Postoperative chylothorax: differences between patients who received median sternotomy or lateral thoracotomy for congenital heart disease.

BACKGROUND: Chylothorax after surgery for congenital heart disease is rare. We wanted to compare the different presentations of chylothorax in patients who received median sternotomy or lateral thoracotomy. PATIENTS AND METHODS: We retrospectively studied pediatric patients with congenital heart disease who received palliative or corrective surgeries and developed postoperative chylothorax between January 1992 and July 2003. Patients were divided into two groups by the type of surgery: median sternotomy and lateral thoracotomy. The average daily fluid amount (mL/kg/24 hours), latency period, duration of chylothorax, and requirement for surgery were compared. RESULTS: Seventeen patients (11 boys, 6 girls; mean age, 14.0 +/- 12.8-month-old) were enrolled. Diagnoses were tetralogy of Fallot (n = 8), right isomerism with complex heart defects (n = 3), patent ductus arteriosus (n = 2), transposition of the great artery (n = 1), ventricular septal defect (n = 1), and endocardial cushion defect (n = 2). There were 9 in the lateral thoracotomy group and 8 in the median sternotomy group. Only one patient required surgery because of the failure of conservative treatment. The lateral thoracotomy group had a significantly lower average body weight (6.9 +/- 2.9 kg vs. 11.0 +/- 3.8 kg) and longer average latency period before postoperative chylothorax (15.1 +/- 9.2 days vs. 7.2 +/- 4.7 days). CONCLUSION: The majority of pediatric patients who develop chylothorax after cardiac surgery can be successfully managed by medical treatment only. To avoid complications in pediatric patients after cardiac surgery, chylothorax should be suspected for patients with unexplainable, prolonged, and abundant pleural effusion.

Serum S-100 beta protein during coronary artery bypass graft surgery with or without cardiopulmonary bypass.

BACKGROUND: Brain damage is a serious complication of cardiac anesthesia. The purpose of this study was to detect brain damage at different surgical stages during coronary artery bypass graft with or without cardiopulmonary bypass. METHODS: We conducted a prospective, longitudinal study to evaluate serum S-100 beta protein, an early marker of brain injury, in patients electively undergoing off-pump (n = 30) or traditional coronary artery bypass graft (n = 60). Blood was sampled immediately before anesthesia, before and after cardiopulmonary bypass, and on the day after surgery. RESULTS: Serum S-100 beta protein was lowest immediately before induction of anesthesia and significantly increased before and after cardiopulmonary bypass, then declined by the first postoperative day in both groups. Peak values were highest in the traditional group directly after coronary artery bypass graft. On the day after surgery, S-100 beta protein levels were similar between groups, but were higher than baseline within each group. Significant increase in serum S-100 beta protein was also observed even before cardiopulmonary bypass in cardiopulmonary bypass patients, or before manipulation of the heart and aorta in off-pump patients. These reflect the possibility that brain damage may occur before major manipulation (cardiopulmonary bypass or manipulating heart and aorta). Moreover, S-100 beta levels did not return to normal on the day after the operation. CONCLUSIONS: This prospective study has shown that serum S-100 beta protein was not only higher than baseline both after cardiopulmonary bypass and on the day after surgery in both groups of patients but it was also significantly increased before cardiopulmonary bypass or manipulation of the heart or aorta. These findings may have implications for anesthesiologic care during the total course of cardiac surgery.

Isolated anomalous origin of right coronary artery from the main pulmonary artery.

The anomalous origin of the right coronary artery (ARCA) from the main pulmonary artery (MPA) is a rare congenital cardiac malformation and usually associated with other cardiac anomalies. Most patients with isolated ARCA from MPA remain asymptomatic, but they may develop myocardial ischemia and even sudden death. We reported an asymptomatic 7-year-old boy referred for evaluation of a heart murmur. Isolation of ARCA from MPA was diagnosed by echocardiography and then confirmed by cardiac catheterization and angiography. The right coronary artery was re-implanted into the ascending aorta. A preoperative thallium-201 myocardial perfusion showed a myocardial ischemia pattern in the anterolateral septal area after a dipyridamole stress test; the ischemia was completely resolved after surgery.

Isolation of the left subclavian artery in a child with tetralogy of Fallot and right aortic arch.

Isolation of the subclavian artery is a very rare vascular anomaly in which the subclavian artery does not communicate with the aortic arch but instead is connected to the pulmonary artery by the ductus arteriosus. The subclavian steal phenomenon from the vertebrobasilar system into the pulmonary and subclavian arteries is usually persistent. We report an 18-month-old boy with an isolated left subclavian artery associated with tetralogy of Fallot and right aortic arch. Subclavian steal phenomenon in this patient resulted in symptoms of diminished pulse and blood pressure of the left arm. He underwent total correction of tetralogy of Fallot and ligation of the ductus arteriosus without reimplantation of the left subclavian artery. There was no substantial blood pressure difference between the upper limbs after the operation. In a patient with right aortic arch and diminished blood pressure or pulse in the left arm, isolation of the left subclavian artery should be included in the differential diagnosis.

Diverticulum of the right ventricle associated with pulmonary stenosis, rhabdomyoma and Wolff-Parkinson-White syndrome.

Congenital cardiac diverticulum is a rare anomaly that may present as an isolated lesion or in association with other malformations. Diverticulum of the left ventricle is more common than that of the right ventricle. We report a case of cardiac diverticulum over the right ventricular outflow tract and associated pulmonary stenosis, right atrial rhabdomyoma, and Wolff-Parkinson-White syndrome in a 9-month-old boy. The delta wave disappeared after removal of the atrial rhabdomyoma.