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.

Arrhythmia in early post cardiac surgery in pediatrics: Siriraj experience.

OBJECTIVES: To determine the incidence, risk factors and outcome of early postoperative arrhythmias in pediatric patients with congenital heart disease. MATERIAL AND METHOD: A prospective study was conducted in every pediatric patient who consecutively underwent open-heart surgery at Siriraj Hospital from January 1st to December 31st, 2006. The collected data were demographic data, diagnosis, pre-operative arrhythmia, cardiac surgical data and continuous electrocardiographic monitoring data throughout the post operative intensive care period. RESULTS: A total of 191 pediatric patients underwent cardiac surgery. Forty-five cases (23.5%) developed early post operative cardiac arrhythmias i.e. junctional ectopic tachycardia 18 cases (40%), heart block 7 cases (15.6%), supraventricular tachycardia 2 cases (4.4%). Cardiac arrhythmia occurred mostly within 24 hours after the operation. Patients with single ventricle physiology repaired developed the highest incidence of acute post operative arrhythmia (36.4%). Longer, cardiopulmonary bypass time- and redo-operation were the risk factors. Thirty-nine cases were treated with medications, 7 cases with temporary pacing, and 1 case with electrical cardioversion. Four patients needed long-term anti-arrhythmic agents. Cardiac arrhythmia played role in the causes of death in 2 cases (1.1% of total cases). CONCLUSIONS: Post operative arrhythmias remained common and important complications of pediatric open-heart surgery. Long cardiopulmonary bypass time and redo-operation were risk factors for early post operative arrhythmia.

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.

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.