Showing papers in "Thoracic and Cardiovascular Surgeon in 1994"

Postoperative visceral hypotension the common cause for gastrointestinal complications after cardiac surgery.

Abstract: In order to identify peroperative risk factors and to evaluate different etiological factors in developing postoperative gastrointestinal complications, clinical variables were studied in 3493 patients undergoing adult cardiac surgery. There were 86 gastrointestinal complications, 2.9%, with an overall morality among these of 22.1%: the mortality rate was 3.9% for all patients undergoing cardiac surgery at our institution (p < 0.001). Paralytic ileus, intestinal ischemia, and acute cholecystitis were the most frequently seen complications. Arterial hypertension, smoking and poor preoperative cardiac function, clinical instability, and the need for an emergency operation were distinct clinical risk factors. Cardiopulmonary bypass time was, by itself, not an important factor. Embolic etiology was also ruled out. The incidence of peroperative myocardial infarction, low postoperative cardiac output necessitating massive use of vasopressor substances and/or intraaortic balloon pumping were significantly more often observed in patients who subsequently developed gastrointestinal complications. The common etiological factor in developing gastrointestinal complications of any kind, after cardiac surgery, seems to be postoperative splanchnic hypoperfusion with visceral ischemia. In order to reduce postoperative morbidity and mortality it is essential to identify patients at risk, support preoperative poor cardiac function, and to carefully monitor these patients postoperatively for abdominal complications to reach an early diagnosis.

Aorto-caval fistula: an uncommon complication of infrarenal aortic aneurysms

Abstract: Aorto-caval fistulas are an uncommon complication of infrarenal aortic aneurysms, being found in 0.22% to 6.04% of all cases. Operating on 1231 patients with abdominal aortic aneurysm in the last 30 years we saw 17 patients with an aortocaval fistula. While 5 patients showed an isolated fistula, 12 had an additional rupture of the aneurysm into the retroperitoneal space or the abdominal cavity. Only in four patients was the aorto-caval fistula diagnosed preoperatively. In 16 patients the fistula was closed from within the aorta. One patient needed ligation of the vena cava and the iliac veins. Mortality rate was 40% in the group with isolated fistula and 66.7% in the group with concomitant rupture. Aorto-caval fistula is a severe complication of abdominal aortic aneurysms, which may be fatal and demands early diagnosis and prompt treatment.

The protective effects of high-dose ascorbic acid on myocardium against reperfusion injury during and after cardiopulmonary bypass.

Abstract: The protective effects of high-dose ascorbic acid (250 mg/kg) on the myocardium were observed in 85 patients undergoing Cardiopulmonary Bypass (CPB). The changes in serum Malonyldialdehyde (MDA). Creatine Phosphokinase (CPK), Creatine Phosphokinase isozyme (CPK-MB) and Lactic Dehydrogenase (LDH) in group B (n = 45, receiving ascorbic acid) were lower (p < 0.05) than in group A (n = 40, no ascorbic acid) during and after CPB. The MDA remained at a higher level two days postoperatively; CPK and CPK-MB, the sensitive and specific reflectors of myocardial injury, recovered very slowly in the control group (A) after the operation. The hearts in all the patients of group B resuscitated automatically intraoperatively while five cases (12.5%) needed defibrillation in group A. The cardiac index (CI) measured in ICU in group B was higher than in group A (p < 0.05). The patients needed shorter ICU and hospital stays in group B than in group A. The results indicate that ascorbic acid can act as a scavenger of free radicals to decrease the peroxidation of the lipids present in the cell membrane and remove the radicals to protect the myocardium from ischemia-reperfusion injury effectively during and after open-heart operation.

Heart transplantation: are there psychosocial predictors for clinical success of surgery?

Abstract: 50 adult patients were extensively psychosocially examined before undergoing heart transplantation. The data obtained and the clinical treatment data were compared with the clinical success of surgery (four groups ranging from excellent to unsatisfactory as determined by the surgeon one year after transplantation). Statistical evaluation by discriminant analysis resulted in the following predictors for successful surgery (all psychosocial): empathy, care and support by one partner (affective involvement), few demands for emotional communication (affective expression), self-control, ability to take stress, emotional stability, high frustration tolerance, low aggression level, and younger age. The following variables did not have predictive significance: schooling, occupation, social status, indication for transplantation, length of stay in intensive care and in hospital, extent of preoperative anxiety and depression, and the life-quality index according to Spitzer determined externally. The results show support by the partner to be the most significant psychosocial variable that can influence the clinical success of heart transplantation.

