Concomitant coronary artery revascularization and right pneumonectomy without cardiopulmonary bypass.

Combined coronary artery bypass grafting (CABG) and pneumonectomy has a high morbidity and mortality rate, especially when the right lung has to be removed. A patient is described who underwent a CABG operation through a midline sternotomy without the use of cardiopulmonary bypass (CPB), and a right pneumonectomy through a right lateral thoracotomy in one operative session. To our knowledge, this is the first case in which this operative strategy was employed. CABG operations without the use of CPB might put concomitant lung surgery in a new perspective.

Predictors of neurological morbidity after coronary artery bypass surgery.

OBJECTIVE: The aim of this study was to analyze the postoperative neurological complications after myocardial revascularization. METHODS: We analyzed the pre-, peri- and postoperative data of 3834 patients who underwent a primary isolated bypass grafting between January 1987 and December 1995. Postoperative neurological complications (A) were divided into mild complications (B) and major complications (C). RESULTS: The incidence of A increased, from 1.4% to 3.0%. Unifactor risk analysis identified: age > 75 years, peripheral vascular atherosclerosis, neurological pathology, aorta-pathology and perioperative myocardial infarction as risk factors for A. Perioperative myocardial infarction and neurological pathology for B; age > 75 years, peripheral vascular atherosclerosis, neurological pathology, perioperative myocardial infarction and aorta pathology for C. Multifactor risk regression analysis identified peripheral vascular atherosclerosis, neurological pathology, aorta-pathology, perioperative myocardial infarction and the time cohort 1993-1995 as independent predictors for A; perioperative myocardial infarction and the time cohort 1993-1995 for B; neurological pathology, aorta-pathology and perioperative myocardial infarction for C. CONCLUSIONS: Peripheral vascular atherosclerosis, neurological pathology, aorta-pathology, the occurrence of a perioperative myocardial infarction and the time cohort 1993-1995 are identified as independent risk factors for neurological complications.

Myocardial revascularization in patients < or = 45 years old: evaluation of cardial and functional capacity, and return to work.

OBJECTIVE: To investigate whether patients < or = 45 years old benefit from myocardial revascularization, measured by New York Heart classification, functional status and return to work. METHODS: The data of 188 consecutive patients 45 years old and younger, and who were undergoing primary isolated aortocoronary bypass operation, were studied. Follow-up information was obtained from our follow-up databank. A cross-sectional follow-up was conducted and an additional functional evaluation by the Duke Activity Status Index and the work situation. RESULTS: The follow-up, was complete for 98.2% of patients and showed a survival rate of 99% at 12 and 86.1% at 120 months. Eight patients died during follow-up. There was a significant improvement of NYHA classification. The Dukes Activity Status Index showed a good correlation with the NYHA class; however, only 47% of the patients returned to work.

Long-term results after correction of anterior chest wall deformities.

BACKGROUND: Surgical correction of pectus deformities was mainly performed for cosmetic and psychologic reasons but eventual cardiopulmonary symptoms improved. Whether this results from alterations in cardiopulmonary physiology is still controversial METHODS: In 25 years 662 patients underwent correction (390 for pectus excavatum-funnel chest, 235 for pectus carinatum-chicken chest, 37 for pectus arcuatum-pouter pigeon chest). Surgical correction was mainly performed for cosmetic and psychologic reasons. Sternochondroplasty was performed without prosthetic material RESULTS: Clinical results for funnel chest were satisfactory in 83.6% (excellent 44.1%, good 39.5%) and were always good for protrusion deformities if enough deformed cartilages were resected. In a retrospective study the pulmonary function tests performed on 152 patients with funnel chest before surgery and at long-term follow-up demonstrated an eventual increased restriction at follow-up, despite symptomatic improvement and increased anteroposterior chest diameter on the X-ray, but restricted anterior chest wall motion. In a prospective study the exercise cardiorespiratory function tests on 35 patients with funnel chest before and one year after operation suggested unchanged work performance, but an increased oxygen consumption and acidification due to a higher work of breathing after operation, caused by decreased chest wall compliance. CONCLUSIONS: The subjective physical improvement after operation cannot be explained by changes in static lung volumes or in cardiorespiratory function at exercise, but is due to other unexplained factors. Satisfactory subjective long-term results of most patients justify surgical correction. Both physical as well as psychologic and cosmetic factors may allow operative correction.

