Coarctation of the aorta: tailoring the surgical approach.

OBJECTIVE: To employ a flexible approach for repairing coarctation of the aorta in an attempt to minimize residual coarctation and avoid the use of synthetic material. DESIGN: Retrospective study of consecutive children undergoing surgical repair of coarctation of the aorta. SETTING: Walter C Mackenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta. PATIENTS: Children presenting with coarctation of the aorta between June 1993 and October 1996 (n = 42), treated by one surgeon. INTERVENTIONS: Children had repair by one of three methods: subclavian flap angioplasty for discrete juxtaductal coarctation, 17 (40%); resection and end-to-end anastomosis, 13 (31%); and resection with extended transverse arch repair, 12 (29%). MAIN RESULTS: Follow-up was 22 +/- 2 months. The preoperative mean arm-leg gradient was 23 +/- 3 mmHg and postoperatively was 4 +/- 2 mmHg (P < 0.001). In late follow-up, five children developed a significant gradient (end-to-end anastomosis, one; transverse arch repair, two; subclavian flap angioplasty, two) necessitating balloon dilation, one of whom (subclavian flap angioplasty) eventually required end-to-end repair. Another child, who had a subclavian flap angioplasty, underwent transverse arch repair at the time of complete cardiac repair. There was one perioperative death in a child who was in extremis preoperatively and three late deaths in children with additional complex intracardiac anomalies. CONCLUSIONS: A flexible surgical approach with avoidance of synthetic material and low threshold for extended repair has yielded good early and intermediate term results.

Blunt cardiac injury: a 10 year institutional review.

A 10 year review of all blunt cardiac injuries (N = 70) at a single trauma institution was conducted. The majority of patients were diagnosed on the basis of elevated myocardial band fraction of creatine kinase (CK-MB), ST/T wave changes or arrhythmias. The presence of CK-MB elevation was not predictive of arrhythmias, cardiac complications, inotrope requirement, or mortality. The presence of ECG abnormalities or arrhythmias was also not predictive of inotrope requirement or mortality. Cardia complications requiring treatment occurred in 26 per cent (N = 18) of patients. Patients requiring inotropes (N = 12, 17 per cent) had higher Injury Severity Scores (ISS), longer times from injury to emergency, and higher mortality rates, than those not requiring them. Patients who died (N = 10) had a higher ISS, lower Revised Trauma Score, and a more frequent need for inotropes. Only three deaths were directly attributable to the cardiac injury. Myocardial contusion is an injury often of little clinical importance. Patients present with injuries of little or no consequence, severe injuries where the diagnosis is readily apparent, or as a confounding variable in a multiply injured patient. Early use of transthoracic echocardiography is advocated.

Traumatic rupture of the thoracic aorta during the second trimester of pregnancy.

A 36-year-old woman in the second trimester of pregnancy underwent emergent operative repair of a traumatic aortic disruption caused by a motor vehicle accident. Left atrial-to-femoral artery bypass was used to maintain fetal circulation during the cross-clamp period. Her healthy, full-term child was subsequently delivered 3 months later by normal vaginal delivery.

Cardiopulmonary bypass for resuscitation after penetrating cardiac trauma.

Cardiopulmonary bypass is only occasionally required acutely in the management of penetrating cardiac injuries, usually to allow coronary grafting. We describe a case of penetrating trauma in which cardiopulmonary bypass was used to resuscitate a patient whose cardiac lacerations were controlled in the emergency department.