Bernard Faidutti

Postoperative Chylothorax in Children: Differences Between Vascular and Traumatic Origin

Twenty-four children with postoperative chylothorax were encountered among 1,264 consecutive thoracic operations over a 7-year period and form the basis of this study. Chylothorax was caused by direct lesion to the thoracic duct or lymphatic vessels in 17 patients and was associated with superior vena cava (SVC) obstruction in seven. Of the latter, five had bilateral chylothorax. Chylothoraces secondary to venous hypertension and thrombosis have a longer interval between operation and diagnosis compared with direct trauma as well as a longer duration and larger volume of chylous drainage. Treatment was entirely nonoperative in 16 patients and operative in 8. Nonoperative treatment consisted of pleural needle aspiration or suction drainage in association with a medium chain triglyceride (MCT) diet (n = 11) or total parenteral nutrition (TPN) after failure of MCT (n = 5). Direct operation on the thoracic duct was performed in 5 patients, four had pleurodesis, and 2 had pleuroperitoneal shunts inserted. All patients were cured of their chylothorax and there were no deaths. Patients with major vein thrombosis were the most difficult to treat. On the basis of this experience, we suggest a step-by-step approach: (1) insertion of chest tube after 3 to 4 pleural punctures; (2) 1-week trial of MCT diet, with intravenous support to correct protein losses; (3) TPN if chylothorax increases or persists with large volumes; (4) Doppler echocardiography or phlebography to rule out obstruction of major thoracic veins; and (5) insertion of TPN line in inferior vena cava in case of such obstruction; and (6) direct surgical approach to the thoracic duct after 4 weeks of unsuccessful nonoperative treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Floating thrombus in the ascending aorta: A rare cause of peripheral emboli

The ascending aorta may be the site of origin of systemic embolization in some cases that do not have an identifiable source. We report a case in which a free-floating thrombus in the noncoronary sinus of Valsalva was detected by transesophageal echocardiography as a source of left axillary artery embolism. After removal of this pedunculated thrombus of unknown cause, which was attached on a macroscopically and histologically normal aortic wall, the patient made an uneventful recovery.

Surgical management of aortic valve injury after nonpenetrating trauma

A case report and a literature review of the patients who underwent surgical repair of an aortic valve injury secondary to nonpenetrating trauma are presented. Thirty-seven patients (32 male and 5 female patients) with a median age of 43 years sustained either blunt chest trauma (34 patients) or muscular strain (3 patients) as a cause of injury. Primary repair was undertaken on 4 patients before 1964 (when the first aortic valve replacement was performed for this condition) and on 6 other patients after 1964. In the former group, 2 patients died because of heart failure and 1 subsequently required a prosthesis. The last patient had an excellent result at 17 years. In the latter group, 1 patient with a complex lesion had persistent moderate aortic regurgitation. The 5 remaining patients had a simple lesion to the valve and showed excellent results on follow-up evaluation (ranging from 6 months to 6 years). Aortic valve replacement successfully corrected the valvular dysfunction in 26 patients. Except for 1 case of hemolytic anemia, specific complications of prosthesis were not encountered, but median follow-up of this review was only 9 months. A modulated approach to this condition is proposed where primary repair is selected for cases with a simple tear or avulsion of one cusp. Intraoperative control of the repair by transesophageal echocardiography increases the safety of this approach. Valve replacement is indicated for more complex lesions or for ineffective primary repair as assessed by intraoperative echocardiography.(ABSTRACT TRUNCATED AT 250 WORDS)

Blunt carotid artery injury: devastating consequences of undetected pseudoaneurysm.

A case of delayed embolization of a traumatic pseudoaneurysm of the right common carotid artery, resulting in fatal cerebral infarction, is reported. This case emphasizes the importance to detect occult lesions to the carotid arteries after blunt neck injuries and to treat aggressively pseudoaneurysms located upstream to a cerebral vessel to prevent embolic complications.

Aorto-enteric fistula is a serious complication to aortic surgery. Modern trends in diagnosis and therapy.

Secondary aorto-enteric fistula (AEF) is a serious, but rare, complication following surgery of the abdominal aorta. AEF occurs in 0.3-2%, but is associated with a hospital mortality between 25-90%. It is also associated with an important morbidity with a lower limb amputation rate of 9%, and a 15% risk for renewed graft infection. Nine secondary AEF were surgically treated. The hospital mortality was high,44% (4/9). Recurrent AEF was observed in 1 patient 2 years after the first operation. During follow-up 2 patients had mild infections which were resolved by antibiotic treatment. Diagnostic modalities, and recent advancements in surgical treatment as well as preventive measures are discussed.

