Venous reconstruction of the inferior vena cava bifurcation for retroperitoneal rhabdomyosarcoma in a child. Case report.

Retroperitoneal tumors, as well as traumatic lesions and occlusions of the bifurcation of the inferior vena cava (IVC) and the common iliac veins may require venous vascular reconstruction. We present a method for inferior vena caval bifurcation reconstruction which employs the advantages of a large size straight expanded polytetrafluorethylene (ePTFE) graft in this position after a new IVC bifurcation has been created by uniting the stumps of both common iliac veins, and construction of an arteriovenous (A-V) fistula with controlled flow to decrease the rethrombosis rate of the graft, and still not cause heart failure. This method was used in a case of recurrent rhabdomyosarcoma in an 8 year old child encroaching upon the bifurcation of the IVC as well as on both common iliac veins. The situation was managed by radical resection of the tumor and by creating a new caval bifurcation of the common iliac veins, followed by interposition of a straight ePTFE graft. An A-V fistula was created between the left femoral vein and left femoral artery using the left greater saphenous vein in controlled fashion. The arterial defect of the right common iliac artery was reconstructed by interposition of a PTFE graft end-to-end.

Simultaneous pectus and open heart surgery.

Various surgical approaches to pectus excavatum repair concomitant with surgery have been recommended. In this article the authors describe their approach to the problem that they applied in 1989 and onward, successfully, in six consecutive patients. The favorable early and long-term results of these cases illustrate that the simultaneous correction of pectus excavatum and the underlying diseases of the ascending aorta, aortic arch, and the heart can be performed successfully even in emergency situations. The technique recommended provides good cosmetic results and a stable chest wall. It is well applicable in patients of adult age.

Perioperative myocardial protection with the calcium antagonist diltiazem.

The effect of the calcium channel blocker, diltiazem, on cardiac performance was examined in 90 patients who underwent isolated aortic valve replacement for aortic valve diseases with marked left ventricular hypertrophy. The patients were randomly assigned to one of five groups dependent on the treatment plan with diltiazem: group 1, 5-day preoperative treatment with oral administration of 60 mg diltiazem 3 times daily, 10 mg diltiazem intravenously as a bolus dose before the beginning of the cardiopulmonary bypass, and 5 mg diltiazem intravenously 10 min before removal of aortic clamp; group 2, 5-day preoperative treatment with oral administration of 60 mg diltiazem 3 times daily; group 3, 10 mg diltiazem intravenously as a bolus dose before the beginning of CPB and 5 mg 10 min before removal of the aortic clamp; group 4, 15 mg diltiazem in 1000 ml cardioplegic solution, given as additive; group 5, control group not receiving diltiazem. All operative procedures were performed in an identical manner with an average cross-clamping time of 57.7 min and cooling the heart down to 16 degrees-17 degrees septal temperature by perfusion of the coronary arteries with 4 degrees C cold cardioplegic solution. In each patient the heart rate (HR), cardiac output and cardiac index (CO, CI), stroke volume index (SVI), left ventricular stroke work index (LVSWI) and systemic vascular resistance index (SVRI) were recorded and calculated before and after the ischemic period. Transmural samples were obtained three times by needle biopsy technique from the anterior free wall of the heart. Analysis of the variables revealed that: (1) complete cessation of electromechanical activity was achieved significantly more rapidly in groups 1 and 3 than in the other groups; (2) recovery of sinus rhythm and function of the conductive system required significantly longer in groups 1 and 3; (3) the time-related values of the important hemodynamic factors (CO, CI, LWSVI and SVRI) showed a significantly more effective postperfusion cardiac performance in groups 1 and 3 than in groups 2, 4 and 5. An oral dose of 180 mg diltiazem for 5 to 7 days preoperatively in combination with intravenous administration of 10 mg before the beginning of CPB and 5-10 mg during reperfusion can be recommended in patients undergoing open-heart surgery for isolated aortic valve diseases and left ventricular hypertrophy.

Incidences and surgical aspects of cardiac myxomas in Bulgaria.

63 patients with cardiac tumors underwent operative treatment between January 1970 and December 1988. Three additional patients refused the operation, despite the large left atrial myxomas and obstruction of the mitral valve, recognized by echocardiography. 62 patients had benign tumors: the only malignant neoplasm was a fibrosarcoma, originating from the right ventricle. Myxomas were found in 57 patients: 54 were located in the left and 2 in the right atrium. In one case the myxoma originated from the left ventricle. The hospital mortality of the 22 patients who underwent excision of cardiac myxomas between 1970 and 1984 was 18.18% (4 deaths), and 2.44% (1 death) of 41 patients operated on from 1984 to 1988 for cardiac tumors (35 of them with myxomas). During the follow-up time of 6 to 140 months, recurrence of myxomas occurred in only one patient, 4 years after surgery for multifocal myxoma in the left atrium. Surgical excision of the myxoma is the only acceptable therapy able to cure. Without surgical treatment, the medium and long-term prognosis is fatal. Therefore once the cardiac myxoma is identified by two-dimensional echocardiography, the tumor should be removed even in patients without symptoms. The removal of myxomas doesn't require excision of the full thickness of the interatrial septum or ventricular wall. The risk of postoperative arrhythmias after extensive excision increases. Conduction disturbances may be related to the resection of a large area of the atrial septum or wall. No recurrences have been registered after less radical procedures-- removal with excision only of the underlying endocard.

