Henry J.C.M. van de Wal

Post cardiac surgery phrenic nerve palsy: value of plication and potential for recovery

OBJECTIVES Evaluation of an aggressive policy for the treatment of phrenic nerve palsy (PNP), following cardiac operations, with emphasis on early diaphragmatic plication. Attention was given to the incidence and predisposing factors for PNP and the potential for recovery following plication. METHODS From 1 June 1991 to 1 January 1996 we prospectively screened patients for PNP following cardiac surgery. The diagnosis was suspected if difficulty was experienced in weaning the child from the ventilator. If abnormal elevation of the hemidiaphragm was present diaphragmatic plication was performed. Echocardiography was used to assess subsequent return of diaphragmatic function. RESULTS Seventeen children (nine boys, eight girls), out of 867 (1.9%) children younger than 16 years of age, undergoing cardiac operations were found to have PNP. The mean age was 66 days (range 1-17 months) with 16 patients below 1 year out of a total of 285 patients (incidence 5.6%) and one patient 17 months old. The incidence following open procedures was 11/190, following closed procedures 2/95 and following reoperation 4/83. PNP was diagnosed from 2 to 44 days (mean 14 days) following surgery. It was present on the right side in seven cases, the left in nine and was bilateral in one patient. Two patients were extubated at the time of diagnosis, one patient could be extubated shortly thereafter. Fourteen children underwent diaphragmatic plication, at a median 5 days post diagnosis. Extubation was possible 1-60 days (mean 4 days) after plication. Mean follow-up was 19 +/- 5 months. Subsequent recovery of diaphragmatic movement was documented in seven (41%) children. Time to recovery following plication was 16 months, without plication 38 months. CONCLUSION Prospective screening for PNP revealed an incidence in children younger than 1 year of 6%. Early plication substantially reduces the duration of ventilation, with its associated reduced morbidity and ICU stay.

Bi-directional cavopulmonary shunt: is accessory pulsatile flow, good or bad?

OBJECTIVE Evaluation of the effect and long-term outcome of accessory pulsatile blood flow versus classical bi-directional cavopulmonary connection (BCPC). METHODS Retrospective review of the medical and surgical records. RESULTS Two-hundred and five patients (119 boys, 86 girls) underwent BCPC from 1990 to 1996. Accessory pulsatile flow was present in 68%, flow being maintained through the pulmonary trunc in 46%, systemic-to-pulmonary artery shunt in 13% and mixed in 7%, or patent ductus arteriosus in 2%. Patients with accessory pulsatile flow had lower hospital mortality (3% versus 5%), while mean pulmonary artery pressure (14.1 versus 12.6 mmHg P = 0.050) and increase of oxygen saturation (12.4 versus 8.7, P = 0.034) were significantly higher. The period of artificial ventilation (1.9 day) and ICU stay (6 days) did not differ for both groups. Late mortality was higher following accessory pulsatile flow (6% versus 1%). At late follow-up patients with accessory pulsatile flow had significantly higher oxygen saturation (mean 85 +/- 4%, versus 79 +/- 4%; P < or = 0.005). If subsequent completion of Fontan is considered the optimal palliation and subsequent systemic to pulmonary artery shunt, arteriovenous fistula and transplantation is considered a failure, patients with accessory pulsatile flow had significantly more and earlier completion of the Fontan procedure (mean 1.7 +/- 2.4 years, versus 2.7 +/- 4.4 years; P = 0.008). Survival is not influenced by age at bi-directional cavopulmonary shunt surgery, left or right functional ventricular anatomy or previous palliative surgery. One patient with accessory pulsatile flow developed systemic-to-pulmonary collaterals eventually requiring lobectomy. CONCLUSION Despite two different initial palliative techniques the outcome was not significantly different. Accessory pulsatile blood flow appeared not to be a contra-indication for a completion Fontan procedure. Moreover, the data suggest that after accessory pulsatile flow can safely be performed, at late follow-up oxygen saturation is higher, while, significantly more and earlier completion of Fontan occurred. Age at bi-directional cavopulmonary shunt, basic left or right ventricular anatomy or previous palliative surgery did not influence survival.

Cardiac surgery by transxiphoid approach without sternotomy

OBJECTIVE In a attempt to avoid the potential drawbacks associated with sternotomy coupled with a desire for a smaller scar led us to investigate the transxiphoid approach without sternotomy. We present our preliminary experience and a comparison between the sternal and thoracic approaches. METHODS From June 1996, at the Institut Cardiovasculaire Paris Sud, Massy, France (ICPS) and the Heart Institute, Sao Paulo, Brazil (HI) the transxiphoid approach was adopted for the correction of selected congenital cardiac defects. The xiphoid was resected through a 6 cm long vertical skin incision. With a special retractor the sternum was elevated cephalad and anteriorly. Closure of the defect was performed in the conventional manner. Twenty-six patients; 17 boys and 9 girls were entered into the study from representing 19 atrial septal defects (ASDs), 4 ventricular septal defects (VSDs) and 3 partial atrio ventricular septal defect (AVSDs). In addition at ICPS the transxiphoid approach for correction of ASD was compared to the thoracic and sternal approaches performed in the same period. RESULTS Both the aortic cross clamp time as well as the duration of extracorporeal circulation were increased when compared to either standard sternotomy or thoracotomy approaches. There were no differences within the groups when comparing body surface area, amount of chest drainage or length of either ICU or hospital stay. However the patients in the transxiphoid group showed less pain and respiratory discomfort. CONCLUSION Our initial experience with the transxiphoid approach without sternotomy confirms that it is a promising technique that can be considered an alternative to conventional sternotomy. The access is adequate for surgical procedures performed through a right atriotomy. The advantages include a better cosmetic scar, less surgical trauma, minimal respiratory discomfort and a potentially lower risk of infection. However cardiopulmonary bypass and cross clamp times are increased. There were no complications, and patient satisfaction was high.