The significance of prognostic factors for the resection of pulmonary metastases of breast cancer.

Abstract: Breast cancer is the most common malignant disease in women in Europe. In 15-25% of cases, the isolated formation of pulmonary metastases occurs. To date these metastases have been treated mainly by chemotherapy, radiotherapy, or hormone therapy. However, good results through pulmonary metastatic resection have been reported increasingly in recent times. From 1979 to 1992, 103 breast-cancer patients underwent surgery for suspected pulmonary metastases in our clinic. Intraoperatively in 88% of the whole group the metastases were confirmed, but in the other 12% they proved to be benign tumors or primary bronchial carcinomas. The operative therapy is standardized in our clinic. The approach is via a median or transverse sternotomy. Wedge resection is the normal procedure, undertaken in 55% of the cases. Complications, which were completely reversible in all cases, occurred in 3%. The 30-day mortality rate was 0%. In the whole patient population, the actuarial 5-year survival was 27%; it was 31% among the completely resected women, whereas no patient undergoing incomplete resection survived 5 years. Taking prognostic criteria into account, there are clear trends. When the disease-free interval exceeded 2 years, the actuarial 5-year survival was 33%, and if the receptor status of the primary tumor was positive, the 3-year survival was 61% compared to 38% for cases with negative receptor status. If a solitary metastasis was removed, the actuarial 5-year survival was 35% as opposed to 0% in cases with more than five metastases.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiple primary lung cancers.

Abstract: Between 1970 and 1990, of 1287 patients undergoing resection for primary lung cancer, we considered 55 (4.3%) to have a second primary lung cancer, being synchronous in 15 cases (1.2%) and metachronous in 40 (3.1%). Two patients had a third primary lung cancer. The 15 patients with synchronous cancers were all treated surgically: ten underwent a two-stage procedure and 5 patients a one-stage. In 6 patients the cancers were located bilaterally and in 4 patients both synchronous cancers had a different histology. There were 3 postoperative deaths (20%). The 3- and 5-year actuarial survival rates were 26% and 15%. Of the 40 patients with metachronous cancers the mean interval between treatment of their first and second cancer was 5 years and 11 months. It was longer for the 21 patients having a contralateral second localization (7 years) than for those having an ipsilateral localization (4 years). There was no dependence of the intervals on whether or not the second cancer had the same histology as the first cancer. In 7 patients the second cancer was treated by chemo- and/or radiotherapy and in 33 patients by surgery. There were 5 postoperative deaths in this group (15.2%). The 3- and 5-year actuarial survival rates were 33% and 18%. For 25 patients with a stage I or II second cancer these rates were 42% and 27%; all 8 patients with a stage III second cancer died within 14 months. Survival was positively affected by: histological type differing between both cancers, an interval of more than 3 years, a bilateral localization, and a stage I or II second cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Omentopexy and Muscle Transposition: Two Alternative Methods in the Treatment of Pleural Empyema and Mediastinitis

Abstract: From March 1987 to March 1993, 64 patients with chronic empyema and mediastinitis were treated with omentum and thoracic muscle transposition. There were 36 male and 28 female patients, age range 29 to 76 years. 31 patients suffered from chronic empyema and bronchopleural fistula after lung surgery, 18 patients had chronic empyema after pulmonary inflammatory disease, and 15 patients developed a mediastinitis with or without pleural empyema after cardiac surgery or irradiation of the chest wall. The pedicled omentum was used in 33, the thoracic muscles latissimus dorsi, pectoralis major, serratus anterior, and trapezius either alone or combined in 31 cases. There were no perioperative deaths. Bronchopleural fistulas and infected spaces were successfully closed in 61 patients (95.3%). Postoperative CT scan, angiography, bronchoscopy, and lung function tests demonstrate the efficacy of both surgical methods. Omentum pedicle and thoracic muscle flaps supply excellent vascularised tissue to fill infected pleural space and mediastinum, particularly in patients with limited cardiopulmonary function.

Postoperative pulmonary torsion: report of a case and survey of the literature including spontaneous and posttraumatic torsion.

