UNLABELLED The number of patients undergoing coronary artery bypass grafting (coronary artery bypass grafting-CABG) older than 70 years is increasing. Cardiac surgeons are investigate applicability of alternative and less invasive methods such as surgery without the use of cardiopulmonary bypass (CPB). The aim of this study was to compare the peri- and postoperative results of CABG in elderly patients operated with and without CPB. PATIENTS AND METHODS The study included subjects older than 70 years, who underwent coronary bypass surgery at the BH Heart Center Tuzla in the period from August 2008 to August 2010, divided into two groups. Group A consisted of 50 patients operated without CPB, group B 50 patients operated with CPB, adjusted by sex, left ventricular ejection fraction values, EuroSCORE, and the number of bypass grafts was made. RESULTS In the group treated without the use CPB there were significantly lower values of the time-duration of mechanical ventilation, length of stay in the Intensive Care Unit (ICU), the amount of postoperative bleeding and blood recovered, the length of hospital stay, levels of serum creatinine, C-reactive protein and creatine kinase MB fraction. CONCLUSION CABG without the use of CPB has a number of advantages over the method with CPB in elderly patients, which is evident from the lower values of renal and inflammatory parameters and markers of myocardial lesion, less time spent on a ventilator, shorter length of stay in the ICU and total hospitalization time, less postoperative bleeding and blood transfusion.

UNLABELLED Anatomical variations of veins often play a crucial role in formation of thrombotic changes in superficial and deep veins of lower extremities. THE AIM of this study was to determine the frequency of the dominant type of the lower extremity superficial veins, and to determine the eventual influence of such variations to the formation of superficial and deep vein thrombosis (DVT). MATERIAL AND METHODS The sample used in this study consisted of 180 patients subjected to ascedent contrast phlebography of lower extremities. The total sample was divided into following groups: patients with and without variations of the lower extremity superficial veins. RESULTS AND DISCUSSION Dominant type of the superficial veins (without variation) consisted of 97 patients (53.89%), while the rest of 83 patients showed some kind of anatomical variation (46.11%). The most frequent variation was the duplicated form ofv. saphena magna in 53.85%, while this procentage in women was 57.89%. Most frequent variations of duplicated v. saphena magna were: simple duplicated form, closed loop form, branching form and combined form. Topographical variation of saphenopopliteal junction besides fossa poplitea in the group of men showed procentage of 53.85%, while in the group of women that value accounted 63.16%. CONCLUSION The percentage of varicose veins was more frequent in men and women without variations, but deep vein DVT showed higher frequency in patients with anatomical variations of superficial veins of lower extremities.

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.

Abstract The present article will review new technology in the invasive approach to mitral valvular disease. Mitral valve pathology continues to present an important challenge to the cardiac surgeon and interventionalist. From the early days of closed mitral valvular commisurotomy, a number of new approaches to this valve have been developed. Mitral stenosis was previously approached through a minimally invasive beating heart surgical approach, but may now be treated with either catheter-based or open surgical techniques. Regurgitation, which has become the leading pathology of the mitral valve in the developed world, may be approached through traditional cardiac surgery or through catheter-based techniques. New imaging techniques and device innovation will cause drastic changes in therapy for mitral valvular disease in the foreseeable future.

We present a case of 71 year old man operated in our clinic for ruptured abdominal aneurysm complicated with aorto-caval fistula, which was revealed during the surgery and successfully repaired by direct sutures within the aorta. This is the first record of the aorto-caval fistula that was so far noticed in our clinic. Urgent surgery and repair of the defect conneting aorta and vena cava by direct sutures within the aorta followed by ruptured aneurysm repair with tube graft is only way of treatment. Despite its infrequent occurrence, aorto-caval fistula should always be considered in any case of ruptured abdominal aneurysm.

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.

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.

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.

