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Showing papers in "European Journal of Cardio-Thoracic Surgery in 1996"


Journal ArticleDOI
TL;DR: Since post-traumatic tricuspid regurgitation is effectively correctable with reparative techniques, early operation is recommended to relieve symptoms and to prevent right ventricular dysfunction.
Abstract: Objective. The review of six cases of valve repair for trau- matic tricuspid regurgitation in our institution and 74 in the literature in order to assess effective methods of treating this lesion. Methods. Tricuspid valve regurgita- tion is a rare complication of blunt chest trauma. Optimal treatment for this condition is still controversial

127 citations


Journal ArticleDOI
TL;DR: This study demonstrates that previous treatment with radiotherapy resection of well perfused lung parenchyma and excessive fluid load are high risk factors for the development of non-cardiogenic pulmonary edema and that patients for whom these factors are relevant should be closely monitored in their postoperative course.
Abstract: Objective. To analyze the risk factors for postpneumonectomy pulmonary edema in 146 consecutive patients. Methods. In 1992, 146 consecutive patients, aged 60.5±9.4 years, under― went pneumonectomy, mostly for cancer (n=136). Pulmonary edema was defined clinically and radiologically in the absence of left ventricular dysfunction or infection. Several parameters, including preoperative functional respiratory values, pulmonary perfusion scan data and intraoperative data were analyzed. Two groups were determined according to the occurrence of pulmonary edema and differences were compared by univariate and multivariate analyses. Results. Twenty-two patients (15%) developed pulmonary edema within the 1st postoperative week. Most cases were mild or moderate. Severe pulmonary edema occurred in five (3.4%) patients requiring mechanical ventilation; among them, two died. Previous chemotherapy (P<0.01), radiotherapy (P<0.0001), predictive postoperative forced expiratory volume in the 1st second less than 45% (P<0.01), a remaining lung perfusion of 55% or less (P<0,05) and an intraoperative fluid load of 2000 ml fluid or more (P<0.01) were associated with pulmonary edema in the univariate analysis. Multivariate analysis identified prior radiotherapy, perfusion of the remaining lung of 55% or less and high intraoperative fluid load as independent and significant risk factors for pulmonary edema. Conclusions. This study demonstrates that previous treatment with radiotherapy resection of well perfused lung parenchyma and excessive fluid load are high risk factors for the development of non-cardiogenic pulmonary edema and that patients for whom these factors are relevant should be closely monitored in their postoperative course.

125 citations


Journal ArticleDOI
TL;DR: Thoracic epidural analgesia yields a slight, but significant, improvement in pulmonary function, most likely due to a more profound postoperative analgesia.
Abstract: Objective. A substantial reduction in lung volumes and pul- monary function follows cardiac sur- gery. Pain may prevent effective breathing and coughing, and as tho- racic epidural analgesia may reduce postoperative pain, we investigated the effect of epidural analgesia on pulmonary function. Methods. Fifty-four male patients, under 65 years and with an ejection fraction of more than 0.5, were ran- domized into two groups: a control group receiving high-dose fentanyl anaesthesia and an epidural group re- ceiving low-dose fentanyl anaesthesia + thoracic epidural analgesia. Time to awakening and time to extubation were recorded. Further, spirometric data, arterial oxygenation, pulmo- nary shunt, haemodynamics, use of vasoactive drugs and fluid balance were followed for up to 6 days post- operatively. Results. Patients with low-dose fen- tanyl and epidural analgesia awoke (1.6 vs 3.6 h) and were extubated (5.4 vs 10.8 h) significantly earlier

113 citations


Journal ArticleDOI
TL;DR: Of the different medical and social factors, only tumor recurrence was determined to have a significant and negative influence on postoperative QL (P < 0.02); when compared to the preoperative assessment, QL had deteriorated on discharge from hospital but was restored within 3-6 months postoperatively in disease-free patients.
Abstract: Quality of life (QL) after the "curative" resection of non-small cell bronchogenic carcinoma was assessed by patients using the EORTC QL questionnaire (QLQ) and by a psychologist using the Spitzer Index. Quality of life was assessed in 52 patients on one occasion 12 months postoperatively and in 20 patients regularly starting with a preoperative assessment. Self- and external evaluation showed a significant correlation (r = 0.41), but QL was assessed as being higher by the external observer. After surgery it was mainly affected by restrictions related to physical activities, job and household tasks, and disease symptoms, whereas limitations in emotional, social, and financial domains were found less frequently and less severely. Of the different medical (surgical procedures, tumor recurrence) and social factors (sex, marital and employment status), only tumor recurrence was determined to have a significant and negative influence on postoperative QL (P < 0.02). When compared to the preoperative assessment, QL had deteriorated on discharge from hospital but was restored within 3-6 months postoperatively in disease-free patients.

96 citations


Journal ArticleDOI
TL;DR: These data suggest that esophagectomy can be performed safely in selected septuagenarian patients, thus allowing a substantial survival with excellent functional status in a portion of these patients.
Abstract: Objective Esophageal cancer is a disease whose prognosis is dismal and its surgery involves considerable risks, consequently the opportunity of esophageal resection in elderly patients with esophageal cancer is questionnable. The aim of this study was to analyze, with respect to their age, the outcome of 386 consecutive patients who underwent esophagectomy and simultaneous replacement for cancer. Methods A chart review of all patients with esophageal carcinoma admitted to our institution was undertaken for the period January 1979-December 1994. Results The portion of patients of 70 years of age and older (14.5%) has slightly increased during the period. Location to the lower third of the esophagus and adenocarcinoma type were prevalent in the 56 elderly patients (group I), but their postsurgical TNM staging was identical to that of the 330 younger patients (group II). Other clinical features, i.e. preoperative weight loss and the presence of co-morbid diseases, however, were comparable in the two groups. Pulmonary function, as assessed by spirometry, was significantly worse among the older patients, but blood gas determinations were not different. Operative mortality was comparable, between the two groups (10.7% vs 11.2%). Major morbidity included anastomotic leak (10.7% vs 13.6%) and pulmonary complications (17.9% vs 20.6%) in both groups. Excellent palliation of dysphagia was achieved in 92% of the 50 group I patients who survived the operation. Long-term survival was not different in elderly patients (5-year rate: 17%) when compared with that of younger patients (18.9%). Conclusion These data suggest that esophagectomy can be performed safely in selected septuagenarian patients, thus allowing a substantial survival with excellent functional status in a portion of these patients.

