Late surgical treatment of tetralogy of Fallot.

AIM: To study early post-operative results and follow up of patients over a year old, operated on for tetralogy of Fallot (ToF). METHODS: This retrospective analysis included 22 patients (14 male and eight female) with a mean age of 9.18 ± 6.5 years (range 13.5 months to 26 years), who underwent complete repair of ToF between April 2003 and June 2009. Data from patients' records, pre-operative cardiac catheterisation studies, operative intervention, and pre-operative and postoperative two-dimensional echocardiographic studies were reviewed. All patients underwent complete repair including closure of ventricular septal defect (VSD). A trans-annular patch was used in 12 patients while an infundibular patch was used in 10 others. Patients were evaluated one, three, six and 12 months after surgery, and annually thereafter. The duration of follow up was from eight months to six years post surgery. RESULTS: Classical ToF was found in 10 patients. Twelve cases had associated anomalies: two patients with hypoplastic pulmonary artery branches, two with arterial duct malformations, and eight had proximal stenosis of the left branch of the pulmonary artery. NHYA class distribution was as follows: class I: two patients; class II: five subjects; class III: 10 patients; class IV: five subjects. The mean stay in hospital was 15 ± 7 days. Two patients (9%) died during the early post-surgical period. At a mean follow-up interval of 32 ± 9 months, all patients were asymptomatic and in NYHA class I. No late deaths occurred. In three patients, we registered isolated monomorphic ventricular extrasystoles. The right ventricle outflow tract (RVOT) pressure gradient was 29 ± 1.5 mmHg in the acute post-surgical period and it did not change significantly during follow up. The right ventricular function was defined as normal in 95% of the patients in the study and was mildly depressed in 5%. CONCLUSION: Even if treated later in life, our study showed very good surgical results of patients with ToF.

Pattern and clinical aspects of congenital heart diseases and their management in Cameroon.

UNLABELLED: The aim of the study was to investigate the occurrence, pattern and clinical aspects of congenital heart diseases and their management in Cameroon. In this multicentred retrospective study from January 2006 till November 2009, out of 51,636 consulting in three referral centres, 505 were recruited. All the patients presented with the following symptoms: cyanosis, clubbing, frequent respiratory tract infections, failure to thrive, growth retardation, precordial murmur and dyspnoea. Patients were sent for the screening of congenital heart disease. After the comprehensive Doppler echocardiography, the recruited patients were diagnosed with congenital (67.2%) and in few, acquired heart disease. Heart murmur, dyspnoea and growth retardation was the triad mostly encountered. The occurrence of congenital heart diseases in Cameroon is 9.87%. In Douala, isolated ventricular septal defect, interatrial septal defect and isolated pulmonary valve stenosis were more diagnosed than in Shisong (P <0.05) and Yaoundé (P <0.05). In Yaoundé, there were more cases of common arterial trunk, transposition of great arteries with ventricular septal defect and Ebstein disease than in Shisong (P <0.05) and Douala (P < 0.05). At Shisong, tetralogy of Fallot, arterial duct, coarctation of the aorta, congenital mitral valve regurgitation, atresia of the tricuspid valve, double outlet right ventricle, anomalous pulmonary venous return and left isomerism were more diagnosed than in Yaoundé (P <0.05) and in Douala (P <0.05). Thirty percent of the patients were operated abroad; 9% in the cardiac centre. CONCLUSION: Our data show that congenital heart diseases are represented in Cameroon as in the literature; isolated ventricular septal defect is the predominant pathology.

Pexelizumab and survival in cardiac surgery.

A recent international consensus conference on the reduction in mortality in cardiac anesthesia and intensive care included pexelizumab, a recombinant monoclonal antibody to the component 5 of the complement system, among the ancillary (i.e. non-surgical) drugs/techniques/strategies that might influence survival rates in patients undergoing cardiac surgery. The consensus conferences state that "A subgroup analysis of a meta-analysis of randomized controlled trials suggested that pexelizumab might reduce mortality (longest follow up available, up to 6 months) in patients undergoing coronary artery bypass grafting. Pexelizumab was not included among the most important topics of the consensus conference as it was the only topic that did not receive a sufficient percentage of votes from the audience (32% at the first round and 35% at the second round). Pexelizumab is no longer on the market, however, the concept of reducing the generalized inflammatory process accompanying cardiopulmonary bypass deserves further investigation.

