RESUMEN
AIM: To review the surgical management of Wilms' tumour with persistent intravascular (vena caval +/- atrial) tumour extension. PATIENTS AND METHODS: Data were collected regarding operative details, tumour and 'thrombus' histology, and long-term outcome for patients with Wilms' tumour with cavo-artial extension. RESULT: From 1988 to 2004, 13 patients underwent treatment for Wilms' tumour with persistent intravascular extension. Preoperative chemotherapy was administered in 11/13 patients and postoperative radiotherapy in eight patients. Intravascular involvement was upto IVC (5), and right atrium (8) patients. Techniques employed for excision of intra-vascular component were: local cavotomy (3), extensive infra-diaphragmatic cavotomy without cardiopulmonary bypass (CPB) (1), and excision of cavo-atrial tumour with CPB (+/- hypothermia and cardiac arrest) (9). Mean time on CPB was 90 min. Caval repair was accomplished by primary repair (6) and pericardial graft in (7) patients. There were no intraoperative deaths and few major complications. Tumour thrombus contained malignant cells in 10/13 cases. Mean follow up has been for 55.4 months. To date, seven patients remain disease-free (one lost to follow up), disease recurred in five patients, three of whom have died. There were no symptoms related to the graft. CONCLUSIONS: Surgery for Wilms' tumour with persistent intravascular extension despite chemotherapy is technically challenging. CPB +/- hypothermia and cardiac arrest and extensive caval repair with a graft is safe and reliable in the long term.
RESUMEN
BACKGROUND AND AIM OF THE STUDY: Despite having been used in many thousands of implants, few published data exist concerning the ATS valve. Clinical data from ATS valve implants are presented, and the first two cases of mitral valve thrombosis with the ATS valve reported. Published data are also reviewed comparatively. METHODS: Between September 1998 and July 2000, 240 ATS valve prostheses were implanted in 199 patients, of whom 88 (36.6%) had mitral (MVR), 70 (29.1%) aortic (AVR), and 41 (17.1%) double valve replacements (DVR). Additional procedures were performed in 31 patients (15.6%). Transvalvular gradients and effective orifice areas were measured by transthoracic echocardiography. Total cumulative follow up of all patients was 241.6 patient-years (pt-yr); mean (+/-SE) follow up was 1.25+/-0.51 years. RESULTS: There were six early deaths (3.0%). Overall and event-free survival rates during follow up were 98.96+/-0.73% and 97.90+/-1.22%, respectively. Anticoagulant-related hemorrhage occurred in one patient. The global incidence of hemorrhagic complications was 0.41 per 100 pt-yr. One patient with AVR was reoperated on for periprosthetic leakage in the first postoperative week. Valve thrombosis occurred in two patients with MVR at 12 and 14 months postoperatively. The incidence of valve thrombosis in MVR patients was 1.84 per 100 pt-yr (0.82 per 100 pt-yr overall). Hemolysis was seen only in one patient, echocardiographic examination revealing periprosthetic leakage. CONCLUSION: The short-term outcome in 240 implants showed the ATS valve to be safe, to have a low incidence of complications, and to provide excellent hemodynamic performance.
