Elastic-Stable Chest Repair: Costal Plate Fixation for Sternotomy Nonunion.

Sterile sternotomy nonunion is a recognized complication after median sternotomy. It is defined as sternotomy that persists after 3 months without evidence of bony healing but with healing of the overlying soft tissues. It is a morbid condition associated with pain and sternal instability. We present two challenging cases of sterile sternotomy nonunion after cardiac operations that were treated successfully with novel methods adopted from the Elastic Stable Chest Repair for complex pectus deformity repair, using transverse costal to costal external cortical plates and bicortical screws, after debridement, autologous bone grafting and double loop wire sternal approximation.

Indirect re-implantation of the left coronary artery during aortic surgery.

OBJECTIVE: Indirect re-implantation of the left coronary artery (LCA) via an interposition graft simplifies difficult LCA re-implantation during aortic root replacement. Little information exists regarding the results of this technique. In this study, we report our experience. METHODS: Between January 2001 and July 2008, of 82 aortic root replacements, 24 (mean age 48.2 years, 83% male) used the indirect re-implantation technique. All case notes were retrospectively analyzed. Indications for operation were; aortic root aneurysm (n = 16), acute dissection (n = 6), existent homograft calcification (n = 1), failed Ross procedure (n = 1). Reasons for indirect re-implantation were: difficult LCA mobilization secondary to previous cardiac surgery (n = 7), short left main stem (n = 6), acute dissection (n = 6), adherence to surrounding tissues (n = 5). All patients had yearly CT or MRI follow-up. RESULTS: Mechanical and tissue valved conduits were implanted in 22 and two patients, respectively. Ten millimeters (n = 17) or 8 mm (n = 7) Dacron grafts were used for LCA re-implantation. Thirty-day mortality was 12.5%. Postoperative complications were: re-opening for bleeding (n = 2), pericardial effusion (n = 4), renal failure (n = 1). Over a median follow-up of 26 months (range 4 to 81), one developed a false aneurysm at the right coronary artery anastomosis five months postoperatively, which was subsequently repaired. All interposition grafts remained patent on MRI or CT. There were six late deaths. At median follow-up survival rate was 71%. CONCLUSIONS: The indirect re-implantation of the LCA during aortic root replacements is a reliable, safe, and effective method in dealing with the LCA in difficult circumstances. Survival at 26 months is equivalent to other series of similar patients.

A clinical and economic evaluation of fast-track recovery after cardiac surgery.

BACKGROUND: In the last 5 decades, the care of cardiac surgical patients has improved with the aid of strategies aimed at facilitating patient recovery. One of the innovations in this context is "fast-tracking" or "rapid recovery." This process refers to all interventions that aim to shorten a patient's stay in the intensive care unit (ICU) through accelerating the patient's transfer to a step-down or telemetry unit and to the general ward. METHODS: Patients were allocated to 2 groups. The fast-track group (n = 84) went through an independent theatre recovery unit (TRU). The patients were then transferred on the same day to an intermediate care unit and transferred on the following day to the ward. The intensive care group (52 patients) went to the ICU for at least 1 day, after which they were transferred to the ward. RESULTS AND DISCUSSION: The fast-track pathway significantly reduced the length of stay (LOS) in an intensive care facility (P < .001). The duration of intubation was reduced from a median of 4.08 hours (range, 1.17-13.17 hours) in the intensive care group to 2.75 hours (range, 0.25-18.57 hours) in the fast-track group (P < .001). However, the median values for total hospital LOS, incidences of complications, reintubation, and readmission were similar for the 2 groups. The incidence of failure in the fast-track group was 10%. The mean (SD) cost of the perioperative care was £4182 ± £2284 ($6683 ± 3650) for the fast-track patients, compared with £4553 ± £1355 ($7277 ± $2165) for the intensive care group. CONCLUSION: Fast-track recovery after cardiac surgery decreases the intensive care LOS and the total duration of intubation. It is a cost-effective strategy compared with conventional recovery protocols; however, it does not reduce the total hospital LOS or the incidence of complications.

Atrial myxomas: a single unit's experience in the modern era.

