Cardiac ischemia after coronary artery bypass grafting is often caused by graft occlusion. Short- and long-term graft patency is related to the quality of the surgical technique during harvesting and anastomosis. Transit time flow measurement is a recognized technique for the quality control of grafts but may not rule out structural abnormalities in the conduits, which can cause graft occlusion. This article reports on two cases of suspected intra-arterial dissection of the left internal mammary artery despite satisfactory flow measurements. Routine ultrasound scanning of arterial conduits is helpful in distinguishing dissection and hematoma in the graft conduits.

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.

Objective: The aim of this study is to evaluate post-operative complications after myocardial revascularisation in patients with very severe ischaemic heart disease. Men typically have a higher incidence of coronary disease than women. Ischaemic heart disease is characterised by reduced blood supply to the heart. The coronary arteries supply blood to the heart muscle, and since no alternative blood supply exists, a blockage in the coronary arteries reduces the supply of blood to the heart muscle. Myocardial infarction can cause very severe dysfunction of the left ventricle. In spite of new medical and surgical treatments, the number of patients with ischaemic disease is constantly increasing. Patients and Methods: A group of 80 patients with ischaemic heart and myocardial infarc- tion was observed, and 40 of them surgically treated in the period 2010-2013. In this study we evaluated only those surgically treated patients. The results: Post-operative complications in patients surgically treated included: ICV 2.5% (1/40); bleeding 2.5% (1/40); arrhythmia 17.5% (7/40); pleural effusion 7.5% (3/40); media- stinitis 2.5% (1/40); sepsis 2.5% (1/40); acute renal insufficiency 2.5% (1/40); multiple organ failure 7.5% (3/40); and perioperative death 2.5% (1/40). Conclusion: Surgical treatment of patients with severe ischaemic disease as a result of myocardial infarction can be performed with minimal operative and post-operative compli- cations, especially in elective cases.

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.

Jehovah's witnesses (JW) belong to a religious group refusing to accept blood transfusion Surgical treatment remains a challenge in this subset of patients. From 1945, JW introduced a ban on accepting blood transfusions, even in life-threatening situations while autologous blood must also be refused if it is predeposited-thus excluding preoperative autodonation. However, autologous blood is acceptable if it is not separated from the patients' circulation at any time. The invasive nature of coronary artery bypass grafting (CABG), the associated decrease of body temperature and the use of cardiopulmonary bypass (CPB) are major reasons for increased blood loss and high incidence for blood transfusions during and after this procedures. Allogenic blood transfusions are often given and considered necessary in such operations, in spite of increased mortality, morbidity and major adverse outcomes resulting from transfusion. Reduction in the use of blood products should therefore be a general desire for every patient due to the associated risk factors. The evolution of less invasive cardiac surgical approaches, such as CABG without CPB (OPCAB) may contribute to a further reduction of blood transfusion and although these minimally invasive techniques may benefit every patient, they might be particularly valuable for JW. In this report, we present our initial experience in JW patient undergoing OPCAB and the way to use patient blood management for improved surgical outcome in such patient.

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.

Insertion of ventriculoatrial (VA) shunts is an effective method of draining cerebrospinal fluid from the cerebral ventricle to the right atrium and significantly improves the survival of patients with hydrocephalus. Some patients who received a VA shunt subsequently developed complications, including thrombus formation around the intracardiac end of the catheter and thromboembolism. The relative rarity of complications and the long latency between shunt insertion and the development of symptoms in VA shunt recipients may result in misdiagnosis or delayed diagnosis. The case presented suggests that such patients may require routine echocardiography at regular intervals. Otherwise, the indwelling foreign body may become the source of a life-threatening thrombotic mass, if not recognised and treated appropriately.

Dextrocardia is a condition in which the heart is pointed toward the right side of the chest instead of normally pointing to the left. The rate of atherosclerotic heart disease in subjects with this condition is similar to that of the general population. We present a patient with situs inversus totalis with dextrocardia who underwent coronary artery bypass grafting without use of cardiopulmonary bypass (OPCAB). A 74-year-old man who was known to have dextrocardia with situs inversus was admitted to the hospital because of angina. Coronary angiography was performed and showed ostial occlusion of the left anterior descendng artery (LAD) unsuitable for percutaneous coronary interventions but collatereralised from the right coronary artery. Patient underwent OPCAB under general anestesia. Right internal mammary artery was anastomosed to LAD on the beating heart with the surgeon standing on the right side of the patient. The patient's post-operative course was uneventful, and he was discharged on the 6th postoperative day in good condition. Performing OPCAB surgery is not technically more demanding, and present no unusual challenge on patients with dextrocardia.