Although it is possible to find a number of comparative studies in the world literature discussing the results of coronary artery bypass surgery (CABG) with and without cardiopulmonary bypass (CPB), until now such analysis has not been made in Bosnia and Herzegovina. The main aim of this scientific work was to compare morbidity and mortality, need for blood transfusions, length of stay in the intensive care unit, total length of hospitalisation and number of complication in two groups of patients operated with these methods. Patients with EuroScore > or =5 with CABG operated in Cardiovascular Clinic Tuzla, from May 2000 to May 2005 divided in two groups, were included in this study. There were 100 patients in the first group operated with CPB and 100 patients in the second group operated without CPB. The average time spent on respirators was shorter in patients operated without CPB (3.7 vs.9.74 hours, p = 0.023) and the time spent in Intensive care shorter too (19 vs. 23 days, p = 0.008). Volume of postoperative bleeding was less in patients operated without CPB (574.9 vs. 988.9 ml, p = 0.038), as volume after blood transfusion (168.8 vs. 350.3 mi, p = 0.001). Intraoperative inotrope support was less in patients operated without CPB (8.0 vs. 19.0%, p = 0.038) as postoperative inotrope support (6.0 vs. 17.0%, p = 0.027). The most usual postoperative complication was atrial fibrillation and there was no difference between patients operated with CPB and without CPB (24% vs. 17%, p = 0.293). Mortality was not different in patients operated with or without CPB (2.0% vs. 6.0%, p = 0.140). The average time of total hospitalisation was also shorter in patients operated without CPB (8.0 vs. 9.5 days, p = 0.039. In conclusion CABG without CPB has many advantages compared to the conventional method. Mortality and morbidity are reduced and there is less need for transfusion. The time spent on mechanical ventilation is reduced and less time is spent in intensive care. The total hospitalisation time is also reduced.

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.

The aim of this study was to analyze the Transit time flow measurement (TTFM) experience in the first 1000 CABG operations. First 1000 patients had coronary artery bypass grafting (CABG) performed in Cardiovascular Clinic, University Clinical Centre Tuzla, Bosnia and Herzegovina, between September, 1998 and September, 2003. CABG without use of cardiopulmonary bypass (CPB)-(OPCAB) was used as the preferential surgical method both because this method is reported to have equal or better results than CABG with use of CPB (ONCAB), and because of the significant cost savings realized. TTFM was routinely used in all grafts as a quality assurance measure. Criteria for a poor functioning graft were: low mean flow (MF), pulsatility index (PI) above 5 and a poor diastolic flow pattern. When no reversible cause of poor TTFM results were identified the graft was revised. A total of 1394 grafts in OPCAB group and 1478 in ONCAB group were performed. A total of 38 grafts (2,72%) in 37 patients (7,07%) were revised in OPCAB group, and 26 grafts (1,75%) in 26 patients (5,45%) in ONCAB group. 1 patient in OPCAB group needed 2 graft revisions. Graft revisions were more common in OPCAB, but with no significant difference (p=0,1035). The most frequently revised graft was LAD graft in both groups. Although the percentage of grafts revised are relatively low, it is still very important to record TTFM. More than 5% of patients in both groups needed graft revision. Although TTFM does not guarantee that grafts will stay open for a prolonged period of time we certainly believe that grafts that are occluded at the time of surgery will continue to stay occluded. TTFM is especially critical in OPCAB surgery where the technical challenge of grafting is higher then in ONCAB.

Angiotensin converting enzyme (ACE) and nitric oxide (NO) have been suggested to be in - The objective of this study is to compare outcomes of coronary artery bypass grafting (CABG) in high-risk patients performed with- (ONCAB) and without -(OPCAB) use of cardiopulmonary bypass. From October 2001 till October 2005, 210 high-risk patients classified according to European System for Cardiac Operative Risk Evaluation (EuroSCORE) (score =or> 5) underwent CABG in Cardiovascular Clinic, University Clinical Centre Tuzla, Bosnia and Herzegovina. 138 patients operated as OPCAB were compared to 72 patients operated as ONCAB. All data were entered in a patient database (DATACOR) and analyzed in SPSS. OPCAB patients received insignificantly less number of grafts than those treated by ONCAB (3,0 vs. 3,2) (p=0,071). Stroke was significantly more common in ONCAB group (2,9 vs. 11,1%) (p=0,034) while the incidence of other postoperative complications and mortality were similar. The ventilation time (4,3 vs. 6,7 hours) (p=0,007), retransfusion volume (392,7 vs. 633,7 ml) (p=0,041) and hospital stay (8,2 vs. 10,1 days) (p=0,031) was significantly less in OPCAB group. OPCAB is safe and effective in treatment of high-risk patients. Avoidance of cardiopulmonary bypass is associated with reduced incidence of neurologic complications, lower intubation time, retransfusion rate and shorter hospital stay, and in our experience the preferred operative method in such patients.