Coronary bypass surgery: what is changing? Analysis of 3834 patients undergoing primary isolated myocardial revascularization.

OBJECTIVE: The patient population undergoing myocardial revascularization has changed during the last few years. Knowledge of these changes, and of the subsequent influence on morbidity and/or mortality is important, not only for up-dating quality control, but also to support decision-making in financial and economical aspects, and in further research concerning coronary artery surgery. METHODS: Pre-, per- and postoperative data of 3834 primary isolated coronary bypass operations, January 1987 December 1995 were analyzed. The total group was divided into three time cohorts. Group A: 1987 1989 (n = 1292); group B: 1990-1992 (n = 1130); and group C: 1993-1995 (n = 1412). RESULTS: Mean age increased from 60.4 +/- 9.0 (S.D.) years in group A to 62.9 +/- 9.9 (S.D.) years in group C (P < 0.0005). Patients with insulin-dependent diabetic (P = 0.005), uro-nefrological (P = 0.002), pulmonary (P < 0.0005)and neurological (P = 0.003) pathology increased significantly, and there was a significant increase in the use of arterial grafts (P < 0.05). Postoperative, hospital mortality remained stable (+/- 2.5%). However, there was a significant increasing percentage of patients with pulmonary (P = 0.04), neurological (P = 0.02) and uro-nefrological (P < 0.0005) problems. CONCLUSION: During the last few years there has been a trend in myocardial revascularization of older patients, with more coexisting disease. Despite the fact that hospital mortality seems stable, there is an increase in major postoperative morbidity.

Surgical treatment of a fistula between the right pulmonary artery and the left atrium: presentation of two cases and review of literature.

OBJECTIVE: A direct communication between the pulmonary artery and the left atrium is a rare anomaly. On the basis of two cases of our own and a literature review of 49 cases, we focus on clinical presentation, anatomy, diagnosis, and the role of surgery. METHODS: Two cases of a fistula between the right pulmonary artery and the left atrium are described in a girl of 4 years and a boy of 15 years. Both presented with unexplained cyanosis. Diagnosis was made on echocardiography and angiography. The fistula was ligated using extracorporeal circulation in the first case and not in the second case. RESULTS: The surgical results were successful with resolution of the cyanosis. CONCLUSIONS: In newborns, urgent surgery may be necessary. In other patients, early elective surgical correction should be performed to prevent complications, especially systemic and cerebral emboli, cerebral abscesses, and rupture of aneurysmal fistulas. Complete cure can be achieved by ligation and possible division or by intracardiac repair.

[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.

Lipomatous hypertrophy of the interatrial septum: indication for surgery?

A fortuitous finding during open heart surgery of lipomatous hypertrophy of the interatrial septum is described in a 65-year old man with ischaemic heart complaints due to coronary artery disease and with premature ventricular contractions. An incision biopsy confirmed the diagnosis. The choice of treatment of lipomatous hypertrophy of the interatrial septum is controversial. Indications for surgery and surgical techniques are discussed.

Morbidity and mortality in 200 consecutive coronary reoperations.

OBJECTIVE: The morbidity and mortality of coronary reoperations is still higher than in primary myocardial revascularization. In the present paper we analyzed the relation between several preoperative and peroperative variables and the perioperative morbidity and mortality of coronary reoperations. METHODS: The data of 200 consecutive patients undergoing isolated aortocoronary bypass reoperation were studied by univariate and multivariate analysis. The mean age was 59 years (range 44-83 years), 163 (81%) patients were male and 37 (19%) female. The overall hospital mortality was 8.5% (17/200), and in 32/200 patients (16%) a perioperative myocardial infarction was noted. RESULTS: By univariate analysis, a myocardial infarction before the initial operation and a myocardial infarction between the initial operation and the reoperation, peripheral vascular disease, diabetes, anginal status and perioperative myocardial infarction were identified as factors influencing the operative mortality. Multivariate analysis identified perioperative myocardial infarction and anginal status as predictors of hospital mortality. Further analysis identified peripheral vascular disease, diabetes, delivery way (ante/retrograde) of cardioplegic solution, and anginal status as univariate predictors of perioperative myocardial infarction. The only significant multivariate predictor of perioperative myocardial infarction was the anginal status. CONCLUSION: The anginal status (New York Heart Association > or = IV-A) is the dominant variable in predicting the operative outcome in coronary reoperations, and a decrease of the operative mortality and perioperative infarction rate can be expected by avoiding 'so called' emergency reoperations.