Abstract: A case of postoperative torsion of the left upper lobe following thoracotomy for removal of a large mediastinal tumor is presented. Diagnosis was made on the sixth postoperative day by axial computerized tomography. At rethoracotomy the upper lobe, well delimited against the lower lobe by deep fissure, was found to be twisted by 180 degrees in clock-wise direction. It was hemorrhagically infarcted and had to be resected. The patient, a 37-year-old woman, made an uneventful recovery thereafter. In a recent epidemiological study in the United Kingdom it could be shown that postoperative torsion occurs more frequently than hitherto presumed. 35 of 117 thoracic surgeons responding to a questionnaire had observed this complication 36 times. In reviewing the literature for welldocumented cases, four cases of spontaneous, five of posttraumatic, and 17 cases of postoperative pulmonary torsion were found. Of these cases and the case reported 12 torsions occurred after partial lung resection and six following other thoracic operations. Especially the right middle lobe is endangered after upper lobectomy and should be fixed to the lower lobe during surgery. The outcome was fatal in 4 of the 18 cases. Prevention and treatment are discussed.

Chylothorax after pleuro-pulmonary surgery: a rare but unavoidable complication.

Abstract: The incidence of chylothorax after pleuro-pulmonary operations as well as its treatment is reported. Of 1744 operations performed postoperative chylothorax developed in 13 (0.74%). It resulted in two cases from the transection of the thoracic duct, in six from the transection of the so-called minor lymph channels, which drain lymph from mediastinal nodes straight into the thoracic duct or drain lung segments into the thoracic duct via the pulmonary ligament; the transection of these channels occurred during mediastinal lymphadenectomy or during the section of the pulmonary ligament. In 5 patients the site of leakage was not determined as reoperation was not required. Conservative treatment with low-fat diet and medium-chain triglycerides and/or total parenteral nutrition was attempted in all but one patient but was successful only in 5 cases whose mean losses were 292 ml/day. Seven patients were reoperated after a mean of 11 days; their mean losses were 930 ml/day. One patient was reoperated on the third postoperative day without attempting conservative treatment; his mean loss was 850 ml/day. Lymphadenectomy seems to be an important risk factor for postoperative chylothorax. Chyle leakage around 500 ml/day or higher that tends to decrease below 500 ml/day after a few days of dietary manipulation usually stops within 10-20 days, while leakage over 500 ml/day that does not tend to decrease below 500 ml/day seldom if ever stops without surgery, so that a more aggressive attitude is justified.

Comparison of transit-time and Doppler ultrasound methods for measurement of flow in aortocoronary bypass grafts during cardiac surgery.

Abstract: To evaluate the accuracy of flow measurements in aortocoronary bypass grafts with the ultrasound transit-time method, an in vitro and in vivo comparison was carried out. The in vitro comparison with evaluation against both true flow and the ultrasound Doppler method, was carried out with a fresh saphenous vein mounted in a pulsatile flow rig. The two flow probes were placed on the graft 4-5 cm apart to avoid acoustic interference, and blood was pumped through the system at different flow rates. The comparison between the methods showed excellent agreement with a linear correlation coefficient of 0.996, and a mean error of -2.9 ml/min with limits of agreement +/- 13.1 ml/min (+/- 2 SD = 95% of measured differences between these limits). However, against true flow, both methods overestimated flow slightly with mean error 4.4 and 7.3 ml/min for the transit-time and Doppler, respectively. Both methods showed excellent correlation with true flow (correlation coefficient 0.998 for the transit-time and 0.997 for the Doppler method). The in vivo accuracy was evaluated by comparison of the two methods in 9 patients. The two probes were placed on the same saphenous vein grafts 4-5 cm apart, and a total of 34 measurements in 17 grafts were carried out including measurements at baseline and after papaverine injection. The correlation coefficient was 0.990 and linear regression analysis gave the equation: Transit-time flow = 1.00 x Doppler flow + 1.3. In terms of flow, the mean error was 1.5 ml with limits of agreement +/- 17.2 ml.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term results of the gamma-irradiation-preserved homograft monocusp for transannular reconstruction of the right-ventricular outflow tract in tetralogy of Fallot.

