Peter Alison

Penetrating cardiac injury: Overcoming the limits set by Nature

Repair of cardiac wounds was considered impossible little over 100 years ago. Despite progress, penetrating cardiac injury remains a highly lethal form of trauma today. Cardiac tamponade and exsanguination are the greatest immediate and life-threatening risks. Clinical presentation is extremely variable and diagnosis may be highly deceptive. Unlike other forms of trauma, resuscitation is of limited value and urgent operative intervention is the only meaningful treatment. Refinements in cardiothoracic surgery and the simultaneous evolution of trauma care systems have both contributed to saving lives. However, mortality rates for this condition have changed little in the last century, due largely to the rising proportion of more lethal injuries caused by gunshot wounds.

Repair of injuries to the thoracic aorta and great vessels: Auckland, New Zealand 1995-2004.

Background:  Traumatic injury to the aorta and great vessels is a surgical emergency with survivors who reach hospital typically having suffered multiple injuries. There are several diagnostic and treatment options available, with new modalities emerging to challenge the gold standards. A review of recent trends in management of these injuries in Auckland, New Zealand was carried out and patient outcomes assessed.

Acute Ischaemic Ventricular Septal Defect—A Formidable Surgical Challenge

BACKGROUND To evaluate our surgical results for Acute Ischaemic Ventricular Septal Defect and suggest practice guidelines. METHODS Retrospective review of data from patient records between 1992 and 2006 for presentation, surgical approaches, morbidity and mortality, statistically analysed to derive guidelines for management. RESULTS We had 36 patients with a mean age of 70.44(+/-6.34) years. Fourteen patients had inferior defects. Twenty-eight patients were in shock (22 on pre-operative IABP). Severe LV and RV dysfunction were present in 18 and 20 patients respectively. At surgery, 17 had infarct resection with patching while 18 had repair with infarct exclusion. Concomitant CABG was performed in 15. One patient was re-operated on for mitral valve replacement and one for recurrent VSD. Recurrent VSD was common (11 patients). Two of these patients underwent percutaneous device closure of whom one died. Prolonged ICU and hospital stay was normal. Early mortality was 52.78% (inferior defects-85.71% and anterior defects-31.82%). Inferior VSD (OR 7.7) and pre-operative shock (OR 6.7), predicted mortality. The subgroup of inferior VSD with shock had mortality equating that with medical management published in literature. CONCLUSIONS Acute Ischaemic VSD is a grim surgical disease marked by residual shunts and high mortality. Patients with inferior defects with shock should be offered surgery only under exceptional circumstances.

Emergency debranching and stent grafting for complex aortic arch injury.

Traumatic aortic arch rupture is associated with a high mortality rate. Historically, the mainstay of treatment has been emergency open repair with cardiopulmonary bypass. This has had significant associated mortality and morbidity in a group of patients who often have multiple injuries. In recent times endoluminal stent graft (ESG) placement has become a treatment option as it is viewed as less invasive with favourable procedural and postoperative outcomes. We describe a case of complex aortic injury involving both the anterior and posterior aortic arch in a high-risk patient, treatedwith off-pump transposition of the arch vessels followed immediately by ESG placement to the mid ascending aorta (zone 0).

CT09 ACUTE ISCHAEMIC VENTRICULAR SEPTAL RUPTURE – A FORMIDABLE SURGICAL CHALLENGE

Purpose  To evaluate our surgical results for ischaemic Ventricular Septal Rupture and suggest practice guidelines.