Robert Xu

Unexplained bloody pericardial effusion: a diagnostic dilemma.

A 38-year-old Caucasian male smoker presented with dyspnoea secondary to a large pericardial and moderate left pleural effusion, with elevated serum inflammatory markers and bloody pericardial aspirate. Large-volume fluid samples proved negative for malignancy and acid-fast bacilli, both on first presentation and at recurrence 1 month later. No malignancy was apparent on contrast computed tomography, and treatment with colchicine and prednisolone was initiated. No further re-accumulation was observed at 2 months; serum inflammatory markers had normalized and …

Peripheral Cannulation for Cardiopulmonary Bypass in Resection of Renal Cell Carcinomas with Level 3 Tumour Thrombus.

BACKGROUND In renal cell carcinomas with tumour thrombus involving the intrahepatic vena cava or above (Level 3+), the urologist will often require the assistance of a cardiothoracic surgeon to establish cardiopulmonary bypass to safely perform a cavotomy for complete resection - this is traditionally through a sternotomy and central cannulation approach. METHODS We present two cases of patients with Level 3 tumour thrombus involvement, in whom resection was performed with bypass established through peripheral cannulation, thus avoiding the added morbidity of a sternotomy. RESULTS The cases were performed without any major adverse events, with bypass times of 55 and 200minutes respectively. CONCLUSIONS Peripheral cannulation is a useful tool in the cardiothoracic surgeons armamentarium, whose utility should be remembered outside of its traditional setting. We describe two cases, where peripheral cannulation for CPB has been shown to be a safe and minimally invasive alternative to sternotomy for resection of locally advanced renal cell carcinomas.

Right video-assisted thoracoscopy thoracic duct ligation as treatment for a case of chyloptysis

CLINICAL SUMMARY A 71-year-old man presented with ongoing expectoration of milky, foul-tasting sputum, while denying any systemic symptoms. He first presented in 2007 with a type B dissection with an aneurysmal complex. He underwent distal aortic arch repair via a left anterolateral thoracotomy approach with femoral-femoral bypass via percutaneous cannulas. The distal aortic arch was transected and a 26-mm Dacron graft was sutured, with a distal anastomosis formed below the pulmonary hilum to the distal descending thoracic aorta. The left subclavian artery was resected as high as possible, anastomosed to an 18-mm Gelseal (Terumo Cardiovascular Systems Corp, Ann Arbor, Mich) graft that was then attached to the aortic graft. The patient was returned to the operating room postoperatively for evacuation of a hematoma, after which he progressed well and was transferred out of the intensive care unit. On day 14, a progressive left pleural effusion was confirmed on computed tomography and tapped using needle thoracostomy. Biochemistry of the specimen confirmed a diagnosis of chylothorax, with a protein level of 22 g/L, an LD level of 530 U/L, and a triglyceride level of 8.3 mmol/L, meeting the diagnostic criteria determined by the Mayo Clinic (>1.24 mmol/L or 110 mg/dL). After a trial of conservative therapy, including tube thoracostomy drainage and 2 weeks of a medium chaintriglyceride diet with octreotide adjunct, the chyle leak persisted and the patient received surgical intervention via redo thoracotomy.

Beating heart minimally invasive mitral valve surgery in patients with previous sternotomy: the operative technique and early outcomes

Objective Reoperative mitral valve surgery is increasingly required and can be associated with significant morbidity and mortality. The beating heart minimally invasive mitral valve surgery has a proposed benefit in avoiding the risks of repeat sternotomy, with reducing the need for adhesiolysis and cardioplegia reperfusion injury. We describe our experience with such a technique in patients with previous sternotomy. Methods A retrospective study was performed and all patients undergoing surgery of mitral valve through a right limited thoracotomy without application of an aortic cross-clamp (beating heart) as a redo cardiac surgery between January 2006 and January 2015 were included (n=25). Perioperative data as well as the operative technique are presented. Results Six patients (24%) had two previous sternotomies and one (4%) had three previous sternotomies. Mitral valve repair was performed in 11 patients (44%). No patient required conversion to median sternotomy. Inotropic support beyond 4 hours after operation was required in seven patients (28%). Ventilation time was less than 12 hours in 14 patients (56%) with another six patients (24%) extubated within 24 hours after surgery. Postoperative course was complicated with cerebrovascular accident in two patients (8%). In-hospital mortality was 4% (n=1). There was no 30-day mortality after discharge. Conclusions Reoperative mitral valve surgery can be safely performed through a limited right thoracotomy approach on a beating heart while on full cardiopulmonary bypass. The technique can be associated with potentially shorter operation, shorter cardiopulmonary bypass and a less complicated recovery.

On-X versus St Jude Medical Regent mechanical aortic valve prostheses: early haemodynamics

Objective We aimed to compare the early haemodynamic data of the On-X and St Jude Medical (SJM) Regent bileaflet mechanical prostheses in the aortic position. Methods A retrospective study was performed using data collected prospectively for a national database. Thirty-three patients who had aortic On-X valve (On-X group) and 33 matched patients who had aortic SJM Regent valve (SJM group) were included. The intraoperative and early postoperative data were collected. The same echocardiographer reviewed all the echocardiograms and obtained the required parameters. Results The peak gradient across the prosthetic valve was comparable between the two groups except for the labelled valve size of 25 mm for which the On-X group had lower peak gradient when compared with the SJM group. Mean gradients and effective orifice area indices of the two valve types within each valve size subgroup were comparable. Conclusions The current study confirms that in the early postoperative period, the two valve types had comparable haemodynamic outcomes.

Staged Bentall procedure and extra-anatomical repair of coarctation of aorta

cal material from colonic insufflation. Acute appendicitis following colonoscopy is a very rare complication of this common procedure. This poses a diagnostic challenge given the similarity of presentation with other more well‐known complications. It is important to recognize that pathophysiological mechanisms are possible in the absence of polypectomy and/or electrocautery. Nevertheless, in the setting of a recent colonoscopy and abdominal pain, a high index of suspicion is needed for a timely diagnosis and early intervention of post‐colonoscopy appendicitis, especially since the rapid progression to gangrene and perforation has been observed.