Long-term outcome after pneumonectomy at Siriraj Hospital.

Objective: The purpose of this study is to identify predictors of long term survival following pneumonectomy and compare New York Heart Association (NYHA) functional classification and ECOG performance status before and after surgery at Siriraj Hospital. Methods: All fifty three patients having a pneumonectomy between 1998 and 2009 were retrospectively studied. We compared each patient’s status before and after surgery. The parameters of survival were tested by univariate analysis, the Kaplan-Meier method, and differences in survival were determined by log-rank analysis. Results: There were 35 males (66%) and 18 females (34%) with a mean age (standard deviation) of 51±17 years (range 0.7-82 years). The majority of patients were lung cancer (77%) and destroyed lungs from infectious (12%) diseases. The mean follow-up time was 33 months, median 22 months, standard deviation 24 months, ranging between 0 and 131 months. Post-operative complication occurred in 11% of patients (bronchopleural fistula, bleeding, cardiac herniation and recurrent laryngeal nerve injury). Hospital mortality occurred in 7.5% (4 deaths). Late death occurred in 52.8% (28 deaths) including metastasis 30% (16 patients), pneumonia 19% (10 patients), and miscellaneous causes 3.7% (2 patients). Using univariate analysis, non lung cancer (P = 0.035) and the slow growing lung cancer (P = 0.007) were independent predictors of long term survival. The decrease in NYHA functional classification and ECOG performance status after surgery was not significant. Conclusion: Long-term survival after pneumonectomy for lung cancer occurred in 20% and non lung cancer in 60% of patients. Non lung cancer and the slow growing lung cancer were independent predictors of long term survival. Decreases in NYHA functional classification and ECOG performance status after pneumonectomy were not significant.

Comparison of intensity of platelet aggregation between patients receiving low and high aspirin dosage in post CABG patients.

Background: Aspirin used after coronary artery bypass graft surgery (CABG) improved patient survival and reduced graft thrombosis. However, individual variations in the antiplatelet effect of aspirin have been reported among CABG patients. Objective: To compare the intensity of platelet aggregation between patients receiving low and high aspirin dosage in post CABG patients. Methods: We prospectively studied the effect of aspirin dosage on platelet aggregation in 100 CABG patients. Oral aspirin was discontinued prior to CABG and re-started within 12 hours after CABG. Blood samples were collected and transferred to a laboratory prior to surgery then again on postoperative days two and eight for platelet aggregation test and platelet count within three hours after venipuncture. Results: One hundred patients (sixty five male and thirty five female patients) post coronary artery bypass graft (CABG) were evaluated for eligibility to enter the trial. The percentage of platelet aggregation was compared between low dose (<100 mg/day), and high dose (>100 mg/day) aspirin, at postoperative CABG days 2 and 8, which showed no significant difference for the platelet aggregation (p = 0.161 post CABG day 2 and p = 0.098 post CABG day 8). Conclusion: Low dosage aspirin should be used in post CABG patients because the intensity of platelet aggregation between patients post CABG receiving low and high aspirin dosage were not different, while the prophylactic effect of the low aspirin dosage in reducing the risk of cardiovascular events proved equally as effective as the high aspirin dosage.

Relationship between selected factors and length of hospital stay in coronary artery bypass graft patients.

Objective: One of the health outcomes indicating the quality of care is the length of hospital stay. This descriptive research aimed to examine the associations between psychological factors (mood state), operative factors (cardiopulmonary bypass (CPB) time, type of surgery) and post-operative length of hospital stay (LOS) in coronary artery bypass graft (CABG) patients. Methods: A convenient sample of 109 coronary artery disease (CAD) patients admitted to a university hospital in central Thailand to have elective CABG surgery for the first time were approached. Data were collected by using a socio-demographic and clinical profile with the Profile of Mood State Brief-Thai (POMS-B Thai). Data were analyzed using Pearson’s Product Moment Correlation and Spearman’s Rank Correlation Coefficient to answer the research questions. Results: The majority of the participants were males with an average age of 63.1 ± 9.5 years. The postoperative LOS ranged from 4 to 15 days with the average being 7.3 days. The total mood disturbance score averaged 10.5 points. The most common negative mood states were confusion and anxiety. The majority of the patients had only CABG surgery with an average CPB time of 89.9 minutes (SD 40.1). The significant factors associated with post-operative length of hospital stay were type of surgery and CPB time, while mood state was not found to be significantly related to LOS. Conclusion: In order to promote patients’ recovery by shortening LOS, a rehabilitation program established by a health care team should be tailored specifically for the type of surgery and CPB time following CABG surgery.