85 citations


Journal ArticleDOI
TL;DR: Left ventriculotomy is a useful approach for closure of low muscular ventricular septal defects in selected patients and demonstrates normal LV shortening without evidence of regional wall abnormality.
Abstract: Received: 29 May 1995 Accepted: 25 October 1995 G. Wollenek i . R. Wyse - 1. Sullivan - M. Elliott • M. de Leval - J. Stark (~) Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK Present address: 1Allgemeines Krankenhaus der Stadt Wien, Universit~tskhnik f/Jr Chirurgie, A-1090 Vienna, Austria Abstract Objective. To evaluate the results of closure of muscular ventri- cular septal defects through a left thoracotomy. Methods. Records of 23 children ope- rated consecutively between 1972 and 1990 were studied. Age of patients was 2_8_+3 years (2 months-10 years), weight 8.9_+5.7 kg (2.6-22 kg). Ten patients (43%) had undergone one and 4 patients (17%) two previous cardiac operations. Late follow-up was obtained from direct examination of patients or from reports of their re- ferring physicians. Bypass time was 89_+28 rain (66-167 rain). The aorta was cross-clamped for 44+15 min (21-66 rain). Until 1977 operations were performed with moderate hypo- thermia and intermittent aortic cross- clamping. After 1978 deep hypother- mia (20-25°C) and cold crystalloid cardioplegia was used. Ventricular septal defects not accessible from other approaches were closed through a small fish-mouth incision in the apex of the left ventricle. Patients' data were sampled and stored in a computerised database_ Risk factors were evaluated by stepwise logistic regression. Results. Four patients died in the hos- pital (17%); two died later_ Two re- quired reoperation for residual/recur- rent defects. All patients, except two from abroad, were available for fol- low-up, which ranged from 36 months to 18 years (mean 11.3 years). All were in NYHA class 1. Only two risk factors were identified: the number of ventricular septal defects (P<0.05) and associated atrial septal defect (P<0.02). Early echocardiographic evaluation showed good LV size and function in all except one patient, who had a perioperative septal infarc- tion. Late echocardiography per- formed in six patients demonstrated normal LV shortening without evi- dence of regional wall abnormality. Conclusions. Left ventriculotomy is a useful approach for closure of low muscular ventricular septal defects in selected patients_ [Eur J Cardio-tho- rac Surg (1996) 10: 595-598] Key words Muscular ventricular septal defects • Left ventriculotomy • Open heart surgery

83 citations


Journal ArticleDOI
TL;DR: It is concluded that massive pulmonary embolism is a frequent early postoperative fatal complication after lung resections, which cannot be safely prevented by postoperative heparinization.
Abstract: Between 1975 and 1993, lung resections were performed in 1735 patients because of malignancies, with an early postoperative mortality of 7.2% (125 patients). Early postoperatively acute cardiorespiratory failure was experienced by 32 patients (1.85%), of whom 26 died despite immediate resuscitation measures. In 20/26 patients autopsy was performed revealing central pulmonary embolism as the cause of death in 19 of them. In one patient a rupture of the free posterior left ventricular wall following transmural myocardial infarction was found. Two patients who could be resuscitated successfully were operated on with extracorporeal circulation after pulmonary angiography had been performed to confirm the diagnosis; however they died 2 days later of right heart failure. Of the survivors three cases had myocardial infarctions, one patient had arrhythmias of unknown etiology. Immediate embolectomy with the use of extracorporeal circulation was performed in two patients, only on the ground of suspected pulmonary embolism and without further diagnostic measures. Both patients survived. Of the 23 cases, with proven pulmonary embolism 17 were still under postoperative prophylaxis with heparin. Six patients were already fully mobilized. We conclude that massive pulmonary embolism is a frequent early postoperative fatal complication after lung resections, which cannot be safely prevented by postoperative heparinization. The only successful life-saving measure in the case of central pulmonary embolism is immediate pulmonary embolectomy, if necessary without further diagnostic measures.

81 citations


Journal ArticleDOI
TL;DR: Gastrointestinal complications after cardiac surgery with cardiopulmonary bypass are uncommon complications with significant morbidity and mortality rates and the clinician must be alert to institute early appropriate treatment.
Abstract: Objective. Gastrointesti- nal (GI) complications after cardiac surgery with cardiopulmonary bypass (CPB) are uncommon complications with significant morbidity and mor- tality rates. Methods. From 1988 to 1995, 36 GI complications were identified in 3158 patients who underwent cardiac surgery (1.14% incidence). The mor- tality rate was 13.9%. Complications included hemorrhage in the G( tract in 22, perforated ulcer in 3, acute cholecystitis in 3, pancreatitis in 2, mesenteric ischemia in 3, diverticu- litis in 1 and liver failure in 2 patients. Results. Clinical risk factors included advanced age, combined coronary artery bypass grafting (CABG)-valve operation, postoperative low cardiac output (LCO), prolonged ventilation time, re-exploration of the chest, ster- nal infection and a positive history of peptic ulcer. Patients with a pro- longed pump time had an increased risk of GI complications (P<0.001). Conclusions. Gastrointestinal com- plications, although of low incidence, carry a significantly high mortality, and the clinician must be alert to in- stitute early appropriate treatment. (Eur J Cardio-thorac Surg (1996) 10: 763 -767)

