Postoperative necrotizing fasciitis of the thorax in cardiac surgery.

Necrotizing fasciitis is a rare soft tissue infection and a life-threatening emergency, often fatal. Its incidence and management are described plentifully in the medical literature regarding the most common anatomical sites involved like the abdomen, lower and upper limbs, and perineum. However, available data and case reports of chest wall necrotizing fasciitis after thoracic procedures are scarce, mainly after major cardiac operations. We report and discuss a case of necrotizing fasciitis of the chest wall occurring in the immediate postoperative period of a cardiac procedure, and include a brief review of the concepts, pathophysiology, and treatment reported in the medical literature. We emphasize the need for early diagnosis and urgent and effective surgical debridement. Of importance is the fact that we have not found any references in the literature to cases similar or equal to the one we describe here, which occurred in the postoperative period of a cardiac procedure.

Partial left ventriculectomy: overall and late results in 44 class IV patients with 4-year follow-up.

BACKGROUND: This study reports long-term results of partial left ventriculectomy (PLV). METHODS: Forty-four patients with dilated cardiomyopathy were operated on in a 4-year study. Echocardiograms, catheterization, and stress tests with oxygen consumption (VO2) were performed. RESULTS: The survivors' preoperative ejection fractions of 22.1% +/- 4.9% improved to 30.9% +/- 9.4%, left ventricular (LV) end-diastolic diameter decreased from 79.4 +/- 9.3 mm to 61.9 +/- 8.2 mm, and maximum VO2 consumption improved from 8.8 +/- 3.9 mL/kg per minute to 15.8 +/- 6.1 mL/kg per minute at 22.6 months. These data also showed improvements in nonsurviving patients, according to the last evaluation before death. Seven of 12 survivors (58.3%) were in New York Heart Association (NYHA) I and II in December 1998. Twelve patients had elevated pulmonary vascular resistance (PVR) contraindicating heart transplant. In five patients the PVR returned to normal and one high-PVR patient was transplanted at the 16th postoperative month. Survival was 56.8%, 47.7%, 38.4%, and 35.9%, respectively, at 3, 6, 12, and 18 months, with a tendency to stabilize at 32.7% thereafter. Arrhythmias and heart failure were the main causes of death. CONCLUSIONS: In spite of improvement of ventricular function and quality of life of the survivors, high mortality is a limiting factor. PLV can be indicated as a bridge to heart transplantation in high-PVR patients or if ventricular assist devices or donor hearts are not available.

Holt-Oram syndrome revisited. Two patients in the same family.

Holt-Oram syndrome was first described in 1960 as an association of familial heart disease and musculoskeletal abnormalities. The most important findings include atrial septal defects, atrioventricular conduction abnormalities, vascular hypoplasia, and upper limb musculoskeletal deformities. We report two patients with this syndrome in the same family and discuss the variability of the musculoskeletal abnormalities and their association with the cardiac morphologic defects. Both patients in this study had associated eosinophilia, which has not been reported in the literature.

End-stage heart failure: is there a role for the Batista procedure?

BACKGROUND: Medically refractory heart failure is traditionally managed with cardiac transplantation although some limited success has also been obtained in selected patients using dynamic cardiomyoplasty or mechanical assist devices. Recently, a new surgical alternative called partial left ventriculectomy (PLV) was introduced by Batista in 1995. The procedure attempts to relieve symptoms of congestive failure by reducing myocardial mass and restoring the normal mass-to-volume ratio of the left ventricle. Despite initial enthusiasm, the results of PLV are not yet known. The aim of this study was to determine survival and clinical outcomes in a group of patients submitted to PLV as a means of surgical treatment for end stage heart disease (ESHD) METHODS: From November 1994 to December 1995, 15 patients with ESHD and dilated cardiomyopathy (DCM) were operated on by the technique described by Randas Batista. We compared preoperative and postoperative assessments of NYHA Functional Class (FC), Quality of Life index (QOL), echocardiographic, ergometric, radioisotopic ventriculography and hemodynamic data at intervals of zero, one, three, six and nine, and twelve months postoperatively. Kaplan-Meier, student t-test and chi-square analysis were applied to the numerical and categoric variables. RESULTS: Survival was 80% at one month, 66% at three months, 53% at six months, 47% at nine months and 40% at one year. We also found that 6 of 7 patients (85%) with tricuspid regurgitation (TR) died compared to 4 of 8 patients (50%) without TR. This was the only risk factor indentified which influenced mortality. Post-operative echocardiographic evaluations demonstrated reduced left ventricular end-diastolic and end-systolic diameters at six months (LVESD 65.5 +/- 8.3 mm preoperatively versus 56.83 +/- 5.74 mm at six months, p=0.007 and LVEDD 73.84 +/- 8.25 mm preoperatively versus 65.33 +/- 5.72 mm at six months, p=0.009). Survivors enjoyed an improved clinical status according to both the NYHA functional class (preoperative Class IV=100% versus postoperative at six months : Class IV = 50%, Class III = 17% and Class II = 33%) and the Quality of Life index (100% were in grade 6 and 7 preoperatively versus 0% at six months). However, statistical significance was not reached in most of these data due to the small number of patients. CONCLUSIONS: Actuarial survival in this series of patients was 53% at six months and 40% at twelve months with survivors showing fewer symptoms and clinical events than preoperatively (100% hospitalized preoperatively versus no patient hospitalized at six months). Therefore, the Batista Operation improves the quality of life patients with dilated cardiomyopathy and can possibly be a new means for bridging to cardiac transplantation in severely ill patients who are not likely to survive long enough to recieve a donor heart. Additional improvements in late results will likely be seen after further experience, evolution of the surgical techniques and better patient selection.

Technical considerations for partial left ventriculectomy (Batista operation).

The surgical technique for partial left ventriculectomy (Batista operation) as performed in two surgical centers is described. This surgical remodeling of the left ventricle restores the abnormal geometric configuration produced by the dilated failing heart. It accomplishes a reduction of the left ventricular end-diastolic diameter and end-diastolic volume with consequent increase in left ventricular function. This procedure represents the newest surgical approach in the management of patients with end-stage cardiomyopathy; it can be used as a bridge to transplantation or perhaps as a definitive form of therapy, particularly in those patients in whom heart transplantation is contraindicated. This report describes technical guidelines to avoid serious intraoperative and postoperative complications directly associated with this technique.