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Prof.Dr.Noyan Temucin Ogus

The normal heart has 2 coronary arteries, which are responsible for the blood circulation of all right and left ventricles and atria:


Right Coronary Artery: RCA

Left coronary arterial system. (Left Main Coronary Artery = LMCA)

The left coronary arterial system is divided into two in itself and is called Circumflex Artery (Cx) while some of it is directed backwards, some of which reach the anterior face of the heart and give birth to a main artery that feeds almost half of the heart: Left Anterior Descending (LAD).


This anatomic formation is found in over 99% of the population considered normal. Nomenclature is based on the origin of the coronary arteries on the aortic valve. The left coronary artery originates from the Valsalva Sinus facing the left side of the patient and the right coronary artery (RCA) originates from the Valsalva sinus on the right side of the patient. In less than 1% of the cases, normal people may have anomalies of origin and course of the coronary arteries. These are usually benign variations and do not cause symptoms.

Sometimes a congenital coronary artery may never have been formed, especially if LAD, the most important branch of LMCA, is not congenital, may cause rhythm disturbances at early ages and cause patient death. It is possible to encounter such rare cases only in centers where heart surgeries are performed in high numbers. We have encountered 5 such cases reported in a patient who we operated on in the world. The patient's LAD artery was thought to be occluded and was called “inoperable başka in another center because it could not be visualized by angiography. Coronary artery was bypassed and the patient is still alive (Oğuş, T., S. Çiçek and Ö. Işık. Işık Absence of Left Anterior Descending Artery Associated with Atherosclerotic Heart Disease, gi Angiology, 52: 87-88 ( 2001).


RCA


The RCA is responsible for the blood circulation of the whole of the right heart, the 1/3 lower part of the muscle layer (Interventricular Septum) that separates the right and left hearts, the Sinoatrial node that provides the rhythm of the heart, and usually the Atrioventricular node, which allows the rhythm electrical conduction path to be transmitted to the ventricles.

In particular, in the occlusion of the largest branch of LMCA, which we call LAD, it creates bridge veins through the heart muscles, thus limiting the infarction the patient is undergoing (see below angiography image). Although RCA may seem smaller and insignificant than other coronary arteries, obstruction (infarction) may still kill the patient. RCA infarction can cause an extremely lethal complication called “Right Heart Failure gibi, as well as bradycardia, also called fatal bradycardia, which is called dakika block ileri, where severe rhythm slows down, or excessive heart rate (400-600 / minute). . If the patient can be brought to hospital on time, the occluded RCA can be opened by applying a stent. Even if this does not succeed; A pacemaker can be implanted to improve the patient's circulation or, if the patient enters ventricular fibrillation, can be kept alive by electric shock. Generally, a patient with RCA infarction can be kept alive in hospital conditions and rarely (patients who do not respond to any treatment) require coronary bypass surgery.

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Angiography image: RCA onset in the upper left of the image; Imaging of the RCA by radiopaque material into the RCA with a catheter inserted into the coronary mouth, which we call the ostium. RCA draws a “C in and descends to the lower face of the heart and gives the RPD-RPL branches; The corrugated artery originating from the upward crux is called the Kugel artery and fills an obstructed LAD artery (red arrow) with a bridging system (collaterals) developing through the muscles in the inerventricular septum.

LMCA


LMCA RCA in symmetrical shape on the aortic valve; but this time it comes out of the back; The 1-3 cm LMCA is divided into two parts behind the pulmonary artery (pulmonary artery). The main branch leading to the rear is called Circumfleks (Cx) and the branch leading to the front is called Left Anterior Descending (LAD).


In the figure below, a case with LMC admission above 90% is presented.

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The LMCA is responsible for feeding an average of 80-90% of the left heart and, in exceptional cases, obstruction results in death. Stenosis over 50% requires patient operation. In LMCA infarcts, the heart can only produce a few beats, within seconds the energy stores become empty and cause the patient to either stop his heart or enter ventricular fibrillation (fatal rhythm disorder). In a patient with LMCA lesion, leg arteries and brain (Carotid) artery diseases are very common.


As with the blockage of Cx, as in RCA, heart blocks and rhythm disorders may develop, and if the feeding of iler Papillary Muscles sorumlu which is mainly responsible for the closure of the mitral valve originating from this region is impaired, it causes serious mitral valve failure. If the patient rapidly enters pulmonary edema and is not recovered by emergency surgery, he is lost in respiratory failure.