80 citations


Journal ArticleDOI
TL;DR: Cadaveric human tracheal homograft use in five children who would otherwise have died has provided an extra therapy in an extremely difficult group of patients.
Abstract: Objective. We report the use of cadaveric human tracheal homograft in the treatment of severe long segment congenital tracheal stenosis in children. Methods. Five children (aged 5 months-8 years) with severe life-threatening airway obstruction due to long segment congenital tracheal stenosis had failed conventional management. All were ventilator dependent or rapidly deteriorating at the time of surgery, two were on extracorporeal membrane oxygenation, and no alternative therapy was available. The stenosed trachea was removed and the posterior trachealis muscle left in situ when possible. Surgical technique involved the use of cardiopulmonary bypass in four of five cases. Stored cadaveric tracheal homograft tissue was shaped and inserted over a silastic intra-luminal stent which was kept in place for up to 3 months. Regular bronchoscopy was necessary postoperatively to clear granulation tissue, which resolved on removal of the stent. Results. Four patients are all now without stents, intubation or tracheostomy. Three are without airway problems 16, 14, and 9 months after surgery and one attends for occasional dilatation of a distal tracheal stenosis, but is now at home despite other severe multiple congenital problems. One patient presented with complete disruption of the trachea and mediastinal sepsis and was supported on extracorporeal membrane oxygenation prior to surgery; this patient eventually died of airway failure and sepsis. Conclusions. The application of cadaveric human tracheal homograft to congenital tracheal stenosis is novel. Its use in five children who would otherwise have died has provided an extra therapy in an extremely difficult group of patients.

79 citations


Journal ArticleDOI
TL;DR: The problem of vein graft occlusion and possible solutions, the theoretical benefits of arterial grafts and the clinical results associated with their use are reviewed.
Abstract: Poor long-term patency of saphenous vein grafts limits the long-term success of the coronary artery bypass operation. If this is to be improved, either measures that increase the patency of saphenous vein grafts or alternative conduits are required. The benefits of using the left internal mammary artery as a pedicled graft to the left anterior descending coronary artery have prompted increasing use of arterial grafts to further improve outcome. Concurrently advances in the understanding of the pathological processes underlying saphenous vein graft occlusion raise the possibility of improving vein graft patency. In this paper we review the problem of vein graft occlusion and possible solutions, the theoretical benefits of arterial grafts and the clinical results associated with their use.

79 citations


Journal ArticleDOI
TL;DR: The number of controlled clinical studies of FS is currently increasing, with the majority of the papers revealing a beneficial effect of FS when it is used as a hemostatic or sealing agent in cardiothoracic surgery.
Abstract: Objective More than 2300 clinical papers have been published on the surgical applications of fibrin sealant (FS), with the largest number in the speciality of cardiothoracic surgery. The purpose of this review of the literature was to find and evaluate controlled studies published in the field of cardiothoracic surgery, to clarify the indications and emphasize the benefits of FS available to the practising surgeon. Methods A database of the surgical publications of FS was created. Up to the end of 1995, at least 24 controlled clinical studies had been published; these may be divided into 20 studies with a positive outcome and 4 studies where the results were not different from the controls. In none of the studies was the clinical result worse after the use of FS. Results In most of the cardiac studies, FS was successfully used at bleeding sites in reoperations and in congenital heart surgery. Postoperative bleeding may also be reduced by the anterior mediastinal spray application of FS or by preparing woven Dacron prostheses with the sealant. In addition, Fs has been found to improve results after type A aortic disections and, by adding an antibiotic to the sealant, the postoperative infection rate for active endocarditis of the aortic root can be reduced. In pulmonary surgery FS can be used to reduce pulmonary air leakage, however the results of some studies diverge due to different clinical test conditions and the inclusion of only a small number of patients in the "negative" studies. In none of the controlled studies of esophageal surgery could FS prevent leakage from esophageal anastomoses. Conclusions Fibrin sealant is safe when it is applied properly, but there is a learning curve for surgeons who start using it. An autologous sealant or a sealant containing human instead of bovine thrombin is preferred, since repeated use of bovine thrombin may induce coagulopthies. The number of controlled clinical studies of FS is currently increasing, with the majority of the papers revealing a beneficial effect of FS when it is used as a hemostatic or sealing agent in cardiothoracic surgery.

Journal ArticleDOI
TL;DR: In conclusion, ascending aortic replacement with a composite graft is a safe procedure especially when performed electively in patients with dystrophic aneurysm or Marfan syndrome.
Abstract: From April 73 to June 94, 203 patients (167 men, 36 women) aged from 10 to 74 years (mean: 44.8 +/- 15) underwent ascending aortic replacement with composite graft for: dystrophic aneurysm (AN) (130 cases, 64.5%), chronic dissection (CD) (35 cases, 17.2%), type A acute dissection (AD) (38 cases, 18.7%). Forty-six patients (22.6%) suffered from Marfan syndrome (24 AN, 13 AD, 9 CD). Thirty patients (14.7%) had undergone a previous cardiac or aortic operation. The ascending aortic replacement was extended to the transverse arch in 28 patients (13.7%). A mechanical valve was used in 193 cases (95%). Since 1986, the ascending aorta has been totally resected and a gelatin-or collagen-coated vascular prosthesis used. The technique of coronary reattachment has varied with time and according to the aortic lesions. The classic "Bentall" technique was used in 87 patients (43%), the "button" technique in 74 (36%), the "Cabrol" technique in 26 (13%) and a "mixed" technique in 16 cases (8%). The hospital mortality rate was 7.3% (15/203) (AN: 2.3%, CD: 11.4%, AD: 21%). The only predictors of hospital death were emergency AD (P < 0.03) and arch replacement (P < 0.02). Mean follow-up was 46 +/- 10 months (2-246). The overall long-term survival rate was (Kaplan Meier) 89 +/- 6% at 1 year, 77.9 +/- 9% at 5 years, 67.7 +/- 12% at 10 years and 61.3 +/- 15% at 12 years. The 10-year survival rate is significantly higher in patients with AN (77.8 +/- 11%) than in those with AD (61.6 +/- 17%) (log. rank: P < 0.01). The late survival rate is also significantly higher after the "button" or Bentall reimplantation than after the "Cabrol" or "mixed" methods (90 +/- 5% in the "button" group and 88.7 +/- 6%, 83.8 +/- 9% and 76.6 +/- 12% in the "Bentall" group vs 80 +/- 18%, 63 +/- 21% and 58 +/- 35% in the "Cabrol" group at 1, 5 and 8 years, respectively). In conclusion, ascending aortic replacement with a composite graft is a safe procedure especially when performed electively in patients with dystrophic aneurysm or Marfan syndrome. The technique of coronary reimplantation has a significant influence on the long-term results. The reimplantation of choice is the "button" technique, especially in the presence of a fragile aortic wall (AD). The "Cabrol" technique must be used when the "button" or the "Bentall" reimplantation is not feasible, for instance during redo procedures.