Abstract: The long-term results of a consecutive series of transannular gamma-irradiated homograft monocusp patches in tetralogy of Fallot were studied. Seven survivors out of 8 patients are doing clinically well after a mean of 22.4 years of follow-up, 5 of them being in New York Heart Association class I and 2 in class II. In one patient the completely calcified gamma-irradiated homograft monocusp patch was replaced 15 years after intracardiac repair. Echocardiographic investigation at the end of follow-up of the remaining 6 patients with a gamma-irradiated homograft monocusp patch in situ showed mild pulmonary regurgitation in 1, moderate regurgitation in 3, and severe regurgitation in 2. Residual pulmonary stenosis was present in 4 patients (gradients ranging from 10 to 40 mmHg). Right-ventricular dilatation was present in all patients. In the long-term the gamma-irradiated transannular homograft monocusp patch behaves like a simple transannular patch.

Treatment of postoperative chylothorax by pleurodesis with the streptococcal preparation OK-432.

Abstract: Of the 2877 patients who underwent chest surgery at our department during the 20-year period between 1973 and 1992, 9 (0.3%) developed postoperative chylothorax. The underlying disease included primary lung cancer in 5 patients, pulmonary metastasis in 1, invasive thymoma in 2, and neuroblastoma of the posterior mediastinum in 1. For the treatment of chylothorax, the thoracic duct was ligated in 2 patients with a high volume of chylous leakage. In 6 patients treated conservatively, early pleurodesis was attained by injecting 1 to 5 doses (mean: 2.2 doses) of the streptoccal preparation OK-432 intrathoracically; favorable results were achieved. In 1 patient, the diagnosis of chylothorax was delayed because of postoperative pyothorax. This patient developed nutritional deficiency, compromised immunity, and disseminated intravascular coagulation (DIC), which led to death before the chylothorax could be treated. In principle, postoperative chylothorax should be treated conservatively. Favorable results can be expected with the intrathoracic injection of OK-432 beginning at the early postoperative period to achieve pleurodesis, combined with the prevention of nutritional deficiency, electrolyte imbalance, and infection.

Simultaneous arterial and coronary sinus cardioplegic perfusion: an experimental and clinical study.

Abstract: UNLABELLED The existence of inhomogeneous distribution of coronary flow with antegrade or retrograde perfusion alone has led to alternating between these delivery routes to maximize their individual benefits. Concern over myocardial damage prevented the simultaneous application of antegrade and retrograde cardioplegic blood delivery. Based upon the predominance of retrograde drainage via Thebesian veins, and evidence that pressure-controlled intermittent coronary sinus occlusion during antegrade cardioplegic delivery enhances its distribution and protective properties, this study tests (a) the hypothesis that simultaneous aortic and coronary sinus perfusion is safe during aortic clamping, and (b) reports initial clinical application of this combined strategy in 174 patients. Five minipigs (25-30 kg) underwent 1 hr of aortic clamping with simultaneous aortic (antegrade) and coronary sinus (retrograde) perfusion at 200 ml/min with normal blood (37 degrees C) before and after 30 minutes of perfusion with either warm (37 degrees C) or cold (4 degrees C) blood cardioplegia (BCP). Furthermore, the combined strategy was used in 174 high-risk patients (NYHA class III-IV) at 3 university hospitals to perform myocardial protection during CABG or valve replacement, or a combination of both. Included were 16 patients in cardiogenic shock and 24 undergoing reoperation. In both the clinical and the experimental studies the coronary sinus pressure was always < 40 mmHg in beating or arrested hearts. EXPERIMENTAL Compared to control values (81.4 +/- 0.4% tissue water content), no right-ventricular (80.8 +/- 0.8%) or left-ventricular (79.5 +/- 0.3%) edema developed, no lactate was produced (control: -1.0 +/- 0.5 mg/100 g/min, empty beating: -0.64 +/- 5, and BCP arrest: -8.6 +/- 6.6).(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term experience with pericardiectomy: analysis of 105 consecutive patients.