BACKGROUND: Although an atrial myxoma is the commonest cardiac tumor, it is still relatively rare, with an annual incidence of approximately 0.5 per million. In our unit, which performs 1000 major cardiac procedures per year, this equates to approximately 3 patients annually. We therefore sought to evaluate our experience of managing this type of tumor over the last 5 years. METHODS: A retrospective review was performed of prospectively collected data from the departmental database. We analyzed consecutive patients who were operated upon between 2002 and 2007. Three patients with a papillary fibroelastoma on histological examination were excluded from this study. RESULTS: We have performed excision of atrial myxoma in 18 patients. Twelve patients (66%) were female; the median age was 64 years (range, 35-80 years), and the median logistic euroSCORE was 5.22% (range, 1.51-27.82%). Fifteen patients (83%) were deemed urgent, 2 elective, and 1 emergency. Sixteen tumors (89%) were left sided. Symptoms attributable to the tumor were found in 16 of the 18 patients (embolic, n = 9; chest pain, n = 3; palpitations, n = 2; incidental finding, n = 2, others n = 4), and the mean time from diagnosis to operation was 3 days (range, 0-22 months). The median cardiopulmonary bypass time was 87 minutes (range, 28-228 minutes), with the median aortic cross clamp time being 61 minutes (16-175 minutes).The approaches used were transeptal via right atriotomy (n = 8), biatrial/Dubost (n = 4), left atrial (n = 4), and right atrial (n = 2); the interatrial septum was involved in 14 patients. The resultant defect was closed using a pericardial (n = 8) or prosthetic patch (n = 5) or directly sutured (n = 5). Concomitant procedures were performed in 8 patients (coronary artery bypass graft [CABG], n = 4; mitral valve replacement [MVR], n = 2; valve + grafts, n = 2). All tumors were completely excised.Postoperatively there were no deaths within 30 days of the procedure. Indeed, only 2 patients have died at 4 and 25 months postoperatively, respectively, both of unrelated causes. Median intensive therapy unit (ITU) stay was 2 days (range, 1-9 days), and median hospital stay was 10 days (range, 5-20 days). A permanent pacemaker was required in only 1 patient, and median blood loss was 340 mL (range, 140-1760 mL). Atrial fibrillation was the commonest complication affecting 6/18 patients (33%). CONCLUSIONS: Excision of atrial myxoma can be performed using a variety of intraoperative approaches and closure techniques, all with acceptable postoperative morbidity and low mortality rates. To date, no recurrences have been found at median 2-year follow-up.

Successful surgical repair of tricuspid valve endocarditis.

Surgical treatment of tricuspid valve endocarditis is challenging especially in intravenous drug users. We present a case of a 30-year-old male active drug user with anterior leaflet endocarditis treated successfully with valve repair. This was achieved through excision of the vegetation with part of the leaflet. Bovine pericardium was used to close the defect. The edges were reinforced with Teflon pledgeted polytetrafluoroethylene Gore-Tex neochordae (W.L. Gore & Associates, Flagstaff, AZ, USA). An annuloplasty ring was used to reinforce the whole annulus. Repair was competent and the patient recovered well. This technique is simple and effective and should be considered for similar cases.

Two-center prospective randomized controlled trial of Blake versus Portex drains after cardiac surgery.

OBJECTIVE: To compare the efficacy of two drain types after cardiac surgery in a randomized controlled trial, with primary outcome measure being depth of pericardial effusion 3 to 5 days after drain removal. METHODS: A prospective randomized controlled trial was conducted at two university hospitals. A total of 199 patients undergoing first-time cardiac procedures were randomized at surgery to receive either small-bore flexible Blake drains (19F) or larger Portex drains (28F). Drains were removed according to the study protocol and patients underwent echocardiography 3 to 5 days after drain removal to measure residual pericardial effusion. RESULTS: Ninety patients received Blake drains and 109 patients received Portex drains. There were no statistically significant differences in preoperative variables between the groups. There was no difference in the number of drains inserted per patient between groups (Blake 2.1 +/- 0.4 vs Portex 2.0 +/- 0.5). Mean difference in size of pericardial effusion between groups was 1.96 mm (95% confidence interval -0.02, 3.95 mm), which did not exceed the predefined non-inferiority margin of 10 mm. There was no significant difference in the mean maximal hourly drainage rate between groups (Blake 94.7 mL vs Portex 123.1 mL; P = .070) or in the total drainage rates (Blake 541 mL vs Portex 679 mL; P = .066). Although the Blake group had a higher percentage of patients with detectable effusion (46.3% vs 27.4%; P = .011) than the Portex group, there was no difference in need for late drainage of pericardial effusions (1.1% vs 1.9%) or insertion of further chest drains (8.8% vs 7.2%). CONCLUSION: The performance of small-bore Blake drains is not inferior to that of standard Portex drains after cardiac surgery.

