Introduction: The aortic valve replacement is a standard operating procedure in patients with severe aortic stenosis. Structure of patients undergoing surgery ranges from young population with isolated mitral valvular disease to the elderly population, which is in addition to the underlying disease additionally burdened with comorbidity. One of the most commonly present factors that further complicate the surgery is coronary heart disease that occurs in, almost, one third of patients with aortic stenosis. The aim is to compare the results of surgery for aortic valve replacement with or without coronary artery bypass graft (CABG). Patients and Methods: From August 2008 to January 2013 in our center operated on 120 patients for aortic stenosis. Of this number, 75 were men and 45 women. The average age was 63.37 years (16-78). Isolated aortic valve replacement was performed in 89 patients and in 31 patients underwent aortic valve replacement and coronary bypass surgery. Implanted 89 biological and 31 mechanical valves. Results: Patients with associated aortic stenosis and coronary artery disease were more expressed symptomatic symptoms preoperatively to patients with isolated aortic stenosis who were on average younger age. Intra-hospital morbidity and mortality was more pronounced in the group of patients with concomitant aortic valve replacement and coronary bypass surgery. Morbidity was recorded in 17 patients (14.3%) in both groups, while the mortality rate in both groups was 12 patients (10.1%). Conclusion: Evaluation of preoperative risk factors and comorbidity in patients with aortic stenosis and coronary artery disease contributes to a significant reduction in intraoperative and postoperative complications. Also, early diagnosis of associated coronary artery disease and aortic stenosis contributes to timely decision for surgery thus avoiding subsequent ischaemic changes and myocardial damage.

ABSTRACT Objectives: The present study evaluates our experience with aorto-coronary bypass grafting in patients with severe dysfunction of left ventricle (LV) and low ejection fraction-EF(<35%). Revascularization of myocardium in this settings remains contraversial because of concerns over morbidity, mortality and quality of life. Material and Methodes: Forty patients with severe coronary artery disease and dysfunction of LV (low ejection fraction <35%) underwent coronary artery bypass grafting in period of 3 years. Preoperative diagnostic of 40 patients was consisted of anamnesis, clinical exam, non-invasive methods EHO, MR and invasive diagnostic methods-cateterization. The major indication for surgery was severe anginal pain, heart failure symptoms and low ejection fraction. Internal mammary artery was used in all operated patients. Results: Average age of patients who have been operated was 59,8. In the present study, 81,3% were male and 18,8% female. We found one-vessel disease present in 2,5% (1/40) of patients, two -vessel disease in 40% (16/40), three-vessel disease in 42,5% (17/40) and four -vessel disease in 15% (6/40) of patients. One bypass grafting we implanted in 2,5% patients, two bypasses in 42,5%, three bypasses in 45 5%, and four bypasses in 10% of patients. Left ventricular ejection fraction assessed preoperativly was 18%-27% and postoperatively was improved to 31, 08% in period of 30 days. Conclusion: In patients with left ventricular dysfunction, coronary artery bypass grafting can be performed safely with improvement in quality of life and in left ventricular ejection fraction.

Introduction: Left ventricular pseudoaneurysm is a rare condition because in most instances ventricular free-wall rupture leads to fatal pericardial tamponade. Rupture of the free wall of the left ventricle is a catastrophic complication of myocardial infarction, occurring in approximately 4% of patients with infarcts, resulting in immediate collapse of the patient and electromechanical dissociation. In rare cases the rupture is contained by pericardial and fibrous tissue, and the result is a pseudoaneurysm. The left ventricular pseudoaneurysm contains only pericardial and fibrous elements in its wall-no myocardial tissue. Because such aneurysms have a strong tendency to rupture, this disorder may lead to death if it is left surgically untreated. Case report: In this case report, we present a patient who underwent successful repair of a left ventricular pseudoaneurysm, which followed a myocardial infarction that was caused by occlusion of the left circumflex coronary artery. Although repair of left ventricular pseudoaneurysm is still a surgical challenge, it can be performed with acceptable results in most patients.