The effects of load on systolic mitral annulus movements by tissue Doppler imaging in cardiac surgery patients.

AIM: The main indexes of ventricular function used in clinical practice are strongly influenced by the ventricular load conditions. Tissue Doppler imaging (TDI) has been reported to be a powerful modality that enables assessment of ventricular wall motion with a high temporal and spatial resolution. The study of the systolic movements of the mitral annulus has been proposed as a valid index of myocardial contractility. The aim of this study was to verify if the systolic movements of the mitral annulus by TDI are load-dependent in patients undergoing coronary artery bypass grafting. We evaluated the effect of load changes on systolic (S(M)) and isovolumic (S(IVC)) velocity waves, and on isovolumic acceleration (S(IVA)). METHODS: Twenty-three patients undergoing coronary artery bypass grafting were evaluate. Load was changed with a rapid infusion of 7 cc/kg of a gelatin solution. The sample volume of TDI was placed at the lateral side of the mitral annulus in the mid-esophageal 4-chamber view. RESULTS: The increase preload resulted in a statistically significant increase of S(M) (8.7+/-1.04 cm/s vs. 9.99+/-0.88 cm/s P=0.01), and a statistically significant increase of S(IVC) (5.65+/-1.95 cm/s vs. 6.75+/-1.53 cm/s P=0.03). S(IVA) does not appear to be changed after the increase of preload (203.45+/-45.69 cm/s(2) vs. 211.41+/-71.28 p=0.81). CONCLUSION: Only S(IVA) seems to be an independent index of cardiac functionality in cardiac surgery patients and appears to be an optimum index in the clinical evaluation of these patients.

Aortocoronary bypass grafting in high-risk patients over 75 years. Propensity score analysis of on versus off-pump, early and midterm results.

AIM: Bypass surgery in high risk patients over the age of 75 results in increased mortality and morbidity, which may be also related to the cardiopulmonary bypass system. METHODS: Using the propensity score analysis, we have selected two homogeneous groups of high-risk elderly patients undergoing coronary surgery: 41 patients operated with cardiopulmonary bypass- coronary artery bypass graft (CPB-CABG), and 78 patients operated without cardiopulmonary bypass (off-pump coronary artery bypass graft, OPCABG). All preoperative and operative variables were similar and outcomes were compared. RESULTS: Perioperative mortality was higher in the patient group operated with CPB (12.2%) as compared to patients operated without CPB (1.3%, P = 0.01). Perioperative complications were more frequent in the CPB-CABG group. Logistic regression analysis showed that avoiding CPB was an independent protective factor for mortality and morbidity. Midterm survival, freedom from angina, freedom from reintervention, and Canadian Cardiovascular Society (CSS) class were comparable between the 2 groups. CONCLUSION: OPCABG is safe in the high risk elderly population and significantly reduces postoperative mortality and morbidity. There are no differences in midterm results between the 2 groups of patients in our study.

Octreotide in the management of postoperative chylothorax.

Chylothorax (KT) may be a complication of thoracic surgery. Its management is not well established and may comprise dietary interventions and surgery. The effectiveness of somatostatin and its analogues has been reported, although their mechanism(s) of action is unclear. We report our experience with octreotide in a series of patients with postoperative chylothorax. Eight patients with KT were treated with a continuous intravenous infusion of octreotide (OCT) at a starting dose of 0.5 microg/kg/hr. They were compared with four additional patients with KT who were treated according to the conventional approach. After a mean of 3.3 +/- 1.9 days of treatment, fluid discharge diminished dramatically. In all patients, fluid losses stopped by postoperative day 10.5 +/- 2.9 and chest tubes could be removed after 12.8 +/- 4.1 days. Compared to a small group of historical controls, OCT reduced significantly the total fluid losses (141.1 +/- 89.3 vs 396.7 +/- 151.0 ml/kg; p = 0.003) and the postoperative length of stay (p = 0.05). No patients in the group treated with OCT required parenteral nutrition (compared to all four of the controls; p = 0.002) and/or thoracenteses (compared to two of four controls). In postoperative KT, OCT seems to be at least as effective as the conventional approach. Furthermore, OCT may reduce total fluid losses and postoperative length of stay. This may have a beneficial effect on the risk of complications and on hospital costs.

Association of Children with Heart Disease in the World: 10-year experience.