Ruptured mediastinal bronchial artery aneurysm: A dilemma of diagnosis and therapeutic approach

R E F E R E N C E S 1. Keane JF, Plauth WH, Nadas AS. Ventricular septal defect with aortic insufficiency. Circulation 1979;56(Suppl):I72-7. 2. Cosgrove DM, Rosenkranz ER, Hendren WG, Bartlett JC, Stewart WJ. Valvuloplasty for aortic insufficiency. J Thorac Cardiovasc Surg 1991;102:571-6. 3. Chauvaud S, Serraf A, Mihaileanu S, Soyer R, Blondeau P, Dubost C, et al. Ventricular septal defect associated with aortic valve incompetence: results of two surgical managements. Ann Thorac Surg 1990;49:875-80. 4. Cosgrove DM, Fraser CD. Aortic valve repair. In: Cox JL, Sundt TM, editors. Operative techniques in cardiac & thoracic surgery: a comparative atlas. Philadelphia: WB Saunders; 1996. p. 30-7. 5. Schoof PH, Cromme-Dijkhuis AH, Bogers JJ, Thijssen EJ, Witsnburg M, Hess J, et al. Aortic root replacement with pulmonary autograft in children. J Thorac Cardiovasc Surg 1994;107:367-73. 6. Elkins RC, Knott-Craig CJ, Ward KE, McCue C, Lane MM. Pulmonary autograft in children: realized growth potential. Ann Thorac Surg 1994;57:1387-93. 7. van Son JAM, Reddy VM, Black MD, Rajasinghe H, Haas GS, Hanley FL. Morphologic determinants favoring surgical aortic valvuloplasty versus pulmonary autograft aortic valve replacement in children. J Thorac Cardiovasc Surg 1996;111: 1149-57.

Aortic valve repair by cusp extension with the use of fresh autologous pericardium in children with rheumatic aortic insufficiency

OBJECTIVES Our goal was to evaluate the midterm results of aortic valve repair by a more sophisticated tailoring of cusp extension-taking into account the dimensions of the native aortic cusps-with the use of fresh autologous pericardium. PATIENTS AND METHODS Forty-one children who had severe rheumatic aortic insufficiency (mean age 11.5 +/- 2.7 years) underwent aortic valve repair by means of this cusp extension technique over a 5-year period. Twenty-four of them underwent concomitant mitral valve repair for associated rheumatic mitral valve disease. All children were then followed up by transthoracic echocardiography before discharge, at 3 and 6 months after the operation, and at yearly intervals thereafter. RESULTS Follow-up was complete in all patients and ranged from 3 months to 5 years (median 3 years). No operative and no early postoperative deaths occurred. Only 1 patient died, 9 months after the operation, of septicemia and multiple organ failure. Actuarial survival was 97% at 1 year and has remained unchanged at 3 years. On discharge, the degree of aortic insufficiency was grade 0 for 27 children and grade I for 14. Exacerbation of aortic insufficiency from grade I to grade II was observed in only 1 patient, and none of the children required reoperation for aortic insufficiency during the follow-up period. Mean peak systolic aortic valve gradients at discharge were lower than preoperative values (P =.04), and no significant increase in the peak systolic transvalvular gradient was detected thereafter during the follow-up period. Mean left ventricular dimensions were significantly reduced at discharge when compared with preoperative values (P <.0001). CONCLUSIONS Functional results of aortic valve repair with cusp extension using fresh pericardium have been satisfactory at medium term, particularly in children with a small aortic anulus at the time of initial repair, because the expansion potential of fresh autologous pericardium is equivalent to that of the growing sinotubular junction and aortic anulus diameters.