Rapid development of fatal TB constrictive pericarditis after cardiac surgery.

We report the case of a 75-year-old male of Asian origin who developed TB constrictive pericarditis less than 6 weeks after CABG. He had no history of active TB, but did show a strong Heaf test reaction in 1987, following a period of weight loss. This was thought to be indicative of previous infection and was not actively treated. Cases of postcardiac surgery constrictive pericarditis have been reported in the literature, but to our knowledge, there is no report of development of TB constrictive pericarditis in such a short period following surgery.

Hemodynamic assessment of mitral mechanical prostheses under high flow conditions: comparison between dynamic exercise and dobutamine stress.

BACKGROUND AND AIM OF THE STUDY: The study aim was to compare the effects of dobutamine stress and exercise on prosthetic mitral valve hemodynamics. METHODS: Twenty-three patients who had recently (3 +/- 1 months) undergone mechanical mitral valve implantation were studied. Hemodynamic variables, two-dimensional echocardiographic and Doppler mitral/aortic flows were recorded at rest, and then repeated during exercise and dobutamine stress. The investigations were randomized place to determine which stress would be performed first. RESULTS: Heart rates and pressure drops rose significantly from resting values. At maximum stress, exercise produced maximum and mean pressure drops which were statistically greater than with dobutamine (19.4 +/- 6.0 versus 12.8 +/- 4.7 mmHg (p < 0.001) and 10.2 +/- 3.5 versus 6.8 +/- 2.8 (p < 0.01), respectively). Exercise was associated with statistically shorter diastolic filling times and higher transvalvular diastolic flow rates. Dobutamine produced a greater augmentation in mitral effective orifice area (EOA) (p < 0.05). The slopes of pressure drop/cardiac flow were calculated for stress type and shown to be significantly lower during dobutamine administration (p = 0.03). CONCLUSION: Normally functioning mitral prostheses can generate significant increases in valvular pressure drops under high flow conditions. Physiological differences exist between dobutamine stress and exercise when assessing diastolic filling. At a given flow rate, dobutamine produces a greater augmentation in the mitral EOA and a smaller drop in transvalvular pressure.

Effects of seven drugs of abuse on action potential repolarisation in sheep cardiac Purkinje fibres.

Seven drugs of abuse have been examined for effects on the action potential in sheep isolated cardiac Purkinje fibres. Phencyclidine (5 microM) induced a significant increase (30.7%) in action potential duration at 90% repolarisation (APD(90)). Similarly, 10 microM 3,4-methylenedioxymethamphetamine (MDMA, 'Ecstasy') induced a significant increase in APD(90) of 12.1%. Although Delta(9)-tetrahydrocannabinol (0.1 microM) induced a small, but statistically significant, 4.8% increase in APD(90), no effects were observed at 0.01 or 1 microM. Cocaethylene (10 microM) induced a significant shortening of APD(90) (-23.8%). Cocaine (up to 1 microM), (+)-methamphetamine ('Speed'; up to 5 microM), and the heroin metabolite, morphine (up to 5 microM), had no statistically significant effects. The possible significance of these findings is discussed in the context of other recognised cardiac effects of the tested drugs.

Preventing saphenous vein graft failure: does gene therapy have a role?

Gene therapy potentially allows local delivery and expression of cytokines, growth factors, and other mediators. In spite of increasing knowledge of the human genome, applications in clinical practice are only just beginning. The main limitations of effective clinical gene therapy are safety and low transfection efficiency. Saphenous vein grafts permit the transfection of the conduit ex vivo. This allows a variety of transfection techniques to be used, enhancing the transfection efficiency while limiting the risk of systemic complications. This review examines the potential mechanisms of gene delivery and genetic targets that may be applied to saphenous vein graft failure.

Casualties from terrorist bombings

The physical factors responsible for injury following an explosion in a room or building are: direct exposure to overpressure; blast-induced whole body displacement; impact od blast energized debris; burns from flash and hot gases. The patterns of injury seen in the casualties from four terrorist bombings are described to illustrate the types and severity of particular wounds. The most common fatal injury is brain damage; blast lung is uncommon in civilian terrorist bombings; flash burns, fractures, serious soft-tissue damage, and eardrum injuries are seen in people close to the bomb, who usually require hospital admission; many others taken to hospital can be treated for injury by debris and released. The environment and its internal structure and the position of the occupants of the space can influence the type and severity of injuries (AU)