[Chronic central cyanosis in children; always an indication for further diagnosis]. / Chronische centrale cyanose bij kinderen; altijd een reden voor nadere diagnostiek.

A girl and a boy, both aged 4 years, had displayed a blue discolouration of the skin for several years. In the girl, electrocardiography and roentgenography of the chest revealed no abnormalities; in the boy, the cardiac murmur was attributed to an insignificant ventricular septal defect. Further examinations were performed only when the children developed sleeping problems and decrease of exercise tolerance, respectively. In both, a right-left shunt was discovered caused by a direct communication between the right pulmonary artery and the left atrium, and tetralogy of Fallot, respectively. Both patients' condition improved after operation. Chronic central cyanosis in a child constitutes an indication for consultation of a paediatric cardiologist.

Complete arterial revascularization using the mammary Y-graft.

The recent trend is to revascularize the entire heart with arterial grafts. Five selected patients were operated using the mammary Y-graft for complete arterial revascularization. The immediate postoperative courses were uneventful. One patient presented five months later with atypical angina and a string phenomenon at the distal part of the Y-graft on catheterization, without ischemic changes on stress test. The four other patients had no complaints and no ischemic changes on stress test nine months to 4.5 years later. Using the mammary Y-graft a complete arterial revascularization can be accomplished.

Coarctation developing after arterial switch repair for transposition of the great arteries.

We describe 2 patients with simple transposition of the great arteries in whom coarctation of the aorta developed after uncomplicated arterial switch operation. Both patients showed no symptoms or signs of this coarctation at the time of arterial switch operation.

Delayed sequelae of penetrating chest trauma: a plea for early sternotomy.

Penetrating wounds of the anterior chest wall are often associated with cardiac tamponade. Eighty to ninety percent of stab wounds to the heart result in acute tamponade, whereas delayed cardiac tamponade or hemothorax are rare, but hurtful for the patient. Of the cases reviewed, fifty percent of the patients who underwent sternotomy required repair of cardiac injuries. The presented case report adds further justification for early sternotomy in case of precordial penetrating chest injury in the danger zone.

Experience and early results of second reoperations for coronary artery disease. Should patent vein grafts be replaced during reoperation?

Reoperation for coronary artery disease has become a routine procedure; however, a second reoperation is exceptional. In this report we describe our experience with 16 patients undergoing a second reoperation for coronary atherosclerosis. The absence of operative mortality is certainly related to the patient selection. The number of patients is still too small to draw major conclusions. Striking, however, is that the first reoperation was usually done for angina because of progression of atherosclerosis in the native coronary system and the second reoperation was done because of graft failure. This experience supports the idea that the replacement of old, even patent, venous grafts and the choice of the best available conduits are of great importance at the first reoperation and may prevent a second reoperation.

Sternal closure: comparison of two techniques.

A clinical trial was performed to evaluate sternal closure with the controlled tension osteosynthesis system and closure with twisted stainless steel wires. Some 451 consecutive patients who underwent isolated coronary bypass surgery between January 1991 and December 1991 were subdivided into three groups. Patients in group A (94 patients) and group B (98 patients) were all operated on by one surgeon, to reduce variability before, at the time of and after surgery, which might influence sternal wound healing. To exclude a possible preference of the surgeon in the study, group C was formed, consisting of 259 patients operated on by other hospital surgeons. In groups A and C, sternal closure was performed with the controlled tension osteosynthesis system. In group B, sternal closure was performed with (six) twisted stainless steel wires. Among groups A, B and C, no statistical significant difference could be found between the rate and the type of sternal wound complications. Despite this finding, there were significantly more reoperations, a longer cross-clamp time and more extensive use of the internal mammary artery as a graft in group B. Despite the non-randomization of the study, and the small patient numbers being a limitation, the use of the controlled tension osteosynthesis system in adults did not result in a decrease of early sternal wound complications.

Prevention of adhesion formation around the internal mammary artery pedicle by Gore-Tex surgical membrane. An experimental study in goats.

