International retrieval of adults on extracorporeal membrane oxygenation support.

A retrieval service was established in New South Wales to provide mobile extracorporeal membrane oxygenation support to patients with severe, acute cardiac or respiratory failure. This service has also retrieved four adult patients from Nouméa, New Caledonia to Sydney on extracorporeal membrane oxygenation support, which are the first international retrievals of this type from Australia. We discuss our experience with these patients, three of whom survived to hospital discharge. However, one patient referred from New Caledonia died before extracorporeal membrane oxygenation could be established.

Composite graft replacement of the aortic root after previous cardiac surgery: a 20-year experience.

BACKGROUND: An aging population and prolonged survival of patients after cardiac operations has meant that composite aortic root replacement after previous cardiac operation is being performed with increasing frequency. METHODS: From January 1979 to July 1999, 32 patients underwent "reoperative" composite replacement of the aortic root at our institution. Previous operations were 16 aortic valve replacement, 9 coronary artery bypass grafting, 5 repair aortic dissection, and 7 others. Indications for operation included ascending aortic aneurysm in 16 patients, ascending aortic dissections in 10 patients, and other in 6 patients. RESULTS: The unit elective mortality was 3 of 26 (11.5%). One surgeon's elective mortality was 1 of 22 (4.6%). The unit emergent mortality was 6 of 6 (100%). There has been one late death. Morbidity was low. CONCLUSIONS: Reoperative aortic root replacement is a technically demanding procedure, but expertise in the area achieves low elective mortality. Consideration should be given to aortic root replacement at the initial procedure. Close follow-up of postcardiac operation patients is necessary to proceed with elective aortic root replacement if indicated. Emergent presentation in the reoperative setting has a very poor prognosis.

Video-assisted thoracoscopy.

Recent advances in video-imaging and minimally invasive surgical instrumentation have expanded the role of thoracoscopy in the diagnosis and treatment of intrathoracic conditions. This prospective study describes the use of video-assisted thoracoscopy (VAT) in 100 consecutive patients. There were 70 males and 30 females with a mean age of 54.6. They underwent 103 VAT procedures with 41 thoracoscopic biopsies of lung, pleural, chest wall and mediastinal abnormalities, 32 for treatment of recurrent or persistent pneumothorax, 18 for thoracoscopic assessment of pulmonary and pleural tumours and 12 for thoracoscopic resection of peripheral lung lesions, chest wall, mediastinal and pleural tumours. Eighty-one patients had VAT procedures alone while the remaining 19 had VAT proceeding to thoracotomy. The mean operating time for VAT alone was 51 min (range 30-135 min). There were no operative deaths. There were 8 significant complications from which patients recovered fully. Patients who underwent VAT alone were shown to have earlier postoperative mobilization, reduction in parenteral analgesic requirement and reduced length of hospital stay compared to patients undergoing additional thoracotomy. A telephone survey of patients on returning home showed that patients undergoing VAT alone returned to full activity earlier than those who had thoracotomy (mean 9.0 vs mean 19.4 days). This study confirms that VAT is a safe and effective procedure in the management of pulmonary, mediastinal and pleural disease and the treatment of persistent and recurrent pneumothorax. Its role in the resection of pulmonary malignancy remains to be defined.

Acute myocardial ischaemia and cardiogenic shock after percutaneous transluminal coronary angioplasty; risk factors for and results of emergency coronary bypass.

Between 1 September, 1980 and 1 January, 1989, 4142 patients underwent percutaneous transluminal coronary angioplasty (PTCA). We retrospectively studied the 155 [3.7%; 119 males, mean age 53.4 years, (range 33-78 years) and 36 females, mean age 59.6 years (range 40-74 years)] who required urgent coronary artery bypass grafting (CABG) (Group I) and a select control group of 155 patients, in whom PTCA was performed without complications (Group II). Before PTCA, 14 Group I and 42 Group II patients had angina Class II, and 78 Group I and 49 Group II patients had angina class IV (chi 2-test, P less than 0.05). There were 445 complications in the 155 group I patients: 303 (68%) early (during PTCA) and 141 (32%) late (within 24 h). On arrival in the operating room 126 patients were stable; five were in cardiac arrest and 19 in cardiogenic shock (AS-group; 24 patients). In the AS-group and control group, respectively, angina Class II occurred in 2/24 (8.3%) and 42/155 (27.1%) patients, angina Class IV in 14/24 (58.3%) and 49/155 (31.6%) (P less than 0.05), single-vessel disease in 8/24 (33.3%) and 85/155 (54.8%), triple-vessel disease in 7/24 (29.2%) and 23/155 (14.9%) (P less than 0.05); elective PTCA in 11/24 (45.8%) and 92/155 (59.4%), urgent PTCA in 12/24 (50%) and 48/155 (30.9%) (P less than 0.05), PTCA of the left anterior descending artery (LAD) in 18/24 (75%) and 86/166 (51.8%), PTCA of the right coronary artery in 2/24 (8.3%) and 47/166 (28.3%) (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Björk-Shiley strut fracture and disc escape: literature review and a method of disc retrieval.

Embolization of a prosthetic valve poppet is a rare but life-threatening event. It was reported sporadically before the introduction of the Björk-Shiley 70-degree convexoconcave prosthesis in 1980. Since that time, there have been a large number of reported mechanical failures with disc escape. The rate for the 29-mm to 33-mm mitral valves is estimated as 5.2%. In 29 of 35 patients (including the 2 presented here) in whom the site of disc lodgment could be determined, the disc was in the descending or abdominal aorta. Fifteen of these patients died. Six survivors had the disc removed at the same operation and 6 at a later operation. In 2 patients, the disc was not removed. In 2 patients in whom the disc was not removed initially, it was thought to contribute to postoperative complications. Two more cases of structural failure of the Björk-Shiley convexoconcave prosthesis are presented. A transpericardial approach to the descending aorta on bypass is described. It allows easy removal of the disc and eliminates the need for a second operation.

Blunt traumatic rupture of the heart. Successful repair of simultaneous rupture of the right atrium and left ventricle.

A case is reported of a 48-year-old man who sustained simultaneous rupture of the right atrium and left ventricle following blunt trauma in a motor vehicle accident. Rupture of one or more cardiac chambers in blunt cardiac trauma is not uncommon. However, survival to reach the hospital is rare. The clinical features of cardiac rupture are those of pericardial tamponade or hemorrhage, depending on whether or not the pericardium is intact. Successful management of cardiac rupture in the few reported survivors has depended on a high index of suspicion when signs of tamponade occur after blunt injury. Prompt exploration is essential, as few patients survive longer than 60 minutes after injury. Ready availability of cardiopulmonary bypass is emphasized. Atrial rupture can be managed without bypass, but left ventricular rupture, as in this case, would seem impossible to repair without it.