Chylous ascites caused by lutembacher’s syndrome: A case report and review of the literature.

Chylous ascites is a well-documented sequelae of traumatic rupture of the thoracic duct and mechanical obstruction of the lymphatic system due to neoplastic, inflammatory, or congenital anomalies. Less commonly, chylous ascites results from altered hemodynamics and lymphatic flow, as seen in constrictive pericarditis and heart failure. We report a case of chylous ascites due to severe mitral stenosis plus atrial septal defect known as Lutembacher’s syndrome. From our knowledge, this has never been reported before. The chylous ascites disappeared after repairing the heart. The pathophysiology of chylous ascites formation in this clinical syndrome will be discussed, with a review of the literature.

Traumatic ventricular septal defect from car bumping: A case report and review of literatures.

A 9-year-old boy developed large apical ventricular septal defect with rapid cardiopulmonary deterioration after a blunt chest injury from a car bump. The defect was successfully repaired 10 hours later. The detailed history, investigations and treatment are reported with a review of the literatures.

Pathology and etiology of 110 consecutively removed aortic valves.

OBJECTIVES: To study the pathology and determine the etiology and prevalence of aortic valve disease from surgically removed aortic valve specimens. MATERIAL AND METHOD: All the native surgically excised aortic valves (AV) received from June 1997 to March 1999 (22 months) were studied macroscopically including cuspal measurements and microscopically. By preoperative echocardiographic and macroscopic studies, they were classified into functional disorders of predominant aortic stenosis (AS), aortic stenosis with regurgitation (AS-AR) and predominant aortic regurgitation (AR). The patients' medical records were reviewed and the clinical information was extracted. The etiology was determined according to the macroscopic, microscopic and clinical findings. RESULTS: Among 110 AV (76 isolated AV and 34 with concomitant mitral valves from patients aged 15-96 years, mean age 47.54 years; male:female = 1.39:1) there were 25 AS (22.73%), 34 AS-AR (30.91%) and 51 AR (46.36%) cases. Eighty-four (76.36%) were tricuspid, 16 (14.54%) were bicuspid and 10 were undetermined. Cuspal measurements of each disease were provided and compared. All AS specimens were related to moderate to severe calcification and causes included postinflammatory disease (14 cases, 56%; age range 38-67 years, mean age 53.29 years, male:female = 0.56:1), degenerative calcific change (11 cases, 44%, age range 56-76 years, male:female = 1.2:1; mean age 69 years of 5 tricuspid AV and 60.83 years of 6 bicuspid AV). In AS-AR, 29 cases (85.29%; mean age 47.10 years; male:female = 1.23:1) were attributable to postinflammatory disease and 5 cases (mean age 70.20 years; male:female = 1.5:1) to degenerative calcific change. In pure AR, there were 21 cases (age range 15-65 years, mean age 29.76 years) of postinflammatory disease, 14 cases of infective endocarditis (IE) and postIE (age range 20-63 years, mean age 42.21 years; all 10 IE cases contained gram positive cocci), 1 case (age 55 years) of bicuspid calcific change, 8 cases of AV with dilated valve ring, 5 cases of miscellaneous causes and 2 cases of indeterminate etiology. Aschoff bodies were found in 3 AR cases. Four of 18 postinflammatory AS-AR and 4 of 14 postinflammatory disease AR cases had past history of rheumatic fever. One postinflammatory AS also had infective endocarditis from gram positive cocci without clinical sign. Severe degenerative calcific change had a higher incidence of underlying diabetes (3 of 15 cases, 20%), hypertension (8 of 14 cases, 57.14%) and dyslipoproteinemia (9 of 13 cases, 69.23%) in comparison with 3.37% (3/89) for diabetes, 9.09% (8/88) for hypertension and 30.99% (22/71) for dyslipoproteinemia in other AV diseases in combination. CONCLUSION: The three common causes of severe AV functional disorders were postinflammatory disease (58.18%), degenerative calcific change (15.45%) and IE-postIE (12.72%). Underlying diseases of severe degenerative calcific change included hypertension, dyslipoproteinemia and diabetes. Macroscopic and microscopic examinations together with clinical information, echocardiographic findings and operative details are important in evaluating the etiology of valvular diseases especially in severely calcified specimens.