Rarely, only 1 of the 2 papillary muscles, sometimes partially affected, develops an ant eccentric kaçak leak in the mitral valve that is not central. With the contraction of the heart back from the lid; This high pressure blood flow to the atrium introduces only one lobe or segment of the lung into pulmonary edema. The picture is often confused with lung infection, which we call pneumonia, and the patient is treated incorrectly for several days. We encountered such a rare patient and a patient who was treated for pneumonia in another center for days was admitted to the hospital with severe dyspnea and was diagnosed with ECO angiography and taken to emergency operation. The mitral valve was changed with coronary bypass and the patient is still alive (Oğuş, T., S. Altınmakus, F. Bilgen. “Eccentric Mitral Regurgitation Can Imitate a Diagnosis of Pneumonia.” International Journal of Cardiology, 77: 307-309 (2001).


The LAD enters the back of the main lung artery and passes to the front of the cabinet and advances through the right-left ventricles (through the interventricular septum) to the end of the heart (apex). If we think of the heart as a pear, the apex is where the stalk of the pear is located. LAD gives successive “Septal” branches that feed the muscle layer (septum) that separates the right and left ventricles, and septal 1,2,3 (S1, S2) etc. from the top to the apex. name. It gives further successive branches towards the anterior and lateral surface of the left ventricle; these branches are also called Diagonal (D) arteries, again called apex D1, D2, etc. from top to bottom. LAD is the most important source of nutrition in the left ventricle. It is responsible for feeding 60-70% of the left ventricle and at least 70% of the interventricular septum. Occlusion of the LAD as soon as the LMCA is separated (proximal LAD) is often fatal, even if the patient can be hospitalized, unless early opening of the LAD by coronary bypass or stent is possible. Large muscle damage and left ventricular aneurysm occur frequently in patients who survive and survive LAD infarction with drug treatments. In these patients, the heart grows severely and important symptoms such as insufficiency and serious rhythm disorders occur. Without surgery, these patients have very short life expectancy (approximately 30% survive for 5 years). The risk of surgery is high in patients who undergo surgery, and the long-term results are considerably worse than those without infarction (5-year survival is approximately 70%).


The most important reason for occlusion of coronary arteries is undoubtedly “arteriosclerosis en called atherosclerosis.


progeria

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Atherosclerosis is responsible for more than 99% of coronary occlusion and stenosis.


Atherosclerosis is an advanced age disease and therefore a large proportion of patients with coronary artery disease are older than 60 years. Although the exact cause of atherosclerosis is not known, it is known that genetic factors, hyperlipidemia, immobility, smoking, stress and additional diseases such as diabetes mellitus and hypertension contribute or accelerate the development of atherosclerosis. It has been suggested that uncontrolled cell proliferation (intimal hyperplasia) that develops in the first row of cells in the artery in the formation of atherosclerosis is a precursor lesion. Intimal hyperplasia is an expected condition after self-repair of the arterial wall. How to treat endothelial cells

There are various hypotheses about how contact inhibition by an event disappears and how it becomes atherosclerosis in later years. It is generally accepted that inflammatory formation in the middle artery layer after intimal hyperplasia, leukocyte accumulation (macrophage migration), intense lipid accumulation (LDL) in this region and the damage in the core are successive stages. Therefore, the presence of this disease at an advanced age can be considered ”somewhere” naturally. One of the most important proofs of this is the disease called g Progeria erken (premature aging) and the end of their lives at the age of 12-13 with heart attacks. Genetics, hyperlipemia and aortic coarctation are also among the diseases that cause surprisingly early onset of atherosclerosis.

Photo (2005: T. Oğuş): The case of il Familial Hypercholesterolemia Yukarıda above; In addition to Xantelasmas (yellow plaque formation due to lipid accumulation in the lower layers of the skin), “tubers muş consisting of completely cholesterol crystals called of tofus de are observed in the joints. Stenosis of the coronary and other arteries is very common in patients at an early age (even at <20 years of age!).

In the following microscopic images, intraluminal thrombosis (clotting) sections caused by cholesterol plaques accumulated in the middle layer of the artery were examined. Examination of “necropsy es specimens of two infarction patients with 75% narrowing at the top and 50% narrowing at the bottom. Rupture of the plate from any location results in a sudden blockage of the lumen with thrombus.