Thousands of children live in developing countries with untreated but correctable congenital heart disease (CHD), and most of them will die simple because they live in poor countries that do not have suitable medical/surgical facilities. The aim of the Association of Children with Heart Disease in the World is to support the operatory and teaching activities of a group of voluntary doctors engaged in the management of children with CHD in developing countries. Since 1992, the association has obtained 160 grants for foreign doctors who have been trained in our hospitals; performed 75 missions abroad, with more than 2150 cases evaluated and 404 cardiac operations performed; obtained millions of dollars worth of donated medical equipment; and constructed two cardiac surgery departments in Syria and Cameroon. Many efforts have been made, but much more can be done as we attain more experience and develop better coordination and collaboration between the international groups engaged in this emerging social need.

Mortality and morbidity from intra-aortic balloon pumps. Risk analysis.

BACKGROUND: The purpose of this study, was to assess the incidence of and predictors for mortality and morbidity in patients who required postoperative intra-aortic balloon pump (IABP) support. METHODS: We have retrospectively estimated 116 patients and data were statistically analyzed, and significant variables were evaluated with multivariate analysis. RESULTS: Mortality rate was 57.8% (67 patients). Nineteen patients (16.3%) had major vascular complications: 12 patients (10.3%) limb ischemia, 1 patient (0.9%) aortic dissection, 6 patients (5.2%) mesenteric infarction. Thirty patients (25.8%) had minor vascular complication: 23 patients (19.8%) bleeding from insertion site, 7 (6%) patients infection of insertion site. Limb ischemia was resolved by IABP removal (10 patients), thrombectomy (2 patients). No patient required limb amputation. Sixty patients (51.7%) had renal insufficiency, of which 40 patients needed dialysis. Fifteen patients (10.3%) had neurological complications, 13 patients (11.2%) thrombocytopenia and 5 patients (4.3%) sepsis. CONCLUSIONS: The incidence of IABP insertion in our institution was 1.5%. Mortality rate is similar to mortality of other studies in which the IABP has been inserted in the postoperative period. We have found that timing of IABP insertion, thrombocytopenia, presence of peripheral vascular disease and the redo intervention are independent predictors of mortality. We also found that female sex, diabetes, history of cigarette smoking and preoperative use of antiplatelet drugs are independent predictors of limb ischemia. The following factors are instead independent predictors of renal insufficiency: postoperative ejection fraction lower than 40% and non use of dobutamine in the postoperative period.

Haemolysis due to active venous drainage during cardiopulmonary bypass: comparison of two different techniques.

To facilitate mini-access for cardiac surgery, two different methods of active venous drainage are used: vacuum assisted drainage and centrifugal pump aspiration on the venous line. The aim of this study was to compare the haemolysis produced using these two techniques. From June to December 1999, 50 consecutive patients were operated on using a ministernotomy. All of these patients had valvular surgery for either valve repair or valve replacement (9 MVRepair, 11 MVR, 29 AVR, 1 AVR + MVR). They were randomized into two groups: Group A, 25 patients who underwent surgery where vacuum assisted drainage was used, and Group B, 25 patients where kinetic asssisted venous drainage with centrifugal pump venous aspiration was used. Patient characteristics of both groups were similar for age, gender, body weight, body surface area, height, cardiopulmonary bypass (CPB) time, aortic crossclamp time, priming volume, cardioplegia volume, haemoglobin concentration, haematocrit, serum creatinine, bilirubin, lactate dehydrogenase (LDH), serum glutamic oxaloacetic transaminase (sGOT), serum glutamic pyruvic transaminase (sGPT), aptoglobin, reticulocytes, and platelet count. We checked all these laboratory parameters preoperatively, at the end of CPB, and 2 and 24 h after operation. We also checked haemoglobinuria at these same time points. We assessed blood loss at 6, 12, and 24 h after the operation and calculated total postoperative bleeding. There was a tendency towards a greater increase in LDH, sGOT and sGPT in Group A more than in Group B, but these data did not reach statistical significance. Platelet count was always lower in Group A and aptoglobin increased in Group A more than in Group B. More patients in Group A had haemoglobinuria. These findings indicate that haemolysis is increased more in patients treated with vacuum assisted drainage, when compared to the rise in haemolysis in those treated with centrifugal pump venous drainage. Total bleeding is also greater in Group A.

Heparin-coated circuits for high-risk patients: a multicenter, prospective, randomized trial.

