King-Loong Cheung

Risk Factors for Development of Acute Renal Failure (ARF) Requiring Dialysis in Patients Undergoing Cardiac Surgery

Acute renal failure (ARF) is one of the major complications after cardiopulmonary bypass for open heart operations. The present study was undertaken to identify the risk factors for the development of ARF following cardiopulmonary bypass (CPB). Four hundred and forty-seven consecutive patients who underwent open heart procedures from July 1994 to June 1995 were analyzed retrospectively. Their mean age was 55.6 ± 14.2 (SD) years (range, 18 to 80). Dialysis was instituted whenever a patient exhibited inadequate urine output ( <0.5 mL/kg/hr) for 2 to 3 hours despite correction of hemodynamic status and diuretic therapy, especially if fluid overload, hyperkalemia, or metabolic acidosis were also present. Twenty variables were analyzed by univariate analysis; these included nine preoperative variables—age, sex, hypertension, atherosclerosis, diabetes mellitus, left ventricular end-diastolic dimension (LVEDD) >5 cm, preoperative congestive heart failure, renal insufficiency (serum creatinine ≥130 μmol/L on two occasions), and sepsis—10 intraoperative variables—duration of CPB, redo procedures, emergency surgery, use of intraaortic balloon pump (IABP) in operating room, use of gentamicin, use of ceftriaxone, use of sulbactam/ampicillin, requirement of deep hypothermic circulatory arrest, duration of low mean perfusion pressure (mean pressure < 50 mmHg for more than 30 minutes), operation on multiple valves—and one postoperative variable— significant hypotension (systolic blood pressure less than 90 mmHg for more than 1 hour). Significant variables or the variables having a trend (p < 0.1 ) to be associated with ARF were included in stepwise multiple logistic regression analyses. Three regression analyses were performed separately. The incidence of ARF requiring dialysis in the study period was 15.0%. Significant risk factors for whole group of patients (regression I) were preoperative renal insufficiency (p < 0.0001 ), postoperative hypotension (p < 0.0001 ), cardiopulmonary bypass time more than 140 min (p<0.005), preoperative congestive heart failure (p<0.01),and history of diabetes mellitus (p<0.01).The risk factors in the valve group of patients (regression II) were preoperative renal insufficiency (p<0.0001) and postoperative hypotension (p<0.05).Risk factors in the CABG patients (regression III) were postoperative hypotension (p=0.0001), CPB time more than 140 min (p<0.05), preoperative renal insufficiency (p<0.05),and age (p<0.05).The authors conclude that preoperative renal insufficiency and postoperative hypotension are the most important independent risk factors for ARF in postcardiac surgical patients. In addition, CPB time greater than 140 minutes and old age are also independent risk factors for ARF in CABG patients. CPB time more than 140 minutes, history of diabetes mellitus, and preoperative congestive heart failure are independent risk factors for development of ARF in our total group of patients. These findings may have important clinical implications in the preven tion of ARF in postcardiac surgical patients.

Adverse effect of topical methylsalicylate ointment on warfarin anticoagulation: an unrecognized potential hazard.

The adverse effect of topical methylsalicylate ointment on warfarin anticoagulation is studied in 11 patients. All patients had an abnormally elevated international normalized ratio after significant usage of topical methylsalicylate ointment as obvious from both the clinical history and a positive blood level of salicylate. Out of the 11 patients, 3 had bleeding manifestation; 2 with bruises and 1 with gastrointestinal bleeding. It is concluded that topical methylsalicylate ointment should be prescribed with care to patients on warfarin and excessive usage is to be avoided since potentially dangerous drug interaction could occur.

Percutaneous balloon mitral valvotomy in pregnancy using the inoue balloon catheter

Percutaneous balloon mitral valvotomy (PBMV) using the Inoue balloon catheter was performed successfully in 2 patients with severe mitral stenosis refractory to medical treatment during pregnancy. Because of its unique design and ease of manipulation, we recommend the Inoue balloon catheter for performing PBMV in selected patients with mitral stenosis during pregnancy, as procedure and fluoroscopy times can be significantly shortened.