Journal ArticleDOI
TL;DR: This experience confirms that, in the treatment of acute type A dissection, an aggressive approach to aortic root pathology is indicated for specific indications, and can be carried out with good early and excellent long-term results.
Abstract: Objective. Failure of the repair at the proximal aorta is an important cause of morbidity and mortality following surgical treatment of acute type A dissection. This review was undertaken to determine the influence of total composite replacement of the ascending aorta and the root on the operative risk and long-term survival. Methods. In a consecutive series of 73 patients with acute type A dissections between 1985 and 1994, 19 (26%) patients with radical root replacement (group I) were compared with 54 patients who had conventional valve-preserving root reconstruction (group II). Results. Group I represented a higher operative risk with the presence of significant aortic regurgitation (13/19 68.4% vs 23/54 42.5% P<0.05), aortic dilatation (19/19 100% vs 32/54 59.2% P<0.00), and coronary dissection (13/19 68.4% vs 3/54 5.5% P<0.000). In spite of this there was no difference in operative mortality (3/19 15.7% vs 7/54 12.9%, NS) or the occurrence of major postoperative complications : bleeding (3/19 15.711 vs 7/54 12.9%, NS), respiratory (5/19 26.3% vs 11/54 20.3%, NS), stroke (2/19 10.5% vs 3/54 5.5%, NS). Patients with radical root replacement had substantially better event-free survival at 5 years (87.5% ± 11.7% vs 67.1% ± 8.9%) and 9 years (87.5% ± 21.9% vs 63.0% ± 19.2%). Conclusions. This experience confirms that, in the treatment of acute type A dissection, an aggressive approach to aortic root pathology is indicated for specific indications, and can be carried out with good early and excellent long-term results.

Journal ArticleDOI
TL;DR: It is concluded that resection is justified in patients with unforeseen N2 disease and Rigorous staging of the mediastinum by cervical mediastinoscopy or anteriormediastinotomy results in a high resectability rate and avoids unnecessary thoracotomies.
Abstract: Objective. Although the results after surgery for N2 disease are disappointing, there seems to be a subgroup of patients which may benefit from primary resection. These patients have clinically unrec- ognized N2 involvement that is dis- covered only at the time of thoracot- omy (unsuspected or unforeseen N2 disease). It was the aim of this retrospective study to analyze the survival after resection for unfore- seen N2 disease and to evaluate dif- ferent prognostic factors. We were interested to see whether our strategy of rigorous staging of the mediasti- num with mediastinoscopy or ante- rior mediastinotomy had an effect on the resectability rate and survival of unsuspected N2 disease.

Journal ArticleDOI
TL;DR: It is concluded that both the risk of developing cyst-related complications and the even smaller risk of malignant degeneration justify surgical treatment in all cases.
Abstract: Objective. All cases of bronchogenic cysts treated in our center are analysed in order to define its clinical and pathological features. These data are used to determine whether surgical treatment in all cases is justified or whether there is a place for conservative treatment. Methods. We retrospectively studied the medical records and pathology reports of all patients with bronchogenic cysts (n=20) referred to our clinic between 1975 and 1993. Results. Fourteen patients (70%) were asymptomatic. Six patients had symptoms because of cyst-related complications (infection or compression). In only 15 patients the diagnosis was established preoperatively. In the other five cases a solid tumour was suspected. All patients were treated by either thoracotomy (n = 19) or thoracoscopy (n = 1 ). The diagnosis was confirmed by histological examination. One cyst turned out to be degenerated into a squamous cell carcinoma. Conclusions. We conclude that both the risk of developing cyst-related complications and the even smaller risk of malignant degeneration justify surgical treatment in all cases.

Journal ArticleDOI
TL;DR: It is concluded that elderly patients suffered respiratory muscle weakness before and after operation and their postoperative recovery of respiratory muscle strength was slower than in younger patients, and VATS and LT resulted in more rapid recovery of ventilation muscle strength than PLT, but the difference between VATs and LT was not significant.
Abstract: Changes in respiratory muscle strength after lung resection were examined concerning age and procedures of thoracotomy. Maximum inspiratory (MIP) and expiratory (MEP) mouth pressure were measured before operation and 1, 2, 4, and 12 weeks after operation in 81 patients undergoing lung resection. In 48 patients undergoing pneumonectomy, lobectomy, or segmentectomy, patients older than 70 showed a significantly lower MIP and MEP before operation and throughout the postoperative period compared to younger ones (P < 0.01). Furthermore, the older patients showed a significantly lower percentage of postoperative MIP and MEP 4 weeks after operation than the younger ones (P < 0.01). In 31 patients undergoing lung wedge resection, patients undergoing limited thoracotomy (LT) and video-assisted thoracic surgery (VATS) showed significantly higher percentages of postoperative MIP and MEP than those undergoing posterolateral thoracotomy (PLT) 1 and 2 weeks after operation (P < 0.01 or 0.05). But there was no significant difference in the values between LT and VATS. We concluded that (1) elderly patients suffered respiratory muscle weakness before and after operation and their postoperative recovery of respiratory muscle strength was slower than in younger patients, and (2) VATS and LT resulted in more rapid recovery of respiratory muscle strength than PLT, but the difference between VATS and LT was not significant.