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These angiographic findings about wall movement do not indicate whether the cells in the wall are al

These angiographic findings about wall movement do not indicate whether the cells in the wall are alive or not. This dysfunction, usually seen after coronary artery obstruction, can also be seen in severe arterial “stenosis olmadan without occlusion. All muscle cells may not die even after coronary occlusion, and if coronary bypass is performed there, it may sometimes improve significantly. We also call chronic ischemic mitral regurgitation if the mitral valve starts to miss after narrowing or infarction of the coronary arteries and gradually develops. The presence of a high amount of viable tissue in the coronary feeding area, even if the mitral valve is advanced, eliminates the need to replace or repair the mitral valve. In this article, although the number of cases was not very high compared to the years it was published, this group of patients with advanced cardiac and miral valve dysfunction contributed significantly to the world literature. In this study, we performed canlı coronary bypass only,, minimizing the risk of surgery, and performing mitral valve replacement or plastic repair in the future. We avoided the problem with the valve and showed that long-term results can be achieved (Oğuş, T., S. Çiçek, H. Oğuş, Ö. Işık.) Coronary Artery Bypass Grafting Alone, for Advanced Ischemic Left Ventricular Dysfunction with Significant Mitral Tex Heart Inst J. 31 (2): 143-8 (2004)).


With the mechanism we call hybernating, akinetic (still) or even dyskinetic (systole) movement has been shown to return to normal by opening the occluded vessel. In order to investigate the viability of the tissue, tests called PET (Positron Emission Tomography), Thallium scintigraphy and dobutamine stress echocardiography are performed. If a significant amount of hücre viable cells lığı are detected in the light of these tests, the patient is taken to the operation considering that it will benefit from coronary bypass. Although the reliability of these tests is high, there is a possibility of error. When deciding on the operation, not only this test is looked at, but after each myocardial infarction, viable tissue remains at least around the infarct area and benefits more or less “theoretically rev from revascularization. It should be kept in mind that, even if left heart dysfunction is a risk factor for heart surgery, the chance that a patient whose heart function is reduced by half is less than 30% for 5 years. While we are learning and teaching, we have adopted the following words that have been taught to us: ir When deciding whether patients should have surgery or not, replace them with your parents and give your indication accordingly. Cerrahi

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Operation photograph (1997; T.Oğuş): Left ventricular real AL-Ap region aneurysm; Pay attention to the thinner structure of the wall, the trabecular structure of the apical part was erased and a white (fibroelastic) connective tissue covered the inner face of the heart.

This region of the heart was removed during surgery, and the patient's heart function increased severely (LVEF reached 20% when it was 20%).


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Site İçeriği

What is Coronary Heart Disease?

coronary-artery

The normal heart has 2 coronary arteries, which are responsible for the blood circulation of all right and left ventricles and atria:


Right Coronary Artery: RCA

Left coronary arterial system. (Left Main Coronary Artery = LMCA)

The left coronary arterial system is divided into two in itself and is called Circumflex Artery (Cx) while some of it is directed backwards, some of which reach the anterior face of the heart and give birth to a main artery that feeds almost half of the heart: Left Anterior Descending (LAD).


This anatomic formation is found in over 99% of the population considered normal. Nomenclature is based on the origin of the coronary arteries on the aortic valve. The left coronary artery originates from the Valsalva Sinus facing the left side of the patient and the right coronary artery (RCA) originates from the Valsalva sinus on the right side of the patient. In less than 1% of the cases, normal people may have anomalies of origin and course of the coronary arteries. These are usually benign variations and do not cause symptoms.

Sometimes a congenital coronary artery may never have been formed, especially if LAD, the most important branch of LMCA, is not congenital, may cause rhythm disturbances at early ages and cause patient death. It is possible to encounter such rare cases only in centers where heart surgeries are performed in high numbers. We have encountered 5 such cases reported in a patient who we operated on in the world. The patient's LAD artery was thought to be occluded and was called “inoperable başka in another center because it could not be visualized by angiography. Coronary artery was bypassed and the patient is still alive (Oğuş, T., S. Çiçek and Ö. Işık. Işık Absence of Left Anterior Descending Artery Associated with Atherosclerotic Heart Disease, gi Angiology, 52: 87-88 ( 2001).


RCA


The RCA is responsible for the blood circulation of the whole of the right heart, the 1/3 lower part of the muscle layer (Interventricular Septum) that separates the right and left hearts, the Sinoatrial node that provides the rhythm of the heart, and usually the Atrioventricular node, which allows the rhythm electrical conduction path to be transmitted to the ventricles.