LOWER LIMB TRAUMA WITH INJURY TO THE POPLITEAL VESSELS

A retrospective analysis of blunt trauma to the lower extremity with injury to the popliteal vessels was undertaken in an attempt to determine the major predictors of outcome and to expose the shortcomings of our management. Thirty-one patients with lower extremity trauma including a popliteal artery injury were admitted to our clinic between 1979 and 1993. Two patients died of hemorrhagic shock or from associated lesions. Amputation of the leg was performed primarily in one patient because of massive tissue damage and secondarily in five patients because of uncontrolled local infection (two patients), excessive tissue damage (two patients), and persistent ischemia (one patient who later died). A peripheral neurologic deficit resulted in 12 of 24 non-amputated extremities. Three additional patients suffered sequelae from bone and joint damage. In all, nine patients recovered completely from their limb injury. Severe ischemia of the leg was found to be an indicator of major limb damage and was a strong determinant of poor outcome. Of 18 patients with severe ischemia, two died (one after amputation), five were amputated, and eight were left with a peripheral neuropathy. Only two patients recovered completely. Of 13 patients with relative ischemia, five recovered completely and four sustained a peripheral neuropathy. The deleterious effects of delayed revascularization were evident in four patients who developed a peripheral neuropathy secondarily. Morbidity from the ischemic insult could have been reduced in seven patients: the diagnosis was missed in two, its seriousness not realized in one, and a non-optimal management led to an excessive ischemic time in four. The magnitude of skeletal and soft tissue injury, alone or in combination, was also strongly associated with an increased morbidity. Most patients with blunt lower limb trauma and popliteal vascular injury are left with serious sequelae from associated neuro-musculo-skeletal damage and from ischemia. Although the magnitude of the first variable is determined by initial trauma and cannot be altered, a constant awareness of possible arterial injury in lower limb trauma, and adherence to a plan of management according to the ischemic state of the leg, should help avoid the additional deleterious effects of prolonged ischemia.

Bilateral radical neck dissection with unilateral internal jugular vein reconstruction

Objective: To describe and evaluate the functional and oncologic results of one internal jugular vein replacement after bilateral radical neck dissection (RND). Study Design: A retrospective historical cohort study. Methods: Since 1972 all patients (n = 9) undergoing bilateral RND with resection of both internal jugular veins had a reconstruction of one internal jugular vein. In six cases the RNDs were staged, and in three cases the RNDs were performed simultaneously. In every case a vascular reconstruction was performed with an autologous vein graft. All patients received radiation therapy, in five patients before and in four patients after the vein grafting. Functional results were evaluated in terms of postoperative head and neck and neurologic complications. In some patients a Doppler scan was performed to assess vein patency. Oncologic results are reported as relapse‐free survival and mortality intervals. Results: In all patients the postoperative course was uneventful, without neurologic complications. Facial edema was noted in four patients, mild in three and moderate in one. Two patients are alive, with follow‐ups of 8 and 18 years. Seven patients are dead, two without evidence of recurrence, four with cervical recurrence after a mean survival of 10 months, and one after distant metastasis after a survival of 7 years. In patients with long‐term survival a Doppler scan confirmed the patency of the vein graft. Conclusion: The lack of operative complications and the absence of postoperative neurologic complications make a unilateral internal jugular vein replacement after bilateral RND attractive, although the oncologic results remain poor. Laryngoscope, 108:1692–1696, 1998

Anterior mitral leaflet prolapse as a primary cause of pure rheumatic mitral insufficiency

BACKGROUND This study was designed to revise the mechanisms and repair techniques of anterior mitral leaflet prolapse observed during the correction of pure rheumatic mitral regurgitation in children. METHODS From March 1993 to May 1998, 36 children suffering from pure rheumatic mitral regurgitation due to anterior leaflet prolapse underwent mitral valve repair. The mean age was 12.5 years (range, 6 to 16 years). Anterior leaflet prolapse was due to chordal elongation in 25 patients (group A), chordal rupture in 6 patients (group B), and retraction of anterior secondary chordae tendineae, creating a V-shaped deformity in the middle of the anterior leaflet, thus moving the free edge of the anterior leaflet away from the coaptation plane, in 5 patients (group C). Chordal shortening, transposition, and resection of anterior secondary chordae tendineae were used to correct anterior leaflet prolapse according to the predominantly responsible mechanism. RESULTS All patients were available for clinical follow-up, which ranged from 6 months to 5 years (mean follow-up, 3 years). Echocardiographic studies were obtained until the 3rd postoperative month, and all patients showed significant improvement in their left ventricular and atrial dimensions. There was one late death related to endocarditis. Two patients in group C who had mitral valve repair underwent mitral valve replacement on the 19th and 24th postoperative months, respectively, because of failure of mitral valve repair. CONCLUSIONS Mitral valve repair for pure mitral regurgitation due to rheumatic anterior leaflet prolapse can be performed safely for all types of mechanisms. Although the techniques we used provide stable short-term results in each of these groups, midterm results are better in groups A and B, where tissue thickening is less important, recurrences of rheumatic carditis are lower, and the interval between the first rheumatic attack and the surgical procedure is shorter than in group C.