Asymptomatic right atrial aneurysm: fortuitous finding and resection.

A rare right atrial aneurysm is described in a 36-year-old man. After median sternotomy for coronary bypass, a thin-walled aneurysmal dilatation of the right atrium was seen by chance. The patient was in sinus rhythm. The aneurysm was surgically resected. The postoperative course was uneventful.

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.

Surgical repair of subacute left ventricular free wall rupture.

BACKGROUND: The natural course of subacute ventricular free wall rupture (FWR) as a complication of acute myocardial infarction (MI) is usually lethal. The aim of this study was to investigate the curability of this entity and to report on five patients successfully treated by rapid diagnosis, hemodynamic stabilization, and emergency surgical repair. METHODS: Five patients with subacute FWR of the left ventricle after previous MI were operated on. Infarctectomy with subsequent closure of the ruptured area was carried out in two patients with anterolateral infarction. Three other patients (two with posterior and one with lateral infarction) were treated by direct closure and the application of a patch. Furthermore, in two patients, concomitant myocardial revascularization was performed. RESULTS: All patients survived the procedure and were alive and well at long-term follow-up (mean 36.4 months). None of the patients suffered recurrent MI. CONCLUSIONS: Our experience and a review of the literature shows that prompt diagnosis and emergency surgical intervention may save the patient. Anterior rupture (with a moderate sized infarcted area) is best treated by infarctectomy and subsequent closure of the ventriculotomy with sutures buttressed with felt, whereas posterior rupture may be treated by direct closure and the application of an epicardial patch. Considering our results, we cannot conclude whether additional coronary artery bypass grafting is beneficial or not. Our suggestion is to perform additional myocardial revascularization only if indicated.

The present status of surgery for lung cancer.

Surgical resection of non-small cell lung cancer (NSCLC) is the treatment of choice if complete resection is possible. There is consensus regarding a pretreatment minimal staging. For the pre-operative exploration CT scan (with contrast) and mediastinoscopy are complemental. Accepted is the New International Staging system with TNM. The 5-year survival following complete resection is stage-dependent. For stage I disease (T1-2, N0 M0) lobectomy is generally possible. The overall 5-year postoperative survival is 65%. No postoperative adjuvant treatment is necessary. For stage II (T1-2 N1 M0) lobectomy is possible in 70% of patients. The overall 5-year postoperative survival is 42.9%. Survival is affected by histology and T-status. The incidence of local recurrence can be reduced by postoperative radiotherapy. For stage III A (T1-3 N0-2 M0) surgery or combined modality treatment is indicated. The overall 5-year postoperative survival is 22.2%. For chest wall involvement (T3) en bloc resection of lung and partial chest wall is performed if possible. The 5-year survivors share common features: asymptomatic before operation, non-smokers, no rib erosion, squamous cell carcinoma, limited chest wall resection and N0 status. Pancoast tumours (T3) are treated according to the Paulson protocol with low dose pre-operative radiotherapy, complete en bloc resection, and postoperative radiotherapy in case of incomplete resection. Long-term survival after pre-operative irradiation and complete resection is possible. N1 or N2 disease is an adverse prognostic factor. When N2 disease is unsuspectedly discovered at operation, complete resection with mediastinal lymphadenectomy is indicated. The subgroup with the best prognosis is the group with negative mediastinoscopy, lobectomy and minimal N2. Multimodal therapy with chemo- or chemoradiotherapy is investigated. The results demonstrate the longest survival in patients with complete resection after major response to chemotherapy. For stage III B (T4 any N M0; any T N3 M0) surgery is usually not indicated and most patients are candidates for radio- or chemotherapy or both. The overall 5-year postoperative survival is 5.6% with 0% for N3 but 8.2% for T4 patients, after extended resection as intrapericardial pneumonectomy, sleeve pneumonectomy, partial resection of the superior vena cava and miscellaneous partial resections. Postoperative radiotherapy may improve local control. For stage IV (any T any N M1) combined surgery can be effective for solitary adrenal or brain metastases. A reported 7.5% 5-year survival was mainly for intrapulmonary metastases, also considered as satellite nodules. Careful follow-up of patients operated for lung cancer is necessary, as the incidence of metachronous lung cancer is as high as 10% for the long survivors. Reoperation with an economic but complete resection is the treatment of choice in the absence of metastases or other contraindications.