In particular, in the occlusion of the largest branch of LMCA, which we call LAD, it creates bridge veins through the heart muscles, thus limiting the infarction the patient is undergoing (see below angiography image). Although RCA may seem smaller and insignificant than other coronary arteries, obstruction (infarction) may still kill the patient. RCA infarction can cause an extremely lethal complication called “Right Heart Failure gibi, as well as bradycardia, also called fatal bradycardia, which is called dakika block ileri, where severe rhythm slows down, or excessive heart rate (400-600 / minute). . If the patient can be brought to hospital on time, the occluded RCA can be opened by applying a stent. Even if this does not succeed; A pacemaker can be implanted to improve the patient's circulation or, if the patient enters ventricular fibrillation, can be kept alive by electric shock. Generally, a patient with RCA infarction can be kept alive in hospital conditions and rarely (patients who do not respond to any treatment) require coronary bypass surgery.


RCM


Angiography image: RCA onset in the upper left of the image; Imaging of the RCA by radiopaque material into the RCA with a catheter inserted into the coronary mouth, which we call the ostium. RCA draws a “C in and descends to the lower face of the heart and gives the RPD-RPL branches; The corrugated artery originating from the upward crux is called the Kugel artery and fills an obstructed LAD artery (red arrow) with a bridging system (collaterals) developing through the muscles in the inerventricular septum.


RCM


LMCA


LMCA RCA in symmetrical shape on the aortic valve; but this time it comes out of the back; The 1-3 cm LMCA is divided into two parts behind the pulmonary artery (pulmonary artery). The leading branch to the rear is called Circumfleks (Cx), the leading branch to the left is called Anterior Descending (LAD).


In the figure below, a case with LMC admission above 90% is presented.


koroner1


The LMCA is responsible for feeding an average of 80-90% of the left heart and, in exceptional cases, obstruction results in death. Stenosis over 50% requires patient operation. In LMCA infarcts, the heart can only produce a few beats, within seconds the energy stores become empty and cause the patient to either stop his heart or enter ventricular fibrillation (fatal rhythm disorder). In a patient with LMCA lesion, leg arteries and brain (Carotid) artery diseases are very common.

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Sequential bypass: the distal distal anastomosis on the right is completed and the next coronary artery is bypassed by sequential technique. Radial artery is used as the graft in the drawing, veins and lateral branches parallel to the artery are connected with small clips or thin ropes. The diameter of the coronary arteries is 1-3 mm. The suture material used is 7 / 0-8 / 0 thin and polypropylene, insoluble in the body, insoluble.

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A technique applied when there is more than one stenosis on a coronary artery: Jumping Anastomosis: A single vessel, not two vessels. In the drawing, there are 2 consecutive stenosis on the LAD artery; If the segment in between is considered; It will be seen that the two lateral branches extend between the two sides. Anastomosis (A), side / side anastomosis. The end of the graft is then sutured (B) (End / side anastomosis) to the end of the LAD. In this way, when the graft is attached to the aorta and blood starts to flow through it, both these branches and the end of the LAD artery will collect blood together.

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If there is more than one stenosis segment on a coronary artery, another technique would be to spread the artery longitudinally over the stenosis and spread the graft over the artery like a spatula; to expand the artery. In the picture above, the LAD artery is enlarged by spreading the LIMA up to 8 cm above the LAD; Gi angioplasty bypass with bypass application. Although the procedure takes a long time (about 15 minutes), it protects the patient from coronary stenosis that may develop in the late postoperative period. Long-term survive in patients undergoing plastic repair is as good as in patients with local plaque stenosis that do not require plastic repair. We documented this situation with our world's largest patient series and control angiography series in 2007 (Oğuş NT, M. Başaran, Ö. Selimoğlu, T. Yıldırım, H. Oğuş, H. Özcan. “Long Term Results of the Left Anterior Descending Coronary Artery Reconstruction with Left Internal Thoracic Artery. ”Ann Thorac Surg; 83 (2): 496-501 (2007).


RCA and RPD were separately CABG with saphenous vein graft and RCA graft was anastomosed to the RPD graft. We could not implement Sequential CABG; It is a technique that can be preferred where the angles of the artery are unsuitable and the required angles cannot be given; As a result, two coronary arteries are connected to a single graft and the blood flow through the graft increases.


