Reduction of post-surgical pericardial adhesions using a pig model.

BACKGROUND: Post-surgical pericardial adhesions pose an increased risk of complications during redo sternotomies. Adhesive tissue formation is a normal response to tissue injury and involves complex patho-physiological processes including the actions of prostaglandins to cause plasma leakage and fibrin formation. The purpose of this study was to assess the ability of two non-steroidal anti-inflammatory agents (Indomethacin and Rofecoxib) and a barrier (Coseal, a polyethylene glycol) to limit adhesion formation following cardiac surgery in a pig model. METHODS: Forty-four piglets were allocated equally to four treatment groups: Group 1: Control, Group 2: intramuscular Indomethacin, Group 3: oral Rofecoxib and Group 4: Coseal sprayed on the heart. A full median sternotomy was performed on each animal and the heart exposed. Adhesions were induced by rubbing tissues with gauze, applying sutures and leaving blood in the pericardial sac before chest closure. Plasma inflammatory markers including prostaglandin E(2) and thromboxane B(2) were measured preoperatively and on Days 2, 5 and 10 after surgery. Eight animals from each group were slaughtered after 12 weeks and 3 after 25 weeks. Adhesions were assessed macroscopically and microscopically. RESULTS: Compared to the Control group, the extent of adhesions was significantly less in all other groups whilst adhesion density was least in the Indomethacin and Coseal groups. Indomethacin and less so Rofecoxib, inhibited the synthesis of prostaglandin E(2) and thromboxane B(2) but there were no significant changes in other inflammatory markers. CONCLUSIONS: We conclude that systemic Indomethacin, and locally applied Coseal are suitable methods to markedly reduce pericardial and retrosternal adhesions.

Intracardiac fistulae: a rare complication of infective endocarditis.

We present the case of a diabetic gentleman who was admitted to the hospital with an infected right foot. Swabs were positive for Staphylococcus aureus and Pseudomonas aeruginosa. His right big toe was amputated. Postoperatively, the patient experienced recurrent episodes of chest pain. He was therefore transferred to the coronary care unit, where he deteriorated rapidly. The patient was subsequently transferred to intensive care. Transthoracic and transesophageal echocardiograms revealed evidence of aortic dissection, but this finding was not confirmed in a computed tomography scan. The patient subsequently experienced cardiac arrest and died. The postmortem examination revealed no aortic dissection but did show a vegetation on the mitral valve with a fistula that tracked into a ruptured epicardium.

Surgical challenges in rheumatic heart disease in the Australian indigenous population.

BACKGROUND: Acute rheumatic fever, leading to rheumatic heart disease (RHD), is rare in Australia except amongst Aboriginal and Torres Strait Islander people. METHODS: Cardiac surgical procedures performed at Flinders Medical Centre on patients from the Top End of the Northern Territory from 1993 to 2008 were reviewed. This study compared Indigenous and non-Indigenous patients on short term morbidity and long term survival employing logistic regression and Cox proportional hazard models. We also outline the challenges of managing Aboriginal patients, as our unit services vast areas of northern Australia inhabited by Indigenous people. RESULTS: The total number of patients from the Northern Territory was 835. Amongst the Indigenous patients, there were 235 (55.6%) isolated coronary artery bypass graft procedures, 171 (40.4%) patients underwent isolated valvular surgery (91 mitral and 80 aortic), and 17 (4.0%) underwent combined valvular surgery with coronary artery bypass graft surgery. CONCLUSIONS: Aboriginal patients requiring valve surgery are younger and have greater comorbidity than non-Aboriginal people. Short term surgical results are similar to non-Aboriginal people but long term outcomes appear to be inferior. Age and socioeconomic conditions of Indigenous patients need to be considered. Cultural issues should be understood and acknowledged and surgery better focused around surgical units with appropriate infrastructure.

Methysergide-induced valvular heart disease: a report of 2 cases.

Methysergide is a serotonin antagonist and is used as a long-term prophylactic treatment for migraine. Although many patients experience adequate control of migraine episodes, methysergide has been reported to cause retroperitoneal and pleuropulmonary fibrosis. Cardiovascular side effects mainly in the form of valvular fibrosis have been less recognized. We report 2 cases of methysergide-related mitral valve fibrosis.

Primary solitary mediastinal mass lesions: a review of 37 cases.

BACKGROUND: Primary solitary mass lesions of the mediastinum, although relatively uncommon, encompass an interesting spectrum of pathologies. METHODS: A comprehensive retrospective review was undertaken of all cases of mediastinal lesions that presented to the two major thoracic surgical centres in North Queensland, Australia, over a 7-year period. RESULTS: Thirty-seven mediastinal mass lesions were managed over the period of the review. Over one-quarter of all cases were clinically silent, the pathology having been discovered incidentally during investigation for other reasons. Malignant thymoma was the single most common pathology, being present in 13 (35.1%) cases. A variety of other pathologies were encountered, including thymic cyst, bronchogenic cyst, neurofibroma, parathyroid adenoma, and lymphoma. Expeditious surgical resection of the lesions, once discovered, afforded good medium-term survival, even for those patients with malignant pathology. CONCLUSIONS: Prompt thoracic surgical referral with view to aggressive, early resection optimizes clinical outcome in the short and medium-term for patients presenting with mass lesions of the mediastinum.

Conservative management of a large oesophageal haematoma as a complication of systemic thrombolysis.

An acute coronary syndrome patient was treated with tissue plasminogen activator to produce thrombolysis. Six hours post-lysis, haematemesis occurred. Computed tomography (CT) revealed a large haematoma around the lower oesophagus and endoscopy showed a tear in the lower end of the oesophagus. This case represents an unusual complication of anticoagulation and thrombolysis associated with the management of acute coronary syndrome. Conservative management was successful.

Angiosarcoma of the right ventricle: a rare encounter.

We report a case of angiosarcoma involving the right ventricle. The patient was seen in our Cardiology Department and subsequently referred to our unit for surgery. He gave a 1-week history of lethargy, chest pain, breathlessness on exertion, fevers, and night sweats. Echocardiography and computed tomography of the chest showed a large pericardial effusion with multiple densities, raising suspicions of a hemorrhagic effusion. Surgical exploration showed an epicardial mass. Histopathology revealed angiosarcoma.