Early postoperative coronary angiography result in Off-pump Coronary Artery Bypass (OPCAB) patients.

Objective : The purpose of this study was to evaluate the early results of coronary artery bypass without cardiopulmonary bypass (off-pump coronary artery bypass - OPCAB) at Siriraj Hospital. Patients and methods : From September, 2001 to April 2002, eight selected coronary artery disease patients were operated on using the off-pump coronary artery bypass technique. Operative data were collected and postoperative coronary angiography was studied in all patients before discharge. Results : There were no death and no need to resort to the conventional procedure. Postoperative coronary angiography revealed good patency of all 17 grafts. Postoperative cardiac enzymes were elevated in one patient. Conclusion : The early of OPCAB in this study showed good outcomes. Early postoperative angiography demonstrated excellent anastormoses. This procedure needed fewer blood transfusions than the conventional technique. However, long-term follow up of these procedures should be evaluated.

The Sternal Turn Over Procedure with Preservation of the Internal Mammary Vessel and Rectus Abdominis Muscle Pedicles for the Repair of Severe Pectus Excavatum.

Pectus excavatum or funnel chest is one of the most common congenital chest wall deformities. Surgical correction should be considered for all patients with moderate to severe deformities because of the significant cosmetic and psychological improvement, subjective increase in exercise tolerance, documented changes in the cardiac and respiratory status, and prevention of the development of scoliosis after surgical intervention in these patients. The sternal turn over procedure with preserved internal mammary vessels and rectus abdominis muscle pedicles for the corrective repair of severe pectus excavatum, involves resection of the deformed thoracic wall, sternum and ribs, preserving an attachment of the rectus abdominis muscle,and a vascular pedicle of the internal mammary vessel. A short segment resection above the ipsilateralcostal cartilage is mandatory to allow reposition of the vascular pedicle onto the presternal surface after turn over of the sternum. Multiple corrective osteotomy and costoplasty must be completed before refixing the sternum and ribs. The modified sternal turn over procedure restores the sternal blood supply and should be applied to the severe form of pectus excavatum which needs extensive and multiple bony resection. The procedure has been applied to a boy and a girl aged 5 years. At a three year follow up, the results obtained are excellent.

Recurrent hemoptysis caused by left subclavian artery aneurysm: A case report.

A 41 year old man with a left subclavian artery aneurysm was presented to the hospital with clinical symptom of recurrent hemoptysis. CT scan and angiography confirmed the diagnosis. Surgical treatment consisted of femoro-femoral cardiopulmonary bypass and left thoracotomy, aneurysm resection and descending aortico-subclavian vein bypass grafting. The incidental two small saccular aneurysms of the lower descending thoracic aorta were excised and directly repaired. The pathologic study revealed typical atherosclerotic changes. The patient had postoperative persistent chyle leakage and required rethoracotomy and supradiaphragmatic ligation of the thoracic duct. The patient was able to resume his usaul activity after two months of surgery.

Surgical treatment for adult congenital heart disease.

A total of 1,408 adult congenital heart disease patients (age over 13 years) underwent surgery between 1979 and 1995 at Siriraj Hospital, contributing 33.75 percent to the overall number of congenital heart disease cases (4,172) who underwent surgery in that period. This finding is similar to statistics in the West. The ages ranged from 13.3 years to 72 years, with a mean of 24.06 years. The oldest patient was a 72 year-old man with coronary cardiac chamber fistula. The most common diagnoses in descending order were: atrial septal defect (41.05 per cent), patent ductus arteriosus (16.19 per cent), tetralogy of Fallot (14.06 per cent) and ventricular septal defect (10.87 per cent). These four categories covered 82 percent of the cases. The overall surgical mortality was 1.78 per cent, compared with 3 per cent in patients who had undergone surgery during childhood. Only patients with double outlet of the right ventricle and congenital aortic stenosis, or left ventricular outflow tract obstruction, showed increased risk of death (20 per cent), compared with 5.77 per cent in those cases who had undergone surgery during childhood. The conclusions drawn from the study are that surgical treatment for adult congenital heart diseases showed a low average of surgical mortality of less than 2 per cent in almost every category except double outlet of the fight ventricle and congenital aortic stenosis, for which early surgery is recommend.