RISK FACTORS AFFECTING THE FUTURE AFFECTING THE PATIENT AFTER CABG


Old age (the younger the surgery, the higher the risk of having problems in the late period)

Female sex (women have both operative and late-stage risk; they are linked to the small vessel structure)

Diabetes (severely negative since it is a disease that narrows the diameter of the coronary arteries)

Multivessel disease, (as it shows the prevalence of atherosclerosis is negative in early and late period)

Left ventricular dysfunction (both operative and late) due to the negative effect of surgery and the development of a heart attack that is likely to develop a new heart attack.

Incomplete revascularization (bypassing 1 vessel instead of 3 vessels required by the patient does not eliminate the risk of heart attack from the other vessels, which is both operative and late).

Chronic nephropathy, obstructive-restrictive lung diseases (vascular stiffness progresses more rapidly and extensively in the presence of such diseases)

Peripheral vascular diseases (leg or brain arteries are 6-10 mm in diameter, coronary arteries are 1-4 mm in diameter, all of which are involved together, indicating that atherosclerosis is common)

Carotid artery disease / history of CVA (a sign of stenosis or obstruction in a distinct arterial network; both operative and late term outcomes are not as good as in cases without additional disease) due to a combination of 2 diseases.

Although the presence of all these additional diseases and pathological conditions disrupts the results of the early and late postoperative periods, it is essential that patients with an operation indication be operated because of the widespread and rapid course of coronary disease, life expectancy is much higher than in patients without additional diseases. is worse.


EXCEPTIONS:


The presence of another systemic disease affecting the patient's survival:

In the case of malignancy (the presence of a malignant disease such as cancer), the CABG indication is as for patients without malignancy if the life expectancy is greater than 6 months. The patient must have a healthy heart in order to have surgery due to this disease or to remove treatments such as chemotherapy and radiotherapy.


The heart-lung machine used in standard coronary bypass operations may cause some undesirable conditions during and after the operation due to its immune system reactions and clotting effect. The presence of infectious diseases such as active or latent tuberculosis and AIDS may cause exacerbations in diseases such as malignancy and chronic hepatitis and may shorten the life expectancy of the patient. For this reason, before the CABG surgery, a serious screening is performed by radiological and biochemical analyzes and it is aimed to reveal these diseases, if any. In a patient with a known coronary artery bypass graft, the patient is forced to teknik perform coronary bypass in the working heart ”or by bypassing two vessels in the operating heart by stent (açmak Hybrid revascularization adan). ) can give much better results for the patient.


Aortic calcification from the ascending: The “main artery çıkan that originates from the heart; where the arterial connection of both the Heart-lung machine is made; This procedure has a different importance because it is the place where the blood of the grafts that are connected to the coronary vessels by bypassing the coronary vessels is removed.

Like the coronary arteries of the aorta hardening - calcification, clamp here, during the procedure such as insertion of some atheroma fragments to fall into the aorta and mixed with the circulation of the brain, especially in many organs, "embolism" causes, causing some arteries.

This condition, which is quite common especially in the age of 70, is seen in more than 50% of patients who have undergone surgery around 85 years of age. Therefore, ascending aortic calcification is a serious problem in patients who have undergone cardiac surgery at an advanced age. The main complication of advanced surgery is paralysis caused by these atheroma embolisms. However, uncontrolled diabetes for many years, extremely high blood fat levels, such as advanced obesity conditions, this elderly disease can be seen even in the 40s.

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RCA and RPD were separately CABG with saphenous vein graft and RCA graft was anastomosed to the RPD graft. We could not implement Sequential CABG; It is a technique that can be preferred where the angles of the artery are unsuitable and the required angles cannot be given; As a result, two coronary arteries are connected to a single graft and the blood flow through the graft increases.


RISK FACTORS AFFECTING THE FUTURE AFFECTING THE PATIENT AFTER CABG


Old age (the younger the surgery, the higher the risk of having problems in the late period)

Female sex (women have both operative and late-stage risk; they are linked to the small vessel structure)

Diabetes (severely negative since it is a disease that narrows the diameter of the coronary arteries)

Multivessel disease, (as it shows the prevalence of atherosclerosis is negative in early and late period)

Left ventricular dysfunction (both operative and late) due to the negative effect of surgery and the development of a heart attack that is likely to develop a new heart attack.

Incomplete revascularization (bypassing 1 vessel instead of 3 vessels required by the patient does not eliminate the risk of heart attack from the other vessels, which is both operative and late).