Intraoperative flow measurement of native coronary artery can help decision making before CABG

We report the case of a patient with three-vessel coronary artery disease whose right coronary artery had been stented at the time of the diagnostic procedure. He had recurrent angina 12 days later and was transferred for urgent coronary artery bypass grafting. No repeat coronary angiography was performed. In the operating room, the flow on the native right coronary artery was determined with an ultrasonic flow probe.

Morphology of pulmonary atresia with ventricular septum in patients dying after operation

In 1976, we adopted staged surgical management of pulmonary atresia with intact ventricular septum: stage 1 = establishment of a systemic to pulmonary artery shunt; stage 2 = open reconstruction of the right ventricular outflow tract and pulmonary valve; and stage 3 = closure of the shunt and interatrial communication. The morphological features of nine specimens obtained from 10 patients who died were reviewed. Special attention was given to features that might have influenced the poor surgical outcome in these patients. Survival after stage 1 depends on adequate systemic to pulmonary artery blood flow, initially as a combination of ductus arteriosus and shunt flow, with subsequent modification if the ductus closes. After stage 2, survival is influenced by left ventricular function and mitral valve function. The success of final correction (stage 3) depends largely on the morphology of both ventricles and their atrioventricular valves. It appears that the behavior of the ductus arteriosus and the size of the shunt are of vital importance for the survival of the infant. In 3 of the specimens, no right ventricular outflow tract was present, and in 2 others, short chordal attachments of the mitral valve were observed. Staged surgical correction appears to be a satisfactory approach if these considerations are taken into account.

Amyloid of heart and lungs in a patient with low output syndrome after coronary artery bypass grafting.

Case Report: A 70-year-old patient with two-vessel disease and moderately reduced left ventricular function after a recent myocardial infarction was admitted for a routine coronary artery bypass grafting (CABG) procedure. During anesthetic induction, he became unstable and cardiopulmonary bypass had to be instituted urgently. Despite good bypass flows, the patient died in myocardial failure shortly after surgery. At autopsy, besides severe atherosclerotic coronary artery disease, cardiac and pulmonary amyloidosis were found.Fallbeschreibung: Berichtet wird von einem 70-jährigen Patienten mit koronarer Zweigefäßerkrankung und mittelgradig eingeschränkter linksventrikulärer Funktion bei Z.n. Myokardinfarkt im Hinterwandbereich. Der Patient wurde zur elektiven Bypassoperation stationär aufgenommen. Während der präoperativen Narkoseeinleitung wurde der Kreislaufzustand instabil, und der Patient musste notfallmäßig an die Herz-Lungen-Maschine angeschlossen werden. Aufgrund der Notfallsituation wurde auf den Anschluss der Arteria thoracica interna verzichtet. Ein Venenbypass auf die rechte Herzkranzarterie hatte einen Fluss von 61 ml/min, ein zweiter Venenbypass auf den Ramus interventricularis anterior einen Fluss von 86 ml/min. Trotz der guten Bypassflüsse war ein Abgehen von der Herz-Lungen-Maschine nicht möglich. Nach zusätzlichen 90 min Reperfusion und Anlage einer intraaortalen Ballonpumpe (IABP) war nur mit sehr hohen Dosierungen von Adrenalin und Noradrenalin die Beendigung der extrakorporalen Zirkulation möglich. Auf der Intensivstation verschlechterte sich der kardiozirkulatorische Zustand des Patienten weiter. Er starb nach einigen Stunden in therapierefraktärem Myokardversagen. Autoptisch wurde ein Befall von Lunge (Abbildung 3) und Herz (Abbildung 4) durch Amyloid gesichert. Retrospektiv gesehen waren ein retikulonoduläres Muster in der Röntgenaufnahme des Thorax (Abbildung 1), eine periphere Niedervoltage im EKG (Abbildung 2a) und leichte ST-Hebungen über den Vorderwandableitungen (Abbildung 2b) diskrete Indikatoren für das Vorliegen einer Amyloidose von Lunge und Herz gewesen. In der Literatur belegt sind ebenfalls die ausgeprägte hämodynamische Instabilität in der präoperativen Narkoseeinleitung und die Resistenz gegenüber kardiosupportiver katecholaminerger Stimulation.

Die chirurgische Therapie der infektiösen Endokarditis: Essener Erfahrungen

Hintergrund: Die infektiöse Endokarditis repräsentiert trotz frühzeitiger Diagnosestellung und sofortiger Therapieeinleitung ein Krankheitsbild mit hoher Morbidität und Letalität. Persistieren die Symptome unter konservativer Therapie oder kommt es zu einem Fortschreiten der Erkrankung, droht die irreversible Destruktiion kardialer Strukturen. Chirurgische Therapie: Die Indikation zur chirurgischen Therapie der infektiösen Endokarditis muss daher so früh wie möglich gestellt werden. Der Erfolg der operativen Behandlung hängt nicht vom verwendeten Prothesenmaterial ab, sondern vom Zeitpunkt der Indikationsstellung.Background: Instead of immediate diagnosis and effective antibiotic treatment morbidity and mortality in infective endocarditis remains high. If the infection cannot be controlled or the disease progresses irreversible destruction of cardiac structures results. Surgical Treatment: In this case surgical therapy should be considered immediately. The outcome of surgical repair is not depending on the implanted prosthesis, but solely on timing of the operation.