Fazal Wahab Khan

Repair of ascending aortic pseudoaneurysm eroding through the sternum

In reoperation for an ascending aortic pseudoaneurysm eroding through the sternum, a left ventricular vent allows careful unhurried sternal division under deep hypothermic circulatory arrest. We repaired ascending aortic pseudoaneurysms in 2 patients who had undergone aortic valve implantation 6 and 21 months earlier. A minithoracotomy was made in the left 5th intercostal space, and a vent was placed in the left ventricular apex. Repair was accomplished with a bovine pericardial patch reinforced with a Teflon felt strip. Both patients made an uneventful recovery with good functional status at discharge at the 8- and 18-month follow-up.

Successful treatment of giant left subclavian artery pseudoaneurysm abutting the arch of the aorta and descending aorta

A 28-year-old woman presented with 3-month history of fever of unknown origin and progressively increasing cough. She was diagnosed with pulmonary tuberculosis on bronchial lavage cultures. A chest X-ray performed on follow-up showed a new opacity in the left apical area of the chest. Computed tomography scan of chest showed a large 10 cm pseudoaneurysm of the left subclavian artery 1 cm from its take off from the arch of the aorta. The pseudoaneurysm was approached through a left posterolateral thoracotomy and opened following a proximal and distal control. A 3 cm longitudinal defect was identified in the subclavian artery within its intrathoracic portion. This was debrided and repaired with an autologous pericardial patch. The patient had an uneventful recovery and remained well on follow-up.

Pulmonary hyalinizing granuloma presenting with dysphagia: a rare presentation.

A 25-year-old man presented with a 2-month history of dysphagia and past history of pulmonary and intestinal tuberculosis. A barium swallow showed a point of constriction 42 mm above the gastroesophageal junction. Computed tomography revealed large opacities in bilateral lung fields, encroaching more on the esophagus. The lesion progressively compressed the esophagus as it moved inferiorly. A right posterolateral thoracotomy was performed for sub-anatomical resection of the mass. A biopsy revealed homogenous whirling hyalinized collagen fibers, highly suggestive of pulmonary hyalinizing granuloma, with no evidence of malignancy. Pulmonary hyalinizing granuloma should be considered in the differential diagnosis of longstanding dysphagia.