Abstract: A retrospective analysis of the records of 105 patients who underwent pericardiectomy from 1983 to 1993 was performed. Primarily, 40 patients (38%) had tuberculosis, 16 patients (15%) a malignancy, 12 patients (11.4%) uremia, and 11 patients (10.5%) had rheumatic disorders. Pericardiectomy was performed through midline sternotomy in all cases, 9 of them required cardiopulmonary bypass. On operation, the anterior pericardium was excised parallel to the phrenic nerves on both side. The early mortality rate was 10.5% (11 patients). Mean follow-up time was 5.8 +/- 2.1 years, ranging from 1 year to 11 years. Actuarial survival of the patients at 1 year and 5 years were 81.1% +/- 6.8% and 63.5% +/- 8.2%, respectively. We conclude that pericardiectomy using midline sternotomy with or without cardiopulmonary bypass can be performed safely and can lead to good functional results and long-term survival.

Fibrin-glue-coated collagen fleece in lung surgery--experimental comparison with infrared coagulation and clinical experience.

Abstract: Diffuse parenchymal bleeding and major air leaks still present a challenge to the thoracic surgeon. This study was therefore designed to evaluate efficacy and handling of fibrin-glue-coated collagen fleece, to address these problems. In an experimental part defects were produced in lungs of troll pigs to compare the use of the fleece with infrared coagulation. Immediate airtightness and postoperative adhesions were evaluated. Scores were designed to evaluate quality and extension of the adhesions. In a clinical study parenchymal resection sites were sealed with fibrin-glue-coated collagen fleece in 52 patients. No patient suffered from postoperative bleeding. In three cases air leaks were still present on the third postoperative day, representing a 5.8% failure rate. 92.3% of the patients showed neither postoperative hemorrhage nor prolonged air leaks. A fixed combination of collagen fleece and fibrin glue consequently can be considered as a valuable tool in thoracic surgery.

Intravenous leiomyomatosis extending into the right ventricle: one-stage radical excision during hypothermic circulatory arrest.

Abstract: A case of intravenous leiomyomatosis with extension into the right ventricle is described. A tumor in the inferior vena cava was detected 5 years after a hysterectomy had been performed for a myomatous uterus, but was misdiagnosed as an intracaval thrombus. Three years later this tumor was discovered after it had enlarged and intruded into the right ventricle. The correct diagnosis was made after a complete evaluation. The patient underwent surgery employing simultaneous sternotomy and laparotomy. Radical excision was achieved using cardiopulmonary bypass with hypothermic circulatory arrest. The diagnostic and surgical approaches are reviewed and discussed.

The octogenarians--a new challenge in cardiac surgery?

Abstract: The peri- and early postoperative outcomes of 75 consecutive octogenarians (38 male, 37 female, mean age 81.7 years) who underwent open heart surgery were analysed to identify independent variables of risk factors influencing morbidity and mortality. There were 48 coronary bypasses, 20 valve replacements, and 7 combined procedures. Multivariate analysis revealed that functional class (New York Heart Association), operative procedure, aortic cross clamp time, total bypass time, and age are independent predictors for morbidity and motality (p < 0.05). There were 6 postoperative deaths (8 %). Postoperative complications included haemorrhage (2), stroke (1), unstable sternum (2), acute cholecystitis (1), pneumothorax (2), and urinary tract infection. It is concluded that octogeniarians may benefit from open heart surgery at an acceptable risk. Es wurde das postoperative Ergebnis bei 75 uber-80jahrigen Patienten (38 mannlich, 37 weiblich, mittleres Alter 81,7 Jahre), welche sich einem Eingriff am offenen Herzen unterzogen, analysiert, um unabhangige prognostische Risikofaktoren fur die postoperative Morbiditat und Mortalitat zu identifizieren. 48 Patienten unterzogen sich einer aortokoronaren Bypassoperation, 20 Patienten einem Klappenersatz und 7 einer Kombination aus beiden. Multivarianzanalysen ergaben, das die klinische NYHA-Klasse, die Art des operativen Eingriffs, die Aortenklemmzeit die Gesamtbypasszeit und das Alter unabhangige, die Morbiditat und Mortalitat beeinflussende Variablen darstellen (p < 0,05). Es gab sechs postoperative Todesfalle (8 %). An postoperativen Komplikationen sahen wir: Nachblutung (2), Insult (1), instabiles Sternum (1), akute Cholezystitis (1), Pneumothorax (2) und einen Harnwegsinfekt. Wir schliesen aus unseren Ergebnissen, das auch uber-80jahrige Patienten bei herzchirurgischen Eingriffen kein besonderes Risiko haben.

