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.

Aortic dissection during pregnancy: A case report.

Aortic dissection during pregnancy is rare, but should be kept in mind by every physician in charge of pregnant women. A case of aortic dissection is reported here without any evidence of dissection during the early antenatal period. The patient had sudden chest pain during thirty-fourth week of gestation, medical and surgical management were undertaken. Delivery by emergency Caesarean section was performed, and both the patient and the foetus were saved. The etiology, association with pregnancy, diagnosis and managements of acute dissection of the aorta are discussed.

Short route of internal mammary artery for coronary artery bypass graft surgery.

The muscle mammary artery (IMA) is currently the ideal conduit for coronary bypass graft surgery (CABG), due to its long-term patency rate and association with low operative mortality compared to saphenous vein grafting alone. Between January 1993 and August 1996, there were 246 patients (174 males and 72 females) that had at least one IMA utilized in CABG with this short route technique. The average number of grafts was 3.45 (range 1-6) with an average operative mortality of 1.63 per cent (four patients out of 246). The only risk factor for death was per-operatively acute myocardial infarction associated with cardiogenic shock that required an intra-aortic balloon pump. In such patients, the operative mortality was high, up to 10 per cent (three deaths out of 30 cases). It the patients had no cardiogenic shock, even when presenting with preoperative acute myocardial infarction, the operative mortality was as low as 0.46 per cent (only one death from ventricular tachycardia five days post-operatively). Associated diseases or conditions were hypertension, diabetes mellitus, hyperlipidemia, smoking chronic renal impairment, left main stenosis, low left ventricular ejection fraction (< 30 per cent) or proximal aortic calcification. None of these conditions were risk factors that contributed to post-operative death. In conclusion, this short route technique is an easy procedure, associated with a low complication and a low operative mortality. Long-term results can be expected and the method is ideal for those patients required to undergo repeated CABG, especially in the young.

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.