Journal ArticleDOI
TL;DR: Results indicate a significant suppression of TH1-induced cell-mediated immune response following CPB, while TH2-induced response remains normal, which may be helpful for recovery following cardiac surgery by cleaning the body of the byproducts of CPB.
Abstract: Growing evidence indicates that cell-mediated immunity is altered after cardiac surgery with cardiopulmonary bypass (CPB). The objective of this prospective randomized study was to investigate (1) if an imbalance in T-helper cell (TH) subsets, i.e. TH1/TH2, may be responsible for these alterations and (2) if they can be counteracted. Twenty patients formed control group A. Twenty group B patients received indomethacin and thymopentin for immunomodulation. In vitro tests included measurements of TH, interleukin (IL)-2 as a cytokine primarily produced by TH1 cells, and IL-6 as a cytokine primarily produced by TH2. Delayed-type hypersensitivity (DTH) skin response and specific antibody (AB) production were used as in vivo tests for TH1- and TH2-induced immune response, respectively. Postoperatively, group A patients showed a persistent, significant reduction of TH, IL-2 synthesis and DTH skin response as compared to baseline values, while IL-6 synthesis remained unaltered and AB production increased (P < 0.05). In group B patients no change in TH, IL-2 and IL-6 synthesis, or DTH skin response was observed (P < 0.05 vs A). Postoperative AB production increased significantly in group B. These results indicate a significant suppression of TH1-induced cell-mediated immune response following CPB, while TH2-induced response remains normal. A normal TH2 response may be helpful for recovery following cardiac surgery by cleaning the body of the byproducts of CPB. A suppression of TH1 response may gain clinical significance whenever a postoperative infection requires this response, but can be effectively counteracted by immunomodulatory intervention with indomethacin and thymopentin.

Journal ArticleDOI
TL;DR: The authors present the current status of surgery for the cardiovascular manifestations of the Marfan syndrome and suggest cautious use of valve-sparing procedures in Marfan patients because of fibrillin abnormalities in the preserved aortic valve leaflets.
Abstract: The authors present the current status of surgery for the cardiovascular manifestations of the Marfan syndrome. In addition, a brief review of current Marfan genetic research is presented. Data on all Marfan patients undergoing aortic root replacement at the Johns Hopkins Hospital (September 1976-June 1995) were analyzed. Survival and event-free curves were calculated and risk factors for early and late death were determined by univariate and multivariate analysis. Two hundred twelve Marfan patients underwent aortic root replacement using composite graft (202), homograft (8) or valve-sparing procedures (2). One hundred eighty-five patients underwent elective repair with no 30-day mortality. Twenty-seven patients underwent urgent surgery, primarily for acute dissection; two patients with aortic rupture died in the operating room. Actuarial survival of the 212 patients was 88% at 5 years, 78% at 10 years and 71% at 14 years. By multivariate analysis, only poor NYHA class, male gender and urgent surgery emerged as significant independent predictors of early or late mortality. Histologic examination of excised Marfan aortic leaflets by immunofluorescent staining for fibrillin showed fragmentation of elastin-associated microfibrils. These studies suggest cautious use of valve-sparing procedures in Marfan patients. Over the last 5 years significant progress has been made in identifying mutant genes that code for defective fibrillin microfibrils in Marfan patients. Attempts are underway to develop animal models of Marfan disease for study of possible gene therapy. Aortic root replacement can be performed in Marfan patients with operative risk under 5%. Long-term results are gratifying. At present, valve-sparing procedures should be used cautiously in Marfan patients because of fibrillin abnormalities in the preserved aortic valve leaflets.

Journal ArticleDOI
TL;DR: Late results after pulmonary embolectomy are excellent in respect to functional class and late mortality and previous thrombolysis does not alter the perioperative risks, occurrence of complications or late outcome after surgical intervention.
Abstract: Objective. Surgical intervention for fulminant pulmonary embolism is nowadays most commonly restricted to patients with failure of or contraindication to thrombolytic therapy. Such a second choice indication may alter operative risks or late outcome, and this was investigated in a retrospective study. Material and methods. Thirty-six patients (17 male, mean age: 50.6±15.5 years) with fulminant pulmonary embolism of either the pulmonary trunk or one of the pulmonary arteries and at least one contralateral segment underwent pulmonary embolectomy on cardiopulmonary bypass during a 15-year period (1979-89: 31 patients, group I; 1990-94: 5 patients, group II). Group II included only patients who did not meet the criteria for acute thrombolysis. All patients were in strongly compromised circulatory conditions (29/36 high dose catecholamines, 20/36 mechanical ventilation, 14/36 pre-operative cardiopulmonary resuscitation). Results. The perioperative mortality rate was 26% in group I (8/31 patients, 7 with pre-operative cardiac arrest) and 20% in group II (1/5 patients not related to failure of previous thrombolytic therapy). Severe but non-fatal complications occurred in six patients who fully recovered following treatment. Follow-up was completed to 93% (25/27 patients) and comprised a total of 248 patient-years (mean: 119 months). Twenty-three out of 25 patients (92%) were in functional class I or II (NYHA). No recurrent pulmonary embolism or late clinical symptoms related to embolectomy were observed. One patient died 8 years postoperatively (late mortality: 0.4% patient-year). There was no difference between group I and group II regarding perioperative mortality, complications and late results. Conclusions. Late results after pulmonary embolectomy are excellent in respect to functional class and late mortality. Early mortality is closely associated with preoperative cardiac arrest. Previous thrombolysis does not alter the perioperative risks, occurrence of complications or late outcome after surgical intervention.