In-vivo evaluation of the "HIA-VAD": a new German ventricular assist device.

Abstract: Helmholtz Ventricular Assist Devices (VAD) are pneumatically driven polyurethane membrane pumps with various volumes. The pumps are placed paracorporeally and connected with commercially available cannulas between the left atrium and aorta (left ventricular assist device) and/or right atrium and pulmonary artery (right ventricular assist device, bi-ventricular assist device). The pumps can be driven with a stand-alone driving system or with a Helmholtz IABP-console interface. Seventeen animal experiments (on calves) with Helmholtz VAD's were performed to evaluate experimental protocols, to optimize surgical techniques, and to improve design and manufacturing techniques. Blood chemistry and cell counts demonstrated that the tested HIA-70 produces low mechanical blood damage. In the course of the animal experiments the Helmholtz VAD's were made totally transparent, whereby they became easy to de-air, efficient, and affordable.

False aneurysm of the ascending aorta with fistula to the right atrium. Noninvasive diagnosis by computed tomographic scan and two-dimensional echocardiography with successful repair.

Abstract: A 57-year-old Japanese man presented with symptoms of congestive heart failure 9 years after aortic valve replacement. On auscultation, a continuous murmur was heard at the left lower sternal border. Chest radiograph showed moderate cardiomegaly and a widened upper mediastinum. Computed tomographic scans showed a dilated ascending aorta, in which there was no intimal flap, and also showed a large mass which compressed the right atrium. Two-dimensional Doppler echocardiography revealed abnormal continuous blood flow directed from the dilated ascending aorta to the right atrium and no periprosthetic leak. At operation, a false aneurysm of the ascending aorta which originated from the aortotomy suture line and a fistula from the aorta to the right atrium were confirmed. The fistula was closed with pledgeted sutures, and the ascending aorta was replaced with a collagen-coated double woven velour dacron graft. The patient recovered uneventfully. Computed tomographic scan and two-dimensional echocardiography are complementary techniques for reliable non-invasive assessment of the complexity of an aortic aneurysm.

Celite and kaolin produce differing activated clotting times during cardiopulmonary bypass under aprotinin therapy.

Abstract: Since the introduction of the proteinase inhibitor aprotinin in cardiac surgery, a strong increase of the activated clotting time (ACT) during the extracorporeal circulation phase (ECC) was reported in many clinical studies, but with a lack of correlation between ACT and heparin concentration. In searching for a cause of this inconsistency we investigated different surface activators of the ACT in a clinical study. During ECC ACT was measured in parallel, using a Hemochron device and corresponding tubes (nominally 12 mg celite activator) for celite ACT, and a HemoTec device with corresponding double tubes (nominally 0.1 ml kaolin activator) for kaolin ACT. Under the conditions of ECC, the kaolin ACT values (482 +/- 145 sec) were significantly lower than the celite ACT values (985 +/- 267 sec). These results were confirmed in ex-vivo experiments using an activated partial thromboplastin time (aPTT) model. With heparin alone, aPTT activated with celite and kaolin were similar. Including aprotinin in this model, the celite aPTT showed no correlation to the heparin concentration, whereas the kaolin aPTT remained well correlated to the heparin concentration and similar to the values without aprotinin. With aprotinin alone there were no changes of the aPTT times, whereas the celite ACT times were without any correlation. Our results indicate that using kaolin instead of celite the ACT measurements under aprotinin therapy stay in the same ranges as without application of aprotinin: aprotinin has no detectable influence on kaolin-activated ACT. In our opinion, kaolin should be used as the surface activator for ACT measurements under the conditions of ECC, heparinization, and aprotinin therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Doppler flow measurement in coronary artery bypass grafts and early postoperative clinical outcome.