The effects of wrapping the internal mammary artery in Gore-Tex surgical membrane on the formation of adhesions were investigated. In seven goats both internal mammary arteries were dissected free from the thoracic wall. In six goats the internal mammary arteries were wrapped in Gore-Tex surgical membrane. In the remaining animal both arteries were removed and used as controls. After 6 months the goats were reoperated and it was found that the wrapped segments of all arteries were completely free of adhesions, whereas the non-wrapped segments showed severe adhesion formation. Histologic examination could not detect differences between the wrapped arteries and the controls. One of the 12 wrapped arteries was occluded by a longer existing thrombus, which is attributed to the surgical technique and the fact that postoperatively no anticoagulation was given. The beneficial effect of the use of Gore-Tex surgical membrane on the prevention of adhesion formation is excellent and this implies that it could be used in coronary artery bypass operations, thus reducing the chance of damage to the bypass in case of reoperation.

Early results with bilateral internal mammary artery grafting in coronary reoperations.

In recent years, use of the internal mammary artery (IMA) as first graft of choice has been expanded with bilateral and sequential grafts in primary myocardial revascularization. The use of bilateral IMA grafts in reoperation has seldom been reported. The experience and early results with bilateral IMA grafting in 47 patients undergoing coronary reoperation are described. Hospital mortality was 6.3%. Four patients had postoperative signs of low cardiac output, and 4 had a perioperative myocardial infarction. At follow-up (18 +/- 18 months), 2 cardiac-related, late deaths were noted. Thirteen patients (29%) improved 1 New York Heart Association class, and 28 (63%) improved > 1 class. In 1 of 44 surviving patients, operation did not result in a decrease in angina. On the basis of the early results, the bilateral use of the IMA in coronary reoperation appears justified.

Management of postcardiotomy cardiogenic shock with a new pulsatile ventricular assist device. Initial clinical results.

The authors began ventricular assist pumping as treatment for postcardiotomy cardiogenic shock in November 1988 with a new automated pulsatile support system, the ABIOMED BVS 5000 Bi-Ventricular Support System. Five patients (0.6% of total cardiac surgery patients) have been placed on support, four after coronary artery bypass grafting, and one after bypass grafting and mitral valve repair. All patients were refractory to pharmacologic and intraaortic balloon pump therapy. Three patients had left ventricular support and two had biventricular support. Four patients were successfully weaned, and three are long-term survivors. Duration of support ranged from 39 to 118 hours (mean, 89.4 hours). Resternotomy was performed in four patients: twice for hemostasis, once for tamponade, and once for inadequate left ventricular drainage. Three patients, two nonsurvivors and one survivor, had perioperative myocardial infarctions. No device related thromboembolic complications, hemolysis, or infection were experienced. Follow-up at more than 1 year demonstrated that all patients are in NYHA Class 1. Ventricular assist pumping with the ABIOMED BVS 5000 Bi-Ventricular Support System is an effective treatment for postcardiotomy cardiogenic shock.

[Aortopulmonary window. The need for early surgical correction]. / Aortopulmonaal venster. Noodzaak tot vroege operatieve correctie.

The diagnosis of aortopulmonary window may be problematical. In 7 patients who had undergone operative closure of an aortopulmonary window the diagnostic and operative techniques, the operative findings, and the postoperative course were retrospectively determined. It appeared that the diagnosis is difficult and that cardiac catheterization with angiocardiography is the most accurate diagnostic technique. Good results of operative correction depend on the timing of the operation (preferably before the first year of life), the operative technique, and the severity of additional anomalies of the heart and great vessels. Delay of surgical correction leads to pulmonary hypertension, caused by irreversible pulmonary vascular disease.

Unusual haemostasis for an unusual tumour. Catastrophic bleeding from a tactile neurofibroma affecting the thoracic vertebrae. Case report.

The symptomatology of a typical acute descending thoracic aorta dissection was imitated by profuse haemorrhage caused by a benign tumour composed almost exclusively of Wagner-Meissner like tactile corpuscles and fatty tissue. The tumour caused extensive destruction of the bodies of the fifth and sixth thoracic vertebrae at the level of the vertebro-costal articulation. Emergency cross clamping of the descending aorta and haemostasis of the bleeding from osteal defects by tamponade with bone polymethyl methacrylate appeared the only way to control the life threatening haemorrhage. It seems that an intrathoracic tactile neurofibroma with a similar case history has not been reported till now.