Journal ArticleDOI
TL;DR: The study has demonstrated the therapeutic efficacy of VATS and in the same time that in VATS the total economic cost is lower (22.7%) in comparison with traditional thoracotomy.
Abstract: OBJECTIVE: Video-assisted thoracoscopic surgery (VATS) represents at present the most suitable treatment of recurrent spontaneous pneumothorax. After three years we consider this interesting to draw up a trial balance of our VATS experience in comparison with the cases treated before 1991 with the classic thoracotomic approach. METHODS: We have considered retrospectively the results obtained in a series of 30 consecutive patients with recurrent spontaneous pneumothorax treated with VATS between November 1991 and August 1994 in comparison with those obtained in a group of 30 patients previously treated with a traditional thoracotomy. The groups have been selected in such a way that surgical indications, sex ratio, age and number of episodes were homogeneous. The parameters we have compared were the postoperative complications, the duration of chest drainage and hospitalization, the operating times and the relapses. Besides these technical parameters we considered the economic data too. RESULTS: On average drains removal occurred one day before in VATS-Group: the time spent in the Hospital was significantly shorter in VATS-Group, being on average 1 week. Short term complications may be considered similar in the two Groups. Prolonged air leaks occurred in 13% and 16% respectively. Emothorax requesting reoperation occurred in 1 case for each Group. One death occurred in thoracotomy-Group in an old patient presenting a severe chronic respiratory insufficience with exacerbation in postoperative time. We have registered 2 relapses after VATS and none after thoracotomy. CONCLUSIONS: The study has demonstrated the therapeutic efficacy of VATS and in the same time that in VATS the total economic cost is lower (22.7%) in comparison with traditional thoracotomy.

Journal ArticleDOI
TL;DR: Bilateral internal thoracic artery grafting with skeletonized harvesting carried low post-operative mortality and morbidity and therefore it could be applied routinely without the fear of increased complication rate.
Abstract: Objective. To test the hypothesis that the skeletonized tech― nique of harvesting the internal thoracic artery improves the surgical results of bilateral internal thoracic artery grafting, we reviewed our 7-year experience with this technique. Methods. Between July 1987 and December 1994, 560 patients received bilateral internal thoracic artery grafts and 236 additional grafts (average 2.6±0.6 anastomoses per patient). There were 515 men (92%) and the average age was 56.9±8.8 years. There were 63 diabetic patients (11.3%). During harvesting, the internal thoracic arteries were always totally skeletonized from the surrounding tissues without the use of electrocautery. Results. Postoperative complications included reoperation for bleeding, 17 patients (3%), phrenic nerve paresis, 17 patients (3%), acute respiratory distress syndrome, 9 patients (1.6%), digestive complications, 8 patients (1.4%), neurologic complications, 6 patients (1.1%), and sternal complications, 6 patients (1.1%). No wound complications were observed in diabetic patients. The hospital mortality rate was 1.6% (9 patients, 2 cardiac causes). The early patency of internal thoracic artery grafts was 97.9%. Follow-up averages 29 ± 20 months. There were 14 late deaths (4 cardiac causes). Angina recurred in 51 patients and the maximal stress test was abnormal in 47 patients. Conclusion. Bilateral internal thoracic artery grafting with skeletonized harvesting carried low post-operative mortality and morbidity and therefore it could be applied routinely without the fear of increased complication rate.

Journal ArticleDOI
TL;DR: S-100 levels after aortic surgery with deep hypothermic arrest correlate with the duration of circulatory arrest, indicating that theduration ofcirculatory arrest is damaging to the brain despite the use ofDeep hypothermia and partial retrograde cerebral perfusion.
Abstract: Objective. Cerebral damage is a major problem after reconstructive surgery of the aortic arch and the descending aorta. Current protective strategies, including deep hypothermia and retrograde cerebral perfusion, are used to prolong the tolerated duration of circulatory arrest, and the latter may also decrease the possibility of air/particle embolization. The aim of the current study was to investigate whether the neurochemical marker S-100 is related to the duration of circulatory arrest. when the influence of embolic injury has been minimized by the use of retrograde cerebral perfusion during the last part of circulatory arrest. Methods. Arterial serum levels of S-100 were followed before, during and after reconstructive surgery of the thoracic aorta during deep hypothermic arrest in ten adults. Retrograde cerebral blood perfusion was used during the latter part of the arrest period in eight of the ten patients. Neurologic status was followed daily. Results. All patients survived the operation. The median (range) duration of cardiopulmonary bypass (CPB) was 184.5 (121-386) min. The median duration of circulatory arrest and retrograde cerebral perfusion was 50 (3 - 118) min and 16 (0 - 84) min, respectively. S-100 increased from 0.10 (0.02-0.18) μg/l preoperatively to 2.37 (0.64-10.80) μg/l after CPB (P<0.01), followed by a decrease to 0.79 (0.21-2.64) μg/l on the first postoperative day (P<0.01). The duration of circulatory arrest correlated with S-100 levels after CPB (r s = 0.71, P<0.05) and even better with the S-100 levels on the first postoperative day (r s = 0.83, P<0.01). However, there was no significant correlation between duration of arrest and duration of CPB. The duration of circulatory arrest without retrograde cerebral perfusion correlated well with S-100 levels on the first postoperative day (r s = 0.88, P<0.01), but not significantly with S-100 levels after CPB. Conclusions. S-100 levels after aortic surgery with deep hypothermic arrest correlate with the duration of circulatory arrest, indicating that the duration of circulatory arrest is damaging to the brain despite the use of deep hypothermia and partial retrograde cerebral perfusion. The highest correlation between S-100 and duration of arrest was seen on the first postoperative day. S-100 appears to perform well under clinical circumstances as a sensitive and discriminative marker for neuronal injury.