Abstract: The present investigation attempts to correlate flow measurements made intraoperatively in coronary bypass grafts with clinical outcome A total of 352 consecutive patients undergoing isolated coronary artery surgery underwent hemodynamic assessment of their bypass grafts (328 internal thoracic artery and 582 saphenous vein grafts) at the end of cardiopulmonary bypass (CPB) by using a 8 MHz pulsed Doppler ultrasound flowmeter The total patient population was divided into three groups of distinct outcome (A: normal, 228 patients; B: complicated, 106 patients; C: poor, 18 patients) on the basis of a combination of the following parameters: difficult weaning from bypass, use of inotropic drugs, reduced left-ventricular stroke work index, myocardial infarction, intraaortic balloon counterpulsation, and death of cardiac origin Univariate analysis has shown clinical outcome to be influenced by preoperative clinical condition and not by flow in bypass grafts (average flow per graft [ml/min] was 60 +/- 2 [mean +/- SEM] in group A, 58 +/- 3 in group B and 43 +/- 6 in group C: NS by analysis of variance) Multivariate analysis (Fisher linear discriminant analysis) selected only the two following factors leading to normal (group A) or adverse (groups B and C) outcome: unstable angina (p = 0026) and duration of additional CPB after unclamping the aorta (p < 10(-5) To conclude, clinical outcome was not influenced by flow as measured in well-functioning bypass grafts by pulsed Doppler technique

Chylothorax after blunt chest trauma: an unusual case with a long latent period.

Abstract: We report on a case of closed chest trauma with an unusual latent period of 11 weeks in a woman 26 years old. The patient had a dual thoracic duct with a dual lesion and was evaluated using lymphography and CT. We discuss the pathogenetic mechanism and the unusual radiological appearance with discontinuity of the duct, and an increase in back pressure which promotes dilatation of lymphatic vessels and nodes. The dual duct had two separate traumatic consequences: a chyloma on the right and leakage in the pleura on the left. Pleuroperitoneal shunting was effective after failure of conservative treatment. Two years after discharge the patient is asymptomatic with normal chest X-ray image. She is near term in a normal pregnancy and without signs of silent malignancy.

Coronary Arteriovenous Fistula: Surgical Correction of a Rare Form

Abstract: In a 60-year-old woman with long-standing angina left heart catheterisation revealed peripheral and central coronary arteriovenous fistulae connected to the left and right coronary system and opening into the pulmonary artery. The fistulae connected to terminal coronary artery branches were corrected by ligation of these feeding arteries while the electrocardiogram was continuously monitored. The central fistulae were closed via a transcoronary approach of the left anterior descending artery. Knowledge of different surgical techniques helps to prevent perioperative myocardial infarction and late fistula recurrence.

Multicentric Angiofollicular Lymph-Node Hyperplasia Associated with Myasthenia Gravis

Abstract: Castleman's disease is often referred to as giant lymph-node hyperplasia. Although this localized disorder most commonly involves the mediastinum, recently many patients have been described with multicentric lymph-node hyperplasia associated with various clinical abnormalities. Here a new case of multicentric angiofollicular lymph-node hyperplasia associated with myasthenia gravis and gammopathy is presented. At first, the patient responded to surgery well, but after some months her condition deteriorated: plasmapheresis was then performed, one year after the operation, with great clinical improvement.

The coronary subclavian steal syndrome: an uncommon sequel to internal mammary-coronary artery bypass surgery.

Abstract: Coronary subclavian steal syndrome is a possible sequel in patients who have undergone myocardial revascularization with an internal mammary artery. We report a case of this syndrome in a 67-years-old man. In 1990 he underwent a quadruple bypass: aorta-obtuse margin, aorta-right coronary (two sequential), internal artery mammary-descending coronary artery. Three months later he started to have angina pectoris. In April 1992 an aortic arch angiography and a coronary angiography were performed. The examination showed an occlusion of the left subclavian artery at its origin. The artery was opacified countercurrently by the left vertebral artery but the left mammary artery was not opacified. Left coronary angiography showed a very severe disease of left anterior descending coronary artery and retrograde flow through the anastomosis in the left mammary artery. The patient underwent a left common carotid-subclavian artery bypass operation using a 6 mm vascutex graft. Eighteen months later the patient is doing well without angina pectoris and with very little alteration of the perfusion in the left frontal lobe observed by SPECT neuroimaging with a lipophilic tracer (99mTc-HMPAO). We think that the coronary-subclavian steal syndrome can be treated successfully with low risk by means of common carotid-subclavian artery bypass.

Spontaneous non-traumatic rupture of the thoracic aorta.