BACKGROUND: Heparin-coated circuits (HCCs) in low-risk cardiac patients who have coronary revascularization have a limited impact on postoperative outcome. In this prospective, randomized investigation, we studied high-risk patients who had cardiac operations with or without HCCs. METHODS: A total of 886 patients who had cardiac operations with cardiopulmonary bypass and at least one patient-related or procedure-related risk factor were enrolled in a multicenter study. They were randomly allocated to have cardiopulmonary bypass with Duraflo II HCCs (HCC group, n = 442) or conventional circuits (control group, n = 444). Postoperative outcome was investigated with respect to the occurrence of organ dysfunction. RESULTS: HCCs are associated with a shorter intensive care unit and postoperative hospital stay and with a lower rate of patients having a severely impaired clinical outcome (stay in intensive care unit for more than 5 days or death) (relative risk 0.66, p = 0.045). Lung dysfunction rate was significantly lower for the patients in HCC group affected by chronic obstructive pulmonary disease or who had mitral procedure (relative risk, respectively, 0.31, p = 0.018 and 0.05, p = 0.02). Renal dysfunction rate was significantly (p = 0.05) lower for diabetics in the HCC group (relative risk 0.28). CONCLUSIONS: When HCCs were used postoperative times decreased and they had a protective effect on lung and kidney function in high-risk patients.

Beneficial effects of Duraflo II heparin-coated circuits on postperfusion lung dysfunction.

BACKGROUND: Heparin coating of the cardiopulmonary bypass circuit reduces the activation of the terminal part of the complement cascade. Conflicting data are reported concerning neutrophil activation and postoperative lung dysfunction. In this study, we compared three different types of oxygenator: a bubble oxygenator, a conventional hollow-fiber oxygenator, and a heparin-coated oxygenator and circuit. METHODS: Sixty patients undergoing myocardial revascularization were randomly assigned to one of three oxygenator groups. All the patients were free from preoperative lung dysfunction. Lung function was studied with repeated measurements of respiratory index, intrapulmonary shunt, alveolar dead space, ventilation/perfusion ratio, and static thoracopulmonary compliance. RESULTS: Immediately after cardiopulmonary bypass, the intrapulmonary shunt and respiratory index values in the bubble oxygenator and hollow-fiber oxygenator groups increased more than those in the heparin-coated oxygenator group. In the intensive care unit, the between-group difference in intrapulmonary shunt disappeared, but the within-group difference in respiratory index (from baseline) remained for the bubble oxygenator group. The other three variables did not significantly differ between groups. Intubation time and stay in the intensive care unit did not differ between groups. CONCLUSIONS: Heparin-coated circuits exert a protective effect on pulmonary function. However, their use did not modify the postoperative clinical course of patients with normal lung function preoperatively.

Renal effects of low dose aprotinin in pediatric cardiac surgery.

Two groups of 15 children aged from 15 days to 6 years, undergoing surgery on cardiopulmonary by-pass for congenital heart disease have been retrospectively analyzed. Group A received a low-dose aprotinin treatment (30,000 KIU/kg in the priming solution); group C (control group) did not receive any aprotinin. Groups were homogeneous for pathology, cardiopulmonary by-pass time, aortic cross-clamping time, cyanotic/acyanotic patients ratio, temperature during cardiopulmonary bypass. A number of postoperative data were measured: activated clotting time was without any difference between aprotinin-treated and control patients; the same went for temperatures, urine output, intubation time, stay in Intensive Care Unit, coagulation tests, platelet counts, hematocrit, survival rate, and blood loss. Serum creatinine levels were significantly higher in group A than in group C both at the arrival in Intensive Care Unit (0.81 +/- 0.27 vs 0.66 +/- 0.12, p = 0.032) and in the first postoperative day (1.01 +/- 0.5 vs 0.72 +/- 0.19, p = 0.038). BUN was significantly higher in group A vs group C in the first postoperative day (43.6 +/- 21.1 vs 33.9 +/- 16.7, p = 0.043). We conclude that low-dose aprotinin did not reduce postoperative bleeding; we cannot exclude that higher dosages could be more effective, but the evidence of a moderate tubular function impairment suggests caution in using high-dose aprotinin in children.

[Surgical technic in the treatment of pectus excavatum]. / Note di technica chirurgica nelk trattamento del pectus escavatum.

19 patients subjected to surgery for correction of p.e. have been followed up. The technique adopted is described. The results show the importance of early correction of the malformation and allow the indication to be extended to purely aesthetic needs.