runoff vessels on the RV) prevents severe RV dysfunction and allows for rapid recovery of RV dysfunction after off-pump coronary surgery.

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Aortic valve endocarditis may be destructive and cause an acquired Gerbode-type defect. The use of biological material in the closure of the Gerbode defect and reconstruction of the aortic valve is essential for both early and long-term survival. Herein, we present a 62-year-old male patient whose Gerbode defect was repaired with bovine pericardium. Additionally, the aortic valve was reconstructed by using bovine pericardium with Ozaki neocuspidization technique.

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Mitral annuloplasty is an integral part of mitral valve repair. Several types of techniques have been described for mitral annuloplasty. The autologous pericardium is used for mitral annuloplasty to allow mitral annular flexibility. Complete mitral ring annuloplasty is done using a D-shaped bovine pericardium. Classical annuloplasty sizers are utilized for the sizing and shaping of bovine pericardium. Biological material covers all parts of the mitral annulus and allows annular flexibility.

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Placing retractor and stabilization devices during open heart surgery can be difficult in obese patients due to extremely short neck and excessive breast tissue. Off-pump coronary bypass operations in these patients can be particularly technically demanding. To overcome this difficulty, we have used two retractors concomitantly. The first retractor is placed to the edges of sternum and the second one is placed into this first retractor. This maneuver ensures an extra height, and placing stabilization devices in this second retractor is relatively easy. Thus, we suggest that adding this maneuver will facilitate off-pump coronary bypass operations.

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Seven patients underwent pericardial patch closure of the left atrial appendage orifice in our clinic. Usually 5-to-7 U-sutures with 4-0 prolene were placed to the left atrial appendage orifice. These sutures were stretched out to measure exact sizes of the left atrial appendage orifice. Then, U-sutures were passed through the pericardial patch which was treated with glutaraldehyde. Pericardium was placed over the left atrial appendage orifice through the left atrium and stay sutures were tied. The upper suture was continuously sutured along the border of the orifice clockwise and tied to the lower suture. The lower suture was continuously sutured in a counter-clockwise direction and tied to the upper suture. Then, mitral valve surgery (repair or replacement) was performed.

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The cervical course of the internal carotid artery is almost straight in contrast to the intracranial portions which are highly tortuous. The incidence of variations in the cervical course of the internal carotid artery of the population is approximately 10-40 percent. In this case report, a 76-year-old female patient with a pulsatile mass at the posterior oropharyngeal wall and anterior neck was presented. Physical examination revealed a pulsatile anterior neck mass, and a pulsatile mass at the right posterior wall of the oropharynx. Imaging revealed a bilateral tortuous internal carotid artery and segmental left internal carotid arterectomy and distal internal carotid artery - lateral common carotid artery anastamosis were performed with no postoperative complications.

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Usually, after mitral leaflet tissue is resected, artificial chordae are used to obtain papillary muscle-to-mitral annulus continuity so as to preserve left ventricular performance. A modified technique that does not require resection of the posterior mitral leaflet and permits implantation of an adequate size of prosthesis is described.

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A new central venous catheterization during open heart surgery is seldom required. Clamping of superior vena cava (SVC) causes adequate brachiocephalic vein distension which facilitates vein puncture. In our experience, approximately 20 s is enough for adequate brachiocephalic vein distension. I usually prefer subclavian vein puncture by supraclavicular approach. By this approach, average superior vein clamping time is about 45 s.

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In OPCAB (off-pump coronary artery bypass) operations, development of cardiac arrest during the distal anastomosis to obtuse marginal coronary artery leads to significantly low blood pressure in the ascending aorta. Therefore, blowing of compressed air in high flow on not-slinged coronary artery may cause air mobilization from the coronary artery system into the ascending aorta that may result in severe brain damage.

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OBJECTIVE: To quantitate the contractile effect of methylene blue on isolated human internal mammary artery (IMA) as used in the vasoplegic syndrome. DESIGN: An in vitro experimental study. SETTING: Cardiovascular Pharmacology Laboratory, Department of Medical Pharmacology. PARTICIPANTS: IMA segments were used from 24 patients undergoing coronary artery bypass surgery. INTERVENTIONS: The responses to methylene blue, norepinephrine, and acetylcholine were recorded isometrically by a force-displacement transducer in an isolated organ bath. MEASUREMENT AND MAIN RESULTS: Methylene blue (10 nmol/L-100 micromol/L) produced concentration-dependent contraction in the arteries. The maximal contraction to methylene blue was 44.2% +/- 3.8% of KCl (68 mmol/L) maximum contraction; the pEC(50) (-log(10) of 50% effective concentration) value was 5.5 +/- 0.1. Methylene blue caused an insignificant leftward shift of the concentration-response curve of norepinephrine. Acetylcholine-induced relaxation in submaximal contracted rings with phenylephrine recovered nearly 6 hours after the methylene blue challenge. CONCLUSION: Methylene blue caused concentration-dependent contraction in human IMAs. Furthermore, the inhibition of ACh-induced relaxation for 6 hours after the methylene blue challenge points out an additional mechanism (ie, receptor occupation). The concentration-dependent contractile effect of methylene blue justifies its use in the vasoplegic syndrome. The findings also suggest that the time course of contraction is longer than the exposure to methylene blue.