Surgical treatment for pulmonary stenosis with intact interventricular septum.

Pulmonary stenosis with intact interventricular septum (PS, IVS) is one of the five most common congenital heart diseases to have required surgery at Siriraj Hospital during the past 17 years. It represents 4.5% of all congenital heart diseases operated upon. We reviewed 166 patients who received open-heart surgical treatment for PS, IVS at Siriraj Hospital from 1979 to 1995. Female predominated in neonates. Overall operative mortality was 2.4% with a failure rate of 0.6%. Infundibular plus valvar stenosis was the most common morphology founded at surgery (46%). There was no difference in operative mortality relevance to the level of obstruction. Operative mortality was higher (22%) in infant age group than in the neonate and childhood groups. Since 1992, there has been no operative mortality in any of the age groups. It can be concluded that, the result of surgical treatment for PS, IVS in Siriraj Hospital is excellent with a very low failure rate.

Long-term results of open mitral valulotomy for mitral stenosis.

Between 1979 and 1990, 163 patients underwent open mitral valvulotomy for pure or predominant mitral stenosi at Siriraj Hospital. There were 114 females (69.94%) and 49 males (30.06%), ranging in age from 7 to 71 years (mean, 30.69 years). Pre-operatively, 13 patients (7.98%) were in New York Heart Association (NYHA) functional class II, 138 patients (84.66%) in functional class III and 12 patients (7.36%) in functional class IV. The follow-up period ranged from 14 days to 11.33 years (mean, 3.27 years). Operative mortality was low (0.61%). Improvement in NYHA classification was found in 98 percent of these patients. At 12 years, the overall cumulative proportion surviving was 74; 59 percent of the patients survived without re-operation. In the analysis of factors affecting long-term results, there was no significant difference in any of the variable; sex, age, cardiac rhythm, mobility of cusps and subvalvular changes. This study clearly demonstrates the advantages of open mitral valvulotomy, which resulted in safe, effective and excellent long-term results.

Cardiac surgery at Siriraj Hospital, B.E. 2522-2532.

An eleven year retrospective analysis of patients being treated for heart disease at Siriraj Hospital, during 1979-1989, was carried out in order to find out the epidemiological characteristics of disease and the results of surgical treatment. There were 4289 patients encountered during the period of study. Of these patients, 2565 (60 percent) had congenital heart disease while the rest had the acquired ones. 40 percent of these patients were 13 years and below. Among patients with congenital heart disease, PDA, ASD, Tetralogy of Fallot, and VSD were encounted in 25, 22, 20 and 15 percent respectively. Valvular heart disease, coronary artery disease and pericardial disease were encountered in 56, 15 and 12 percent respectively. The opened heart surgery was carried out in 2753 patients (64 percent) while only 1536 patients (36 percent) had the closed one. The overall mortality following surgery was 3.1 percent. The mortalities among patients with the congenital and the acquired heart disease were 2.03 and 5.22 percent and for those underwent opened and closed surgery were 3.92 and 2.21 percent respectively.

Open lung biopsy in patients with pulmonary infiltrations.

A retrospective study is composed of 23 patients with pulmonary infiltrations whose hospital records were available who underwent open lung biopsy at Siriraj Hospital from January, 1982, to December, 1986. The patients were separated into two broad groups. The first, there were those patients who were in clinically stable condition. The second group identified patients who were systemically ill and whose course was rapidly deteriorating. Time delayed in diagnosis was critical in these patients whose urgent and correct treatment was necessary. Open lung biopsy revealed correct diagnosis in all patients. The prospective diagnosis was changed in 60.87 percent of all patients and the biopsy results altered therapy in 56.52 percent. Hence open lung biopsy appears to be a valuable procedure with low morbidity and mortality in patients who have otherwise undiagnosable pulmonary infiltrations.