Abstract: Spontaneous non-traumatic rupture of the aorta is a very rare condition that requires immediate surgery. However, correct preoperative diagnosis is difficult or impossible to establish. We report a case of spontaneous aortic rupture which was successfully treated by emergency surgical exploration following a transesophageal echographic diagnosis of hemopericardium. This case, as well as other reports, suggests that hemopericardium along with symptoms which suggest aortic dissection or rupture (e.g., acute chest or back pain) should raise a strong suspicion of spontaneous aortic rupture even in the absence of intimal flap or aortic dilatation, and the emergency surgery may be life-saving.

A new approach for aortocaval fistula from ruptured abdominal aortic aneurysm. Balloon occlusion technique under echogram guidance.

Abstract: Aortocaval fistula is a rare but well-recognized complication of abdominal aortic aneurysms. However, it is difficult to make preoperative diagnosis due to various clinical findings in a patient. Once the diagnosis is made surgical treatment is urgently required. Successful surgical therapy depends on control of bleeding from the fistula. We used two Forgaty balloon catheters inserted into the inferior vena cava under echogram guidance, thus restricting bleeding from the fistula. This new approach is safe and useful for intraoperative control of hemorrhage from a ruptured abdominal aortic aneurysm.

Primary Pulmonary-Artery Sarcoma

Abstract: A case of pulmonary leiomyosarcoma originating in the left pulmonary artery stem in a 28-year-old Japanese man is reported. The patient complained of recurrent hemoptysis. The diagnosis was made at exploratory thoracotomy. Two days following thoracotomy, under cardio-pulmonary bypass, the upper one-third of the pulmonary trunk and part of the right pulmonary artery stem were resected and left pneumonectomy was performed. A Dacron prosthetic 23 mm composite graft was inserted to replace the pulmonary trunk and a portion of the right pulmonary artery. Postoperative course was uneventful. The patient died about 8 months after surgery because of right lung metastases. In our review of surgically treated forty-eight cases, complete resection was performed in 11, incomplete resection in 23, and embolectomy in 6, whereas 8 were unresectable. A localisation often not allowing adequate resection of the tumor or the advanced stage of the tumor at surgery are considered the main causes of the poor prognosis of the pulmonary sarcoma.

The effects of prolonged cardiopulmonary bypass on cell-mediated immunity.

Abstract: Studies of T-cell subsets (CD3+, CD4+, CD8+, CD8+ CD57+ cells), lymphocyte response to concanavalin A (Con A), phytohaemoagglutinin (PHA) and the alterations of white cell membranes shown by scanning electronic microscope (SEM) in 51 patients who underwent cardiac operation were performed. Out of these 51 unselected patients, for 16, duration of CPB was 110 minutes). Although variations of the lymphocyte subset observed between groups A and B were slightly significant (p < 0.05 before CPB and on postoperative day 7), the T-cell reactivity in group B in comparison to that of group A did not normalize by postoperative day 7 regardless of stimulation with PHA or with Con A. With the use of the SEM, the folded aspect of lymphocyte surface decreased after surgery in about 71% (group A) and 78% (group B) of the observed cells. The outcome of the immunological effects given by our studies could have been due to an elongated CPB even if there need to be taken into consideration multifactorial influences, i.e. biological, pharmacological and hormonal hypotheses, and rapid changes in CPB-micro-environment.

Sinus of Valsalva aneurysm: a late complication after repair of ascending aortic dissection.

Abstract: Surgical advances and the introduction of new more rapid and accurate diagnostic techniques have led to significant improvement in the survival of patients with aortic aneurysms. However, considerable long-term morbidity and mortality remains a concern. In the present study we report on the occurrence of sinus of Valsalva (SV) aneurysm after repair of the ascending aorta for aortic dissection as a significant long-term complication. Since transesophageal echocardiography (TEE) became available it has been used for the follow-up of 33 hospital survivors after ascending aortic replacement for a mean of 27 +/- 20 months. Those patients who received a valved conduit were excluded from this analysis. The aortic valve was conserved in 22 patients: 17 had a dissecting aneurysm involving the ascending aorta and 4 patients non-dissecting aneurysms. A sinus of Valsalva diameter > 45 mm was considered an aneurysm and was found in a total of 7 patients (33%), 5 being patients with aortic dissection. The overall reoperation rate on account of SV aneurysms was 24%. We conclude that SV aneurysm is a significant long-term complication of patients after repair of the ascending aorta. In the light of these results we have changed our operative policy of repair to include resorcin glue as a reinforcing agent or to perform more extensive repair.