Sinus of Valsalva (SV) aneurysm is rare cardiac lesion with variable clinical presentation. We presented a case of a 41-year-old female who was admitted to our Center because of severe heart failure and a signs of ruptured aneurysm of the SV into the right atrium. Transthoracic echocardiography confirmed communication between noncoronary SV and right atrium measuring 12 mm in diameter, tricuspid insufficiency, biatrial dilatation and preserved left ventricular function. Urgent heart catheterization showed normal coronary arteries. Surgical repair with patch repair of the ruptured aneurysm was performed. Control echocardiography showed no communication with regression in tricuspid insufficiency. Eight days after surgery the patient was discharged home in good condition with no symptoms. Rupture of SV aneurysm may produce serious hemodynamic instability with heart failure or sudden death. Our experience supports the concept that early diagnosis and surgical treatment can save lives for most of the patients.

Objective The purpose of this randomized study was to evaluate the effect on graft patency by adding clopidogrel to aspirin in off-pump coronary artery bypass (OPCAB) grafting and the possible side effects of such therapy. Methods Twenty patients who underwent standard OPCAB through median sternotomy were randomized immediately after surgery in two groups. Patients in group A (n = 10) received 100 mg of aspirin starting preoperatively, continuing indefinitely. Patients in group B received 100 mg of aspirin and, in addition, 75 mg of clopidogrel starting immediately after the operation and for 3 months. Postoperative bleeding and other perioperative parameters were compared. Angiography was repeated 3 months after surgery to determine the patency and quality of grafts. Results Preoperative risk factors were similar in the two groups. There was no significant difference in average number of distal anastomosis (P = 0.572), operation time (P = 0.686), postoperative bleeding (P = 0.256), ventilation time (P = 0.635), and intensive care unit stay (P = 0.065). Length of stay was shorter in group B (P = 0.024). There was no postoperative complication in either groups. Eight of 27 grafts in group A and 2 of 29 grafts in group B (P = 0.037) were occluded at the time of control angiography. Conclusions Early administration of a combined regimen of clopidogrel and aspirin after OPCAB grafting is not associated with increased postoperative bleeding or other major complications. Despite the small number of patients in this study and small number of examined grafts, the results suggest that the addition of clopidogrel may increase graft patency after OPCAB grafting.

Study comparing the results of coronary artery bypass grafting (CABG) with and without cardiopulmonary bypass (CPB) in the treatment of left main stenosis (LMS) has not yet been made in Bosnia and Herzegovina. The main aim of this study was to compare result of CABG performed on 176 patients, in Cardiovacular clinic of University Clinical Center in Tuzla from May 1999 to January 2005, by these two methods in LMS group of patients in the early and late postoperative period. The study was divided in two parts. In the first part, early postoperative period (30 days after the surgery) has been analysed, which encompasses results of CABG in 92 patients revascularisied without CPB (OPCAB) method (Group A), and 84 patients with LMS revascularisied with CPB method (ONCAB, CCAB) (Group B). In the second part, late postoperative period (one year after surgery) has been analysed. Patients from both groups were contacted and interviewed. Total number (276 versus 278), same as average number of grafts per patients (3.0 +/- 1.45 versus 3.31 +/- 0.86 p = 0.096), was insignificantly higher in group B. Perioperative and postoperative results revealed significant differences between two groups in reduced mechanical ventilation time (2.9 versus 7.3 hours, p = 0.039), less blood transfusion requirement (200.3 versus 419.9 ml, p = 0.035) and postoperative length of stay (7.4 versus 8.3 days). Inotrop support requirement was significantly higher in group B during the surgery (14.1% versus 29.8%, p = 0.019) and postoperative period longer than 12 hours (7.6 versus 22.6%; p = 0.009). Significant difference for mortality was noticed in early postoperative period in group A (0.0 versus 5.95%, p = 0.023). There was no significant difference for any of additional procedures (7.9 versus 7.8, p = 0.802), for major complications (8.0 versus 9.1%; p = 0.985) or for mortality (7.9 versus 5.2%; p = 0.692). Patients' survival after CABG for period of 12, 24, 36 and 48 months after surgery was not statistically significant (97.0 versus 96.1%, p = 0.802; 95.5 versus 96.1%, p = 0.857; 93.2 versus 94.8%, p = 0.913; 92.0 versus 94.8%, p = 0.692). This study revealed that OPCAB is effective and safe method for treatment of LMS, and there are certain advantages in comparison to classical method in short-term follow up, with no difference in long-term results.

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.