Georgios P. Georghiou

Surgical management of aortopulmonary window and associated lesions.

BACKGROUND Aortopulmonary window is a rare congenital heart defect commonly associated with other cardiac anomalies. Although single institutional experience is low, several surgical techniques have been reported. The purpose of this study is to describe our approach to the management of aortopulmonary window and its associated lesions. METHODS Between February 1996 and November 2002, 13 patients underwent repair of aortopulmonary window. The age range went from 4 days to 5.5 months (mean 42 +/- 52 days), with 9 patients younger than 1 month old. The weight range was from 1.9 to 6.7 kg (mean 3.5 +/- 1.2 kg). Concomitant cardiac anomalies were present in 11 patients. The major additional anomalies were interruption of aortic arch in 4 patients and tracheal stenosis in 1 patient. Initial diagnoses were made using two-dimensional echocardiography only. RESULTS There was one postoperative death. In general, patients with aortopulmonary window and additional major defects had a prolonged intensive care unit and hospital stay when compared with the other patients. Follow-up time ranged from 2 months to 6.8 years (mean of 2.5 +/- 2.2 years). There were no reoperations and no late deaths. Transcatheter balloon dilatation of the repaired aortic arch was required in 1 patient and of the right pulmonary artery in another. All other patients had good flow to both pulmonary arteries. No residual shunts were detected at the aortopulmonary window site, and pulmonary pressures were normal. CONCLUSIONS Aortopulmonary window may be effectively diagnosed with echocardiography. Early surgical treatment (neonatal period, if possible) is safe and associated with the best long-term results, even in the presence of other cardiac anomalies. Complete separation and reconstruction of both aorta and pulmonary arteries under direct vision may prevent recurrence and distortion of adjacent structures.

Pulmonary arteriovenous malformation treated by lobectomy

Pulmonary arteriovenous malformation (PAVM) may occur primarily or in association with hereditary hemorrhagic telangiectasia. We present a case of PAVM in the central lower lobe of the left lung of a 75-year-old woman, which was successfully treated by lobectomy. Contrast echocardiography is an excellent tool for evaluation of this uncommon lesion. Advances in interventional radiology have led to the introduction of obliterative techniques for the treatment of PAVM. However, in the presence of a large solitary malformation centrally located, as in our case, and in high-risk patients, surgery is still a safe and effective first option.

Pulmonary inflammatory myofibroblastic tumorinvading the left atrium

Inflammatory myofibroblastic tumor is a rare solid tumor that most often affects children and young adults. Although benign, the tumor may be very aggressive locally. We describe a 9-year-old boy with primary inflammatory myofibroblastic tumor of the left upper lobe involving the left atrium.

Successful resuscitation of a patient with acute massive pulmonary embolism using emergent embolectomy

Acute massive pulmonary embolism is associated with a high mortality rate. Prompt diagnosis and treatment are mandatory for a successful outcome. Although thrombolysis is effective, it is associated with a high rate of bleeding complications. This report describes the use of emergent pulmonary embolectomy as an effective and aggressive therapeutic approach to a massive saddle pulmonary embolism in a 66-year-old woman. With the application of specific surgical techniques and good interdisciplinary cooperation, pulmonary embolectomy may serve as more than a last resort for the management of this clinically unstable and dangerous condition.

Advantages of the ultrasonic harmonic scalpel for radial artery harvesting.

The aim of the study was to examine the safety and effectiveness of the Harmonic Scalpel® for reducing spasm caused by thermal injury during radial artery harvesting. The study sample included 100 candidates undergoing coronary artery bypass grafting. In half the patients, radial artery harvesting was performed using the ultrasonic Harmonic Scalpel equipped with coagulating curved shears and a 14 cm scissor-grip handle and in the other half, hemostatic clips, scissors, and minimal electrocautery were employed. Comparison of outcome between the groups showed that radial artery harvesting with the Harmonic Scalpel was associated with a shorter harvesting time, lower frequency of spasm, larger internal diameter of the radial artery graft, and a significantly reduced need for clips to control bleeding than the standard method. In addition, there were no cases of hematoma or superficial wound infection in the arm, and no postoperative reduction in soft touch sensation or objective pin-prick sensation. In conclusion, the Harmonic Scalpel provides excellent control of bleeding without the need for potentially damaging electrocautery, and with a markedly decreased use of hemostatic clips. Harvesting time is also shorter. The minimized thermal injury decreases the rate of radial artery spasm. Further studies using additional objective measures are currently underway to confirm these findings.