Lipomatous hypertrophy of interatrial septum presenting as recurring pericardial effusion and mistaken for constrictive pericarditis.

A case of interatrial septal lipoma, presenting as recurrent pericardial effusion with signs of constrictive pericarditis, was described. The tumor was removed successfully. The case demonstrated that the difficulties in the differential diagnosis between right atrial tumor and any other cardiac disease still exist. Because of its extreme rarity, the interatrial septal lipoma is rarely considered in the differential diagnosis.

[Infection prophylaxis with cefamandole. Clinical evaluation in the open heart-surgery and the prosthetic vascular reconstruction (author's transl)]. / Infektionsprophylaxe mit Cefamandol. Ergebnisse einer klinischen Prüfung in der offenen Herz- und prothetischen Gefässersatzchirurgie.

The experience with the cefamandole prophylaxis in 244 patients with open heart-surgery, and another 84 patients operated upon on prosthetic vascular reconstruction was evaluated. No case of endocarditis, sepsis or massive wound infection with infected prosthesis was found in the reviewed patients. Considering the fact that patients undergoing open heart-surgery and prosthetic vascular reconstruction are subjected to much more bacterial contamination than patients undergoing any other surgical procedure, the cephalosporin treatment (in our study cefamandole) should be considered the antibiotic of choice in preventing of infection during and after such surgical intervention.

Surgical management of massive pulmonary embolism.

Between 1972 and 1976, 24 patients have been treated by open pulmonary embolectomy with the aid of cardiopulmonary bypass (CPB). In 17 (71 percent) acute pulmonary embolism occurred 3 to 60 days after a surgical procedure. The remaining seven (29 percent) patients had chronic medical diseases. The interval between clinical manifestation of acute pulmonary embolism and the performance of open embolectomy ranged from 8 to 36 hours. The definitive diagnosis in all patients was made by pulmonary arteriography. Candidates for pulmonary embolectomy were selected by assessment of hemodynamic stuides: shock, arterial Po2 less than 65 mm. Hg, acidosis, pulmonary artery pressure higher than 20 to 30 mm. Hg, and central venous pressure elevated (patients in Class III or IV according to the Greenfield classification). The definitive indication for embolectomy was occlusion of the main pulmonary artery of more than 50 percent as well as occlusion of the right or left pulmonary artery. Of the seven patients operated upon between 1973 and 1974, three (43 percent) died in the early postoperative period. Between 1975 and 1976 the operative mortality rate in 17 patients was 23 percent (four patients). Our results show that prompt diagnosis of acute massive pulmonary embolism and better selection of patients may improve significantly the survival rate after open pulmonary embolectomy with CPB.

Assays of cephalosporin antibiotics administered prophylactically in open heart surgery. Determination of serum and tissue levels before, during and after cardiopulmonary bypass.

Twenty-eight patients who underwent open-heart surgery were divided into three groups, each of which received a different antibiotic from the cephalosporin series (cephalotin, cefazolin or cefamandole) in order to prevent infection. All antibiotics were given via intravenous infusion in a dosage of 2 g prior to surgery. To clarify the question of antibacterial activity under operative conditions with the cardiopulmonary bypass, the serum and tissue levels were determined before, during and after the surgical procedure. The effectiveness of the cephalosporins against bacteria most frequently encountered in open-heart surgery was demonstrated and substantiated by the serum and tissue concentrations. It became apparent that, in view of the favorable serum and tissue levels during and after the cardiopulmonary bypass, cefamandole should be considered the antibiotic of choice in preventing infections during open-heart surgery.

[Prevention using cephalothin in open-heart surgery]. / Die Cephalotin-Prophylaxe in der offenen Herzchirurgie.

To assay the efficiency of cephalothin prophylaxis in open-heart surgery, bacteriological examination of pressure-measurement units, intravenous catheter tips, and urine were made in 211 consecutive patients as well as blood cultures and sputum in suspected postoperative sepsis. Furthermore, cephalothin concentration in serum and tissue was determined in 12 consecutive adults with intact kidney function. Samples were taken before, during, and after the cardiopulmonary bypass, the tissue from the right atrium only before and after cardiopulmonary bypass. A high serum cephalothin level (80.04 +/- 23.35 microgram/ml) was measured 30 min after administration of 2 g cephalothin given as a 15-min-long i.v. infusion on induction of anesthesia. An antibiotic regimen - 4 X 2 g dose of cephalothin daily (first dose on induction of anesthesia) - provides a serum cephalothin level which is significantly higher than the cephalothin minimum inhibitory concentrations for most gram-positive organisms (0.475 microgram/ml) and so ensures an adequate antibiotic coverage throughout the surgical procedure and during the early postoperative phase of open-heart surgery.