The increasing number of reoperative CABG procedures is primarily a function of progressive atherosclerosis affecting the saphenous vein grafts and native coronary arteries in patients who underwent a CABG procedure at an early age. During the first year after surgery, up to 20% of venous grafts occlude; between 1 and 6 years, the graft attrition rate is 1% to 2% per year; and between 6 and 10 years, it is 4% per year. Ten years after surgery, only 60% of vein grafts are patent, and only 50% of patent vein grafts are free of significant stenosis. Reflecting this graft attriton, angina recurs in up to 20% of patients during the first year after surgery and in approximately 4% of patients annually. The incidence of reoperation after primary CABG (REDO) is approximately 3% at 5 years, 11% at 10 years, and greater than 17% at 12 years. Despite the increasing number of reoperations for coronary revascularization only minimal data are available concerning patients undergoing a third time CABG (RERE-CABG). RE-RE-CABGs are not so frequent; but these patients constitute a special group, which may increase in the coming years. In this report we describe the short-term results and the clinical status of a patient after RE-RE-CABG without touching the aorta, using arterial grafts.

The research included 200 subjects, of which 150 had angiographically proven coronary disease with the coronary artery stenosis of 50% or more, and 50 subjects who did not have angiographically proven coronary disease. Patients were chosen randomly out of approximately 1000 patients who underwent angiography. All the subjects were treated at the Clinical Center of University of Tuzla--at the Clinic for Cardiovascular Diseases. The average value of homocysteine concentration in plasma of patients with angiographically proven coronary disease was 13.86 micromol/L, and 10.65 micromol/L in the controls, which is statistically significant difference (P < 0.0001). Lowered values of ejective fraction of the left ventricle of 50% and over was found in 25 patients (or 16.66%) with angiographically proven coronary disease, while the control group had only 4 subjects (or 8%). Student's t-test have proven that the average values of ejective fraction of the left ventricle of subject with angiographically proven coronary disease were statistically significantly different in comparison with the values of ejective fraction of the subjects in the control group (t = 5.87, df = 197, P < 0.0001). In all the groups the negative values of coefficients of correlation (R) shows that with the increase of plasma homocysteine concentrations the ejective fractions of the left ventricle dropped. Using logistical regressive analysis it was established that the following factors contribute the most to the development of coronary disease: increased concentration of plasma LDL-cholesterol, increased concentration of plasma homocysteine, diabetes mellitus and hereditary factors. In all the different forms of angiographically proven coronary disease (coronary disease in a one-vessel or in multiple-vessels), the increased concentration of plasma homocysteine was the significant risk factor for the development of coronary disease.

This study investigated outcomes in patients undergoing coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB), who needed conversion to CPB. Between September, 1998 and September, 2003, 1000 CABG procedures were performed in a Cardiovascular Clinic, University Clinical Centre Tuzla. Multivessel CABG were selected arbitrarily for CABG without CPB (OPCAB) or CABG with CPB (ONCAB). Patients who required conversion due to technical difficulty with grafting were performed with ONCAB including cardioplegic arrest. Patients with severe hemodynamic instability and cardiac arrest were performed as ONCAB without crossclamping, while patients converted for mild to moderate hemodynamic instability were given cardioplegic arrest or not, depending on surgeon preference. 493 operations were scheduled and performed as ONCAB (49.3%), 468 as OPCAB (46.8%) and 39 originally scheduled OPCAB operations were converted to ONCAB (7.7% of originally scheduled OPCAB patients or 3.9% of total number of CABG). Reasons for conversions were: mild to severe hemodynamic instability--28 (71.8%); poor vessels or difficult graft revision--11 (28.2%). Patients converted because of technical difficulty or mild hemodynamic instability behaved as regular ONCAB patients. In the 9 patients who were emergently converted due to cardiac arrest or ventricular fibrillation, 3 patients had stroke and 3 severe myocardial ischemia requiring intraaortic balloon pump. It is of great importance to keep conversions to CPB due to cardiac arrest at a low level. The serious complications seen in such patients can significantly impede the overall benefits of a successful OPCAB program.