Chronic nephropathy, obstructive-restrictive lung diseases (vascular stiffness progresses more rapidly and extensively in the presence of such diseases)

Peripheral vascular diseases (leg or brain arteries are 6-10 mm in diameter, coronary arteries are 1-4 mm in diameter, all of which are involved together, indicating that atherosclerosis is common)

Carotid artery disease / history of CVA (a sign of stenosis or obstruction in a distinct arterial network; both operative and late term outcomes are not as good as in cases without additional disease) due to a combination of 2 diseases.

Although the presence of all these additional diseases and pathological conditions disrupts the results of the early and late postoperative periods, it is essential that patients with an operation indication be operated because of the widespread and rapid course of coronary disease, life expectancy is much higher than in patients without additional diseases. is worse.


EXCEPTIONS:


The presence of another systemic disease affecting the patient's survival:

In the case of malignancy (the presence of a malignant disease such as cancer), the CABG indication is as for patients without malignancy if the life expectancy is greater than 6 months. The patient must have a healthy heart in order to have surgery due to this disease or to remove treatments such as chemotherapy and radiotherapy.


The heart-lung machine used in standard coronary bypass operations may cause some undesirable conditions during and after the operation due to its immune system reactions and clotting effect. The presence of infectious diseases such as active or latent tuberculosis and AIDS may cause exacerbations in diseases such as malignancy and chronic hepatitis and may shorten the life expectancy of the patient. For this reason, before the CABG surgery, a serious screening is performed by radiological and biochemical analyzes and it is aimed to reveal these diseases, if any. In a patient with a known coronary artery bypass graft, the patient is forced to teknik perform coronary bypass in the working heart ”or by bypassing two vessels in the operating heart by stent (açmak Hybrid revascularization adan). ) can give much better results for the patient.


Aortic calcification from the ascending: The “main artery çıkan that originates from the heart; where the arterial connection of both the Heart-lung machine is made; This procedure has a different importance because it is the place where the blood of the grafts that are connected to the coronary vessels by bypassing the coronary vessels is removed.

Like the coronary arteries of the aorta hardening - calcification, clamp here, during the procedure such as insertion of some atheroma fragments to fall into the aorta and mixed with the circulation of the brain, especially in many organs, "embolism" causes, causing some arteries.

This condition, which is quite common especially in the age of 70, is seen in more than 50% of patients who have undergone surgery around 85 years of age. Therefore, ascending aortic calcification is a serious problem in patients who have undergone cardiac surgery at an advanced age. The main complication of advanced surgery is paralysis caused by these atheroma embolisms. However, uncontrolled diabetes for many years, extremely high blood fat levels, such as advanced obesity conditions, this elderly disease can be seen even in the 40s.

Carotid artery exploration; Arteria Carotica Interna (ACI) is the main brain artery that goes into the brain, Arteria Carotica Externa (ACE) mainly nourishes organs such as the eyeball, thyroid, Arteria Carotica Communis (ACC) is the main body of these, with the right arm artery and the aorta. ) creates. Completed operation; After the endarterectomy, saphenous patch was used, and a diameter of <3mm was used during the operation. entries have been expanded (T.Oğuş; 2010)


Myocardial Infarction Complications

Myocardial infarction refers to the death of muscle tissue in a region of the heart as a result of obstruction of the coronary artery that brings blood to it. When the dead muscle tissue is large, “mechanical problems” arise in the heart. Accordingly, these mechanical problems are examined in four main groups:

Left ventricular rupture (rupture): This is the case where the dying muscle tissue is not able to resist the pressure created in the heart during the contraction of the heart. The rupture occurs inside the sheath (Pericardium) where the heart is located. As soon as the rupture develops, the blood is filled into the pericardium rapidly, the blood is compressed with the pressure filled into the sheath, and this blood, which compresses the heart during the relaxation period of the heart, prevents the filling of blood into the heart and the patient is lost within minutes. It is a very rare complication today.