Inoue Balloon Pericardiotomy for Patients with Recurrent Pericardial Effusion

The results and follow-up data for 11 patients with recurrent pericardial effusion due to various etiologies who underwent balloon pericardiotomy with the Inoue balloon catheter between May 1992 and July 1994 are described. Inoue balloon pericardiotomy was successful in 10 patients (91%), who remained free of pericardial effusion at a mean follow-up duration of 4.2 months. All patients tolerated the procedure well with minimal discomfort and with no complications. Despite good symptomatic relief, 9 patients (82%) eventually succumbed to disease dissemination, with a mean survival time of 1.4 months. It is concluded that Inoue balloon pericardiotomy is a safe and useful alternative to surgical pericardial windowing for the symptomatic treatment of recurrent pericardial effusion.

Pericardial effusion in adults undergoing surgical repair of atrial septal defect

The incidence of pericardial effusion and tamponade postatrial septal defect repair in adult patients are 16 and 1.5%, respectively. Small, medium, and large effusions progressed equally, and echocardiographic study on days 7, 14, and 28 best detects potentially significant effusion.

Infected atrial myxoma.

A patient is reported in whom a left atrial myxoma was found to be infected with Staphylococcus aureus. The clinical presentation, diagnosis and treatment are described and discussed.

Large Unruptured Aneurysm in Sinus of Valsalva An Unusual Cause of Right Ventricular Inflow and Outflow Tract Obstruction

A 64-year-old man with a large cavitating squamous cell carcinoma (6×6 cm) in the right lower lobe of the lung was referred for prelobectomy cardiac assessment because of incidental finding of Q waves in leads II, III, and aVF on the ECG. Physical examination revealed an ejection systolic murmur at the left sternal edge. Cardiac size was normal on chest radiograph. A transthoracic echocardiogram revealed a large cavity at the aortic root, …

Venous Thrombosis After Long-Term Transvenous Pacing in the Chinese

To determine the incidence of venous thrombosis after long-term transvenous pacing in the Chinese, venograms were performed in 50 consecutive Chinese pa tients seen at the pacemaker clinic. There were 25 women and 25 men. The mean age was sixty-six years (range thirty-two to eighty-one). The indications for pac ing were complete heart block in 16 patients and sick sinus syndrome in the re mainder. All pacemakers were of the single-chamber ventricular pacing type and had been implanted for a mean period of four years (range two to seven). In 27 patients the route of entry for the pacing electrode was through the cephalic vein and in the other 23 patients the subclavian veins were used. Of the 50 veno grams, 1 showed partial and 1 showed total obstruction at the subclavian vein. Both patients (4%) were asymptomatic. All others (96%) were normal. The in cidence of venous thrombosis was not related to the routes of entry of the pac ing electrodes. All patients tolerated the procedure well and had no complications. It is concluded that the incidence of venous thrombosis after long-term trans venous pacing is extremely low in the Chinese (4%), and venograms are both safe and useful for identifying venous thrombosis related to transvenous pacing.

Dextrocardia with Single Coronary Artery Ostium in a Patient with Aortic Regurgitation and Supraventricular Tachycardia A Case History

A sixty-year-old man who presented with dyspnea and palpitations was investigated in this institution and was found to have dextrocardia, single aortic coronary ostium, severe aortic regurgitation, and atrioventricular nodal reentrant tachycardia. The association of single aortic coronary ostium and this combination of cardiac abnormalities has not been previously reported.

Resolution of spontaneous echocardiographic contrast after percutaneous balloon mitral commissurotomy

Abstract Two patients with mitral stenosis are described in whom spontaneous echocardiographic contrast in left atrium as detected by transoesophageal cross-sectional echocardiography resolved after percutaneous balloon mitral commissurotomy.