Right atrial rupture after road traffic accident

Accidents and post-traumatic injuries are one of the most important health and social problems. Non-penetrating chest trauma with injury to the heart has become increasingly common particularly as a result of acceleration/deceleration injuries in modern, high speed, vehicular accidents. Most of them require immediate medicosurgical intervention. The classic clinical presentation is not universal and a subset of patients may present asymptomatically. In blunt chest trauma, cardiac chamber rupture is uncommon although associated with high mortality rate. Blunt traumatic atrial rupture has better prognosis than ventricular tear. Rapid transportation to medical care, accurate timely diagnosis and emergent operative intervention are essential for successful outcome. A 28-year-old male with history of road traffic accident presented to the emergency department with severe shortness of breath, tachycardia and left leg injury. This gentleman had a head-on collision with a car while he was riding a motor bike. He sustained injury on his chest due to the handle of the motorbike. When he was received in the resuscitation room, he was tachypneic, tachycardic and hypotensive. He was resuscitated as per Advanced Trauma Life Support protocols. On chest X-ray he had a widened mediastinum. Ultrasound focused assessment with sonography for trauma (FAST) was negative and showed a moderate pericardial effusion on echocardiogram. On being haemodynamically stable after initial resuscitation, he had chest and abdomen computed tomography scan that showed significant pericardial effusion. On the suspicion of major vessel or myocardial injury, he was taken for emergency surgery. At the time of sternotomy the patient became hypotensive and required cardiopulmonary resuscitation from which he revived. The pericardium was seen bulging with clots and blood, which was opened, and careful evacuation of blood clots was performed. Venous blood was seen gushing from the superior aspect of the right atrium that was controlled by packing. It was found that there was a near total transection of superior vena cava (SVC) from the right atrium junction above the sinoatrial node. Using inflow occlusion technique, SVC and inferior vena cava were occluded with vascular clamps, and rent was repaired using 4/0 Prolene in continuous doublelayered fashion (Fig. 1). Clamps were removed on completion of the first layer of suture, which was no more than 1 min of inflow occlusion time and then the second layer was performed, with no significant haemodynamic instability or rhythm disturbance. Thorough irrigation was performed. Mediastinal drains were placed and the chest closed using sternal wires. The patient was extubated on the first post-operative day; however, his post-operative course was eventful with requirement of non-invasive positive pressure ventilation and diuretics. His serial post-operative chest X-rays showed bilateral opacification probably due to blunt lung parenchymal injury. After a complete resolution of symptoms, he was discharged home with mediastinal drains. In blunt trauma, cardiovascular injuries are second only to central nervous system injuries as the most frequent cause of death. Out of them 75% are road traffic accidents. Fulda et al. reported in a retrospective review of 59 patients requiring emergency surgery for blunt heart trauma. Majority had vehicular accidents (68%), and overall mortality rate was 76%. Rapid transportation and expeditious surgical treatment can save many patients. Right atrium is thin walled and anteriorly located so it is more prone to rupture. The mechanism of various blunt cardiac injuries can be explained as compression of the heart between the anterior chest wall, and the vertebral direct transmission of increased intrathoracic pressure to the cardiac chambers transmitted hydraulic effect from the abdominal or extremity veins to the right atrium (the so-called hydraulic ram effect), cardiac laceration from fractured ribs or sternal fragments, and deceleration junctions of fixed and mobile portions of the heart, such as the disruption of the atrial junction with either the vena cava or the pulmonary vein. Early identification of cardiac tamponade, using FAST and focused echocardiographic evaluation in life support, is the new horizon for rapid management of blunt thoracic trauma with sensitivity and specificity for cardiac tamponade 93 and 99%, respectively. Various techniques have been used to control bleeding from SVC and right atrium injury, inflow occlusion, side biting clamps, vascular shunts, cardiopulmonary bypass and even circulatory arrest depending on the extent and nature of injury. Cardiac chamber injuries can be repaired by simple suture with or without the use of pledgets using vascular clamps (inflow occlusion technique for right atrium). Small tears can be repaired primarily without

A selection of cases of direct cannulation in surgery for type A dissection

We read with interest the article by Yamamoto and colleagues. In type A dissection, direct cannulation of the ascending aorta, as described by Jakob and colleagues and Conzelmann and colleagues, offers promising aspects due to the establishment of antegrade flow in the true lumen of the ascending aorta and a reduction in the time required to initiate cardiopulmonary bypass. We have used the same technique in 4 patients with excellent results. However, we have employed certain modifications to make the procedure easier. We would like to describe those modifications. Carbon dioxide field flooding was used in all cases. The heart was fibrillated with the help of a fibrillator just before making the incision in the aorta. This stops the ejection of blood, thereby improving visualization and identification of the true lumen. Patients were ventilated with 100% oxygen before draining the blood from the heart, and ice bags were placed around the patient’s head. The arterial cannula was held in place with a tourniquet as described earlier, but in one case, there was excessive leakage around the cannula. This was controlled by applying a Cooley vena caval clamp proximal to the ring in the arterial cannula. This part of the aorta was heavily diseased and was later excised and replaced with a graft on circulatory arrest. The aorta was fully opened after establishing cardiopulmonary bypass, and cardioplegia was given in the coronary ostia in all cases. We also used retrograde cardioplegia for maintenance of cardiac arrest. The aortic valve, coronary ostia, and proximal part of the aorta was treated as appropriate, while the patient was cooled down. As experience with direct cannulation of the aorta is increasing, we feel that the suggestions above will be helpful.