Left ventricular aneurysms: The muscle mass that dies as a result of infarction becomes thinner over time and is replaced by a semi-flexible, white colored connective tissue during the recovery period. This region, which is devastated during the contraction of the heart, cannot participate in the contraction, as it becomes thinner and loses its strength, it makes an inverse (paradox) movement with the increase of intracardiac pressure, causing blood to remain in the heart, creating a mechanical obstacle for the heart to pump the required amount of blood. Aneurysms may occur on the anterior, posterior or inferior sides of the heart relative to the occluded coronary artery. If the aneurysm is large, creates a rhythm disorder and disrupts the function of the heart, it must be removed by surgery (aneurysmectomy). Aneurysm is a chronic event, and it should be 6-8 weeks after the infarction in order for an aneurysm to be called a an real aneurysm ”. Intraoperatively, if aneurysmatic tissue of the heart is found to be thin, the dead area is surgically removed and intact muscle masses are sutured to close the patency of the heart. Sometimes the patient develops rupture of the ventricle within 1-2 weeks but there is not much bleeding, the blood spilled into the pericardial cavity clots there to prevent further bleeding. In this pocket, blood enters into the pocket at each contraction of the heart, and when the heart loosens, the blood entering the pocket returns back to the left ventricle; we call this a ancı pseudoaneurysm.. This latter situation is also very rare. Real aneurysms are becoming more and more rare as infectious patients develop timely intervention.


Interventricular Septum Rupture (Postinfarct Ventricular Septal Defect): The right and left ventricles are separated from each other by an approximately 1 cm thick muscle tissue called interventricular septum. In a normal adult, the maximum pressure is 25 mmHg in the right ventricle and 120 mmHg in the left ventricle. Due to this large pressure difference between them, it creates a great transition to tearing and suddenly developing from the left ventricle to the right ventricle. As the blood circulation in the lung increases by several times within minutes, increased pressure puts the patient into pulmonary edema and the patient is lost due to lack of oxygenation. Patients with initial onset can survive for several hours or days with intra-aortic balloon pump and breathing apparatus, and rarely survive if the patient is not urgently operated.


Papillary muscle dysfunction or rupture: Papillary muscles are the bundles of muscles in which the mitral valve between the left ventricle and the left atrium is attached. The muscle tissues coming out of the two main bundles are connected to the mitral valve by threadlike connective tissues which we call “corda,, and as the heart contracts, the papillary muscles contract and the mitral valve pulls both leaves into the heart and prevents it from hanging into the atria. Reduction or discontinuation of blood leading to papillary muscles leaves these muscle bundles inactive, and the mitral valve hangs to the atrium each time the heart contracts, causing severe valve failure. The blood that the heart has to pump into the aorta escapes to the left ventricle in the left ventricle at each contraction, and in the next relaxation period, it fills into the heart causing excessive heart filling. Since the left ventricle cannot pump this much blood into the aorta, blood accumulates in the left atrium and in the lung bed, enters the patient into pulmonary edema, and the patient loses within hours-days due to lack of oxygen. We call papillary muscle rupture as a result of unconfined dysfunction, that is, dysfunction, feeding of papillary muscles.

Postinfarction Apical VSD and Anterolateral-apical infarction (*) formation; Internal PTFE (Poly Tetra Fluoro Ethylene) patch for VSD - black arrow on the apex where the heart is opened; The left ventricle is opened and the left ventricle walls are closed end-to-end without aneurysm and tissue removal (exclusion technique). The stitches are supported by Teflon woven ribbon material (yellow arrows) to prevent rupture of the highly sensitive new infarcted tissue. On the 11th day of the anterior wall infarction, the patient developed sudden detoriation, diagnosed with ECO, partially stabilized by intra-aortic balloon pump, and operated without angiography. (T. Oğuş 1998)

* Even if dead tissue can be seen at this stage, it should not be called an aneurysm. Since the LAD, which feeds the patient's damaged area, is obstructed and is also bypassed during surgery, it will be able to participate in the contraction again when the cells that retain their viability reach the blood until the operation. For this reason, it is not right to remove the tissues by describing them as “dead, and such removal may also cause unstoppable bleeding in the operation. As a matter of fact, Echocardiography performed in the first postoperative month showed that the anterior wall was able to contract to some extent (LVEF 40%; normal value 60% and above, but this allowed the patient to live without any complaints).

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 Postenfarkt VSD onarımın tamamlanmış hali, iki Teflon şerit arasına bir şerit daha konulmuş ve ikinci bir sıra dikişle açılan karıncığın duvarları birleştirilmiştir. Tıkalı LAD’e yapılmış olan Safen ven Greft Bypass’ı sağ alt köşede gözlenmektedir (mavi ok). 

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Posteroinferior postinfarction VSD repair finished. Teflon strips were also used to close the ventri