Journal ArticleDOI
TL;DR: This study shows that OC with DSC is a beneficial adjunct in the treatment of postoperatively impaired cardiac function, profuse hemorrhage and persistent arrhythmias and can be performed without increased sternal morbidity.
Abstract: Objectives : Open chest (OC) and subsequent delayed sternal closure (DSC) has been described as a useful method in the treatment of the severely impaired heart after cardiac surgery. Methods : Prolonged open chest was used in 142 to 3373 adult cardiac operations (4.2%) between January 1987 and December 1993. The indications were : hemodynamic compromise (121), intractable bleeding (9) and arrhythmias (12). Delayed sternal closure was carried out in 123 of 142 patients at a mean of 2.0 ± 1.4 days (range 0.5-8 days). Open chest and DSC were used proportionally more frequently after combined cardiac surgery (28/293, 9.6%) than after coronary artery bypass grafting (CABG) alone (108/2891, 3.7%) or valve operation (6/230, 2.6%). Results : Ninety-seven of the 123 who had DSC (78.9%) survived and were discharged an average of 8.6 ± 4.2 days after closure. Fourty-five patients died : 19 before DSC and 26 after this method. Mortality was related to indications for OC : when the indication was low cardiac output the mortality was 38.6%, for hemodynamic collapse on closure 0%, diffuse bleeding 33.3% and arrhythmias 27.3%. Delayed sternal closure in patients without intra-aortic balloon pump support was more likely to be successful (mortality rate 4/25, 16.0% versus 35/76, 46.3%, P<0.01). Superficial sternal wound infection occurred in 2 of 123 (1.6%) patients after DSC, mediastinitis in 1 (0.8%) and sternal dehiscence in 3 (2.4%) patients, which does not differ from a control population that had primary sternal closure. The follow-up of 97 survivors at an average of 28 ± 4 months revealed an improvement of NYHA class by 1.4 ± 0.4. There were 16 deaths (13 cardia-related) during the follow-up period and 3 redo CABG. One case of sternal osteomyelitis occurred without any other late sternal morbidity. Conclusions : This study shows that OC with DSC is a beneficial adjunct in the treatment of postoperatively impaired cardiac function, profuse hemorrhage and persistent arrhythmias. It can be performed without increased sternal morbidity. Long-term results are also encouraging.

Journal ArticleDOI
TL;DR: The prognosis of carcinosarcoma of the lung is assessed to be comparable to that of patients with other pulmonary carcinoma: in this study survival times ranged from only 3 months (T2N3) to 4 years 6 weeks (T3N1).
Abstract: Objective. Bronchopul- monary carcinosarcoma is a very rare tumor and the prognosis of pa- tients with carcinosarcoma is as- sessed as unfavourable. The prob- lems concerning diagnosis, therapy, and prognosis after resection treat- ment are discussed with reference to our seven cases and with considera- tion of the pertinent literature. Methods. The retrospective data of seven patients with pulmonary car- cinosarcoma were analysed. All were staged postoperatively according to the international TNM staging system. The diagnosis was verified by immunohistochemical investiga- tion. The prognosis of the patients with carcinosarcoma was compared with the prognosis of patients with non-small cell carcinoma of the lung.

Journal ArticleDOI
TL;DR: In selected patients reoperative coronary artery bypass grafting can be performed with a low perioperative morbidity and mortality rate and satisfactory early graft patency rate with good symptomatic improvement.
Abstract: Objective. To minimize the risk of standard and reoperative coronary artery bypass, we developed a minimally invasive approach. In this study we have evaluated the effectiveness of this technique. Method. Between April 1994 and September 1995, 12 men and 6 women, aged 55-84 years (mean, 69 years) with chronic stable angina (4) and recent post-myocardial infarction unstable angina (14), with left ventricular ejection fractions ranging 17-60% (mean 37%), underwent reoperative coronary artery bypass grafting using 7-cm mini-left and right anterior thoracotomy and subxiphoid incisions. Coronary artery anastomoses were carried out on beating hearts with local coronary occlusion. Ischemic preconditioning, beta and calcium channel blockers and the maintenance of mean arterial pressure at 75 - 80 mmHg, were used as adjuncts for myocardial protection. The internal mammary artery was isolated under direct vision up to the second rib with excision of the fourth costal cartilage. Coronary artery target sites were the left anterior descending in 12, right coronary artery in 4, obtuse marginal in 3, posterior descending in 1 and diagonal branch in 1 patient. Arterial grafts (mammary, right gastroepiploic, radial), either as single or composite grafts, were used liberally. Preoperative risk factors included congestive heart failure (7), chronic renal insufficiency (5), second reoperation (2), third reoperation (1), cerebrovascular disease (5), prior angioplasty (8) and preoperative intra-aortic balloon pumping in two patients. Results. There was no perioperative mortality with minimal morbidity. Twelve patients underwent patency study of the grafts 48 - 72 h postoperatively. Ten of the twelve grafts were patent; one internal mammary artery graft to the left anterior descending coronary artery (<1.5 mm) early in our series was occluded and one additional left internal mammary graft had a kink several centimeters away from the anastomosis, which was successfully opened by angioplasty. At a mean follow-up interval of 8 months all 16 surviving patients are in functional class I or II and all of them remain free of angina. Conclusion. In selected patients reoperative coronary artery bypass grafting can be performed with this minimally invasive approach with a low perioperative morbidity and mortality rate and satisfactory early graft patency rate with good symptomatic improvement.