Video-assisted pericardial fenestration for effusions after cardiac surgery.

Delayed-onset pericardial effusion following cardiac surgery can give rise to significant morbidity due to its presentation as well as management by traditional surgical techniques. An institutional experience of a video-assisted thoracoscopic technique to create a pericardial window, with the advantages of a minimally invasive approach combined with excellent visualization in such patients, was reviewed. A retrospective analysis was conducted on all patients undergoing video-assisted thoracoscopic for delayed pericardial effusion after cardiac surgery from January 2001 to January 2006 at our center. Seven patients with echocardiographically diagnosed delayed tamponade underwent video-assisted thoracoscopy; 5 were receiving anticoagulants after valve replacement, and 2 had undergone heart transplantation. Pericardial windows were created under general anesthesia and single-lung ventilation using 2 to 3 trocars. Mean operative time was 45 min. There were no complications of the thoracoscopic technique. Video-assisted thoracoscopic creation of a pericardial window is safe and effective treatment for loculated pericardial effusions secondary to cardiac surgery.

Optimizing early extubation after coronary surgery.

Early extubation after isolated coronary artery bypass surgery was assessed retrospectively in 545 of 779 patients treated by the same surgical team over one year. All underwent extubation within 10 hr of arrival at the cardiothoracic intensive care unit: 343 in < 6 hr and 202 in 6–10 hr. Operative mortality was 2.2%. Group comparisons revealed that patients who had earlier extubation were younger (61 vs. 66 years; p < 0.001), more likely to be male (72.5% vs. 61.3%; p < 0.05), with a shorter aortic crossclamp time (49.2 ± 15.0 vs. 53.3 ± 14.0 min; p < 0.05), cardiopulmonary bypass time (65 ± 18.4 vs. 72.2 ± 19.2 min; p < 0.05), intensive care unit stay (18.8 ± 5.6 vs. 22.4 ± 3.2 hr; p < 0.05) and postoperative hospital stay (5.2 ± 2.2 vs. 6.0 ± 2.4 days; p = 0.01). Extubation < 6 hr after cardiopulmonary bypass may accelerate recovery. The finding of no significant differences in clinical parameters between the groups suggests that efforts to further reduce the time to extubation might be worthwhile.

Outcome of Marginal Donors in Heart Transplantation

THE NUMBER of patients awaiting organ transplantation has progressively increased over the last decade. The progression of the discrepancy between suitable donors and potential recipients on waiting lists will have the consequence of an increasing use of organs from marginal donors. Organs that would have been thought unsuitable for transplantation not so long ago are currently used for transplantation. Advanced age, prolonged CPR, heavy inotropic support, or coronary lesions define marginal donors. Marginal recipients are advanced in age, have other diseases as limiting factors, or have been hospitalized in critical condition. From a total number of 100 transplantations (heart and/or lung) performed in our center, we present three cases in which ethical difficulties arose.

Giant schwannoma of the posterior mediastinum.

Resection of a mediastinal tumor (Fig. 1) in a 57-year-old woman who presented with progressively aggravated dyspnea at rest, productive cough, and a referred vague left chest pain, established the diagnosis of schwannoma (Fig. 2a,b), a benign, slow-growing neoplasm that frequently arises from a spinal nerve root but may involve any thoracic nerve. European Journal of Cardio-thoracic Surgery 24 (2003) 1030 www.elsevier.com/locate/ejcts

Primary Pulmonary Amyloidosis Due to Low-Grade B Cell Lymphoma

Pulmonary involvement is not an infrequent complication of systemic amyloidosis, although affected patients rarely have significant pulmonary symptoms. In contrast, localized (primary) pulmonary amyloidosis is rare. We report a case of pulmonary low-grade B cell lymphoma with amyloid production, causing localized pulmonary amyloidosis.