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Classical internal cardiac massage mostly can increase systolic blood pressure to maintain sufficient brain and systemic organ perfusion but diastolic blood pressure commonly remains below 10 mmHg. To be able to increase the diastolic blood pressure sufficiently, the surgeon grabs the distal part of the ascending aorta between the thumb and index finger of the left hand and squeezes it during the diastolic time period to increase the diastolic pressure. Ascending aorta is released during ventricular squeezing, and subsequently ascending aorta is squeezed during the ventricular relaxation.

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OBJECTIVE: To compare continuous insulin infusion (CII) and intermittent subcutaneous insulin therapy for preventing supraventricular tachycardia. The authors propose that continuous insulin therapy is more effective to reduce supraventricular tachycardias. DESIGN: A prospective randomized study. SETTING: This study was performed in 2 different centers between April 2005 and February 2007: Gülhane Military Medical Academy and University of Süleyman Demirel. PARTICIPANTS: Two hundred diabetic patients were included in this prospective randomized study. Patients were divided into 2 groups according to their insulin therapy in 2 different centers. INTERVENTIONS: Group 1 included 100 diabetes mellitus (DM) patients, and CIIs were administrated. These patients received a CII infusion titrated per protocol in the perioperative period (Portland protocol). Group 2 also included 100 DM patients, and subcutaneous insulin was injected every 4 hours in a directed attempt to maintain blood glucose levels below 200 mg/dL. Sliding scale dosage of insulin was titrated to each patient's glycemic response during the prior 4 hours. MEASUREMENTS AND MAIN RESULTS: There were 5 hospital mortalities in the intermittent insulin group. The causes of death were pump failure in 3 patients and ventricular fibrillation in 2 patients. There were 2 hospital mortalities in the CII group (p = 0.044). Thirty-six patients in the intermittent insulin group and 21 patients in the CII group required positive inotropic drugs after cardiopulmonary bypass (p = 0.028). Low cardiac output developed in 28 and 16 patients in the intermittent and CII groups, respectively (p = 0.045). Univariate analysis identified positive inotropic drug requirement (p = 0.011, odds ratio [OR] = 3.41), ejection fraction (EF) (p = 0.001, OR = 0.92), cross-clamp time (p = 0.046, OR = 0.97), left internal mammary artery (p = 0.023, OR = 0.49), chronic obstructive pulmonary disease (COPD) (forced expiratory volume in 1 second <75% of predicted value (p = 0.009, OR = 2.02), intra-aortic balloon pump (p = 0.045, OR = 1.23), body mass index (p = 0.035 OR = 5.60), and CII (p < 0.001, OR = 0.36) as predictors of SVT. Stepwise multivariate analysis confirmed the significance of some of the previously mentioned variables as predictors of SVT. The value of -2 log likelihood of multivariate analyses was 421.504. These were EF (p < 0.001, OR = 0.91), positive inotropic drug requirement (p < 0.001, OR = 3.94), COPD (p = 0.036, OR = 2.11), and CII (p < 0.001, OR = 0.19). CONCLUSION: Continuous insulin therapy in the perioperative period reduces infectious complications, such as sternal wound infection and mediastinitis, cardiac mortality caused by pump failure, and the risk of development of supraventricular tachycardias.

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Polycythemia vera is a myeloproliferative disorder associated with the thromboembolic events. Normalization of the hematocrit and elevated platelet counts is obligatory to reduce the thrombotic risk of patients with PV. Therapeutic strategies include phlebotomy, myelosuppressive agents, and, more recently, interferon-alpha. In addition, appropriate antiplatelet therapy should be administered to prevent life-threatening complications and reducing the viscosity of the blood. Although aspirin is widely preferred in such patients, this monodrug therapy or combined with clopidogrel as an alternative approach might not be enough, especially after coronary artery surgery. Therefore, warfarin should be added to anticoagulant therapy. This short report describes the use of warfarin, associated with aspirin and clopidogrel as an anticoagulant regimen after coronary artery bypass surgery in two cases with polycythemia vera. We believe that a combination of warfarin with other oral antiplatelet agents may be more effective in preventing the coronary artery bypass graft thrombosis.

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