Journal ArticleDOI
TL;DR: A patient with coronary heart disease and a heparin- induced thrombocytopenia is presented, who was successfully treated by coronary bypass grafting (CABG) using recombinant hirudin as an anticoagu- lant for cardiopulmonary bypass (CPB) instead ofHeparin.
Abstract: We present a patient with coronary heart disease and a heparin- induced thrombocytopenia , who was successfully treated by coronary ar- tery bypass grafting (CABG) using recombinant hirudin as an anticoagu- lant for cardiopulmonary bypass (CPB) instead of heparin. (Eur J Car- dio-thorac Surg (1996) 10: 386-388)

Journal ArticleDOI
TL;DR: Early repair of TAPVD with aggressive management of pulmonary hypertensive crises carries low operative mortality nowadays and long-term results are gratifying: no late death after 6 months, no reoperation and functional good results.
Abstract: Objective. To present our 17-year experience of surgical repair of total anomalous pulmonary ve- nous drainage (TAPVD) in 71 conse- cutive neonates and infants, with particular emphasis on the role of preoperative pulmonary venous ob- struction (PVO), the management of postoperative pulmonary hyperten- sive crises and the long-term results.

Journal ArticleDOI
TL;DR: Although there is no difference between transaxillary thoracic sympathectomy and the endoscopic intervention in terms of efficacy, the latter is associated with less postoperative pain, shorter hospital stay and a rapid recovery.
Abstract: Thoracic sympathectomy is effective in the permanent cure of primary axillary and palmar hyperhidrosis and facial blushing, which can be so troublesome for patients that their social and professional relations can be affected. Between October 1988 and April 1994, a total of 50 thoracic sympathectomies (10 surgical and 40 endoscopic) were performed on 5 and 23 patients, respectively. The operations were performed unilaterally, followed by the contralateral intervention after a period of 6-8 weeks. The thoracic ganglia T2-T5 were resected for hyperhidrosis. If the patient suffered from blushing, the lower 1/3 of the stellate ganglion was also resected. Postoperatively, all the operated limbs were warm and dry. In the group of patients who were operated bilaterally, only one had persistent facial blushing. The efficacy for blushing in this series was therefore 93.3%. The late relapse rate of sympathetic activity was 14.3%. Compensatory sweating was seen in 67%, gustatory sweating in 37.5% and phantom sweating in 29% of the patients. None of them considered these side effects to be troublesome. Although there is no difference between transaxillary thoracic sympathectomy and the endoscopic intervention in terms of efficacy, the latter is associated with less postoperative pain, shorter hospital stay and a rapid recovery. The thoracic sympathectomy is the treatment of choice for primary hyperhidrosis and excessive facial blushing.

Journal ArticleDOI
TL;DR: The results suggest that valve repair is a reasonable treatment option for tricuspid valve endocarditis in all cases with localized infection of the valve.
Abstract: Tricuspid valve endocardititis is treated surgically by total valve excision or valve replacement. Both procedures are controversial with regard to the hemodynamic consequences and to the long-term prognosis. In the following, results of tricuspid valve repair in acute infective endocarditis are reported and discussed as an additional treatment option. Between January 1988 and December 1993, 118 patients were operated on for acute valve endocarditis at our institution. Eleven of these patients had tricuspid valve endocarditis, isolated (n = 7) or combined with endocarditis of a left-sided valve (n=4). In the cases with isolated tricuspid valve endocarditis, the indication for surgery was intractable infection in six and hemodynamically relevant tricuspid insufficiency in one out of seven patients. In all patients with associated left-sided endocarditis, the indication was hemodynamic deterioration. In eight patients the tricuspid valve endocarditis was treated as follows : debridement, vegectomy, patch reconstruction of the cusps, reducing the cusps to two. In three patients reconstruction was not possible because of extensive involvement of all parts of the valve, including the valve ring and the papillary muscles. In these patients primary valve replacement (n = 1) or valve excision with secondary replacement (n = 2) was performed. In four patients tricuspid reconstruction was combined with mitral (n = 1), aortic (n = 1) or double valve replacement (n = 2). Postoperatively, signs of infection vanished in all surviving patients (n = 10) and tricuspid valve endocarditis healed without recurrences. Implanted prosthetic material did not lead to recurrent infection. One patient died early postoperatively after valve excision, in septic shock and multi-organ failure. In seven patients late echocardiographic follow-up showed tricuspid regurgitation grade 0 in three patients, I in two, II in one and III in one. Our results suggest that valve repair is a reasonable treatment option for tricuspid valve endocarditis in all cases with localized infection of the valve. Only if extensive valve destruction excludes valve repair, would we now favor primary valve replacement over simple valvulectomy. In all other cases primary valve reconstruction is the treatment of choice for tricuspid valve endocarditis, if surgery is indicated.

Journal ArticleDOI
TL;DR: A very low complication rate can be achieved without recourse to bronchial wrapping, telescoping anastomoses or steroid avoidance in isolated pulmonary transplants, performed at one centre between 1987 and 1994.
Abstract: Objective. To review the results of bronchial healing in a consecutive series of 100 isolated pulmonary transplants, performed at one centre between 1987 and 1994. Methods. A retrospective review of 123 assessable bronchi (61 in single lung and 62 in bilateral lung) transplants was carried out. All anastomoses were assessed by bronchoscopy at 7-10 days, and follow up was from one to seven years. The effect on bronchial dehiscence or stenosis requiring endobronchial stent, of suture technique, pre and post operative steroid administration, bronchial wrap, donor ischaemic time and time to first rejection episode was assessed. Results. Complications of airways healing occurred in four patients: stenosis in two and dehiscence in two (1.6% of bronchi at risk in both groups). Airway complication was not affected by steroids, pre-operative diagnosis, presence of a wrap (34 with pericardium or omentum, 89 with peribronchial tissue alone) or any other variable. There was a higher incidence of dehiscence (2/36) with continuous rather then interrupted (0/87) suture, but this was not statistically significant. There was one airway-related death. Two patients who required anastomotic stenting remain alive and well. Conclusions. A very low complication rate can be achieved without recourse to bronchial wrapping, telescoping anastomoses or steroid avoidance. Combined heart-lung transplantation or bronchial revascularisation are not required to achieve reliable bronchial healing.