Completion pneumonectomy. A retrospective analysis of indications and results.

Between 1970 and 1993, 446 patients underwent pneumonectomy. Completion pneumonectomy was performed in 37 patients (8.3%): 34 men and 3 women, with a mean age of 61 years (range 20-78 years). Indications were benign disease in 4 patients and carcinoma in 33. Of the latter, 21 patients underwent resection for metachronous lung cancer, 6 for recurrent lung cancer, 4 for previous incomplete resection, 1 for primary lung cancer after previous resection for benign disease and 1 patient after previous segmentectomy for metastasis. The mean interval between first operation and completion pneumonectomy was 41 months (range 1-187 months) for the whole group, 30 months for benign disease and 42 months for carcinoma. The overall operative mortality was 6/37 (16.2%); 1/4 patients with benign disease and 5/33 (15.2%) patients with carcinoma. Nine patients (29%) had one or more major non-fatal complication. Actuarial 3- and 5-year survival rates were 41.0% and 24.5% for the entire group, 75% at both times for patients with benign disease, 36.4% and 18.3% for all patients with carcinoma at the time of completion pneumonectomy and 24.3% and 14.5% for patients with metachronous or recurrent lung cancer. For 15 patients with stage I or II metachronous lung cancer, the 3- and 5-year survival rates were 33.9% and 16.9%. All six patients with stage III metachronous cancer died within 18 months. In conclusion, completion pneumonectomy carries a high operative mortality and morbidity. Long-term survival is negatively influenced by stage III lung cancer.

Antegrade versus retrograde crystalloid cardioplegia: perioperative assessment of cardiac energy metabolism by means of myocardial lactate measurement.

The effects of retrograde and antegrade delivery of cold St. Thomas' Hospital cardioplegia were evaluated and compared in 21 patients who underwent elective myocardial revascularization. The patients were randomly separated into two groups: the antegrade group (n = 10), and the retrograde group (n = 11). Cardiac energy metabolism was monitored by evaluation of arterial and coronary sinus (CS) lactate concentration. There was an increase of the CS lactate concentration during aortic cross-clamp period in both groups. After release of the aortic cross-clamp, there was an increase of the CS lactate concentration in the antegrade group, and a decrease of CS lactate in the retrograde group. Analysis of the patients operated with antegrade delivery of cardioplegia showed an increase of the CS lactate concentration in 9/10 patients after aortic cross-clamp release. In the retrograde group, in 8/11 patients the CS lactate concentration decreased immediately after aortic cross-clamp release. Whereas the differences in the CS lactate concentration were not significantly different, the lactate extaction immediately after aortic cross-clamp release was significantly higher for the retrograde group (p = 0.034). This can be related to a faster reconsolidation of mitochondrial oxidative phosphorylation in the retrograde group. For the other registered parameters, hemodynamic recovery of cardiac function, release of creatine kinase MB isoenzyme, and clinical outcome, there was no significant difference between the groups. Based on this study we conclude that retrograde delivery of a cold non-oxygenated cardioplegic solution results in a better preservation of myocardial energy reserve than antegrade delivery.

Cardiac reoperations with a patent internal thoracic artery graft. A double challenge?

Cardiac reoperations remain a challenge. Reoperations in patients with a patent internal thoracic artery graft have a double challenge; the patent internal thoracic artery graft and the problem of peroperative myocardial protection. Our experience in 25 patients is described and discussed.