Asian Cardiovascular and Thoracic Annals

The author reviewed his personal experience with 776 video-assisted thoracoscopic procedures on 526 patients over a 34-month period, with particular attention to perioperative complications and procedure failures. There was one death (mortality rate 0.2%). Nonfatal complications comprised persistent air leaks (13), bleeding (4), wound infection (2), intercostal neuralgia (5), cerebrovascular accident (1), reexpansion pulmonary edema (1), deep vein thrombosis (1), prolonged ventilatory support (1), and port site recurrence (1), giving rise to an overall nonfatal complication rate of 5.5%. Procedure failures consisted of 4 incidences of recurrence of pneumothorax (out of 213 cases or 1.9%); 2 recurrences of malignant pleural effusion (out of 39 cases or 5.1%); 2 recurrences following resections for stage I lung cancer (out of 32 cases or 6.3%). Proportionally more complications and procedure failures were seen in the first 17 months compared to the following 17 months, in spite of the fact that more technically advanced procedures were performed in the latter period. Careful patient selection and attention to details are essential in optimizing surgical results.

Understanding of the importance of the role of compensatoty mechanisms in heart failure has been translated into therapeutic options which can improve cardiac function, favorably alter disease progression, and improve survival. Sinus tachycardia in heart failure results from neurohormonal activation, which reduces ventricular filling time and thus further increases atrial pressure and venous congestion. It may also cause myocardial ischemia, leading to progressive ventricular dysfunction. In this review, the role of heart frequency modulators in heart failure is discussed.

Ten patients (mean age 36.6 ± 8 years; 5 male) with idiopathic inferior vena cava obstruction underwent balloon angioplasty, followed by placement of a self-expanding stent. Six had total occlusion, 5 had restenosis (including 2 with total occlusion), and I had a suboptimal result after initial dilatation. The mean diameter of the inferior vena cava increased from 1.5 ± 2.1 mm to 14.4 ± 2.7 mm, and the pressure gradient between the vena cava and the right atrium decreased from 15.2 ± 5.0 mm Hg to 1.1 ± 1.5 mm Hg. Follow-up venography after 74 ± 35 days in 6 patients, revealed ho restenosis, with further enlargement of the mean diameter by 5.2 ± 3.1 mm (44 ± 35%) and abolition of pressure gradients. One patient died 6 months after the procedure from acute Budd-Chiari syndrome. Autopsy revealed a widely patent stent with hepatic vein thrombus. Stent implantation is useful in the management of inferior vena cava obstruction with prior restenosis, total occlusion, or suboptimal results of balloon angioplasty.

To evaluate the size adequacy of CarboMedics prosthetic heart valves, Doppler pressure gradients after aortic valve replacement were determined at rest and immediately after exercise in 83 patients, at a mean time of 18.8 days after aortic valve replacement with CarboMedics prosthetic heart valves (31 standard and 52 R-series). There were 54 males and 29 females, average age 55 years; 12 had pure aortic stenosis, 47 had aortic regurgitation, and 24 had combined lesions. Exercise significantly increased (p < 0.01) the peak velocity (from 2.50 to 2.88 m/sec), the peak pressure gradient (from 25.9 to 34.6 mm Hg), and the mean pressure gradient (from 13.9 to 18.4 mm Hg). Significant differences were observed even in patients with seemingly large valve sizes. Significant correlation (p < 0.0001) was observed between pressure gradients at rest and immediately after exercise, as well as between pressure gradients and theoretical performance index. A theoretical performance index larger than 1.0 cm²/m² was needed to obtain a postexercise Doppler peak pressure gradient of less than 60 mm Hg early after aortic valve replacement using either the Carbomedics standard or R-series prosthetic heart valves.

Between July 1989 and July 1995, 89 CarboMedics prosthetic heart valves were implanted in 70 patients (38 males, 32 females) ranging in age from 13 to 54 years (mean 33 years). Forty-one of these patients underwent mitral valve replacement, 10 had aortic valve replacement, and 19 had double aortic and mitral valve replacement. Early mortality was 4.9%, 0%, and 15.8% respectively in these groups. Mean follow-up time was 3.4 years and was 95.4% complete (3 lost). There were 5 late deaths (7.7%); 1 in the mitral group, 1 in the aortic group, and 3 who had double valve replacements. Three of these late deaths were considered valve-related. The 5-year actuarial survival rates, hospital mortality excluded, were 97% for mitral, 88% for aortic, and 88% for double valve replacement. Preoperatively, 80% of the patients were in New York Heart Association functional class III or IV, whereas postoperatively, 99.5% of the patients were in class I or II. No structural failures were observed. There was 1 case of systemic embolism and 1 case of valve thrombosis, neither of these patients were taking anticoagulants. Hemorrhage was the most frequent complication; 1 of 4 events was fatal. A less intensive warfarin regimen and improvement in hepatic function may reduce hemorrhagic risk while maintaining thromboembolic protection. On the basis of this experience, the CarboMedics prosthetic heart valve appears to be an excellent mechanical prosthesis for cardiac valve replacement, in terms of hemodynamic performance and low thrombogenicity, in patients receiving anticoagulants.

The management of mild tricuspid valve disease associated with left-sided valve lesions remains controversial. Between January 1985 and September 1995, 87 patients underwent combined double (aortic and mitral) valve replacement and tricuspid valve repair at the Shanghai Chest Hospital. The early mortality was 16.1%. Predictors of early mortality were found to be New York Heart Association functional class IV and right ventricular systolic pressure of 65 mm Hg or more, by multivariable regression analysis. The mean follow-up was 4.6 years. Cumulative 3-year and 5-year survival rates in patients discharged from hospital were 80% ± 4% and 63% ± 7%. Late mortality was due to sudden death (18.7%), myocardial infarction (6.5%), and cerebral embolism or hemorrhage (31.2%). Of 48 patients still alive, 45 are in New York Heart Association functional class I or II. None of them has mild or moderate tricuspid regurgitation. Based on these results, we recommend early surgical treatment prior to the appearance of severe hemodynamic deterioration and we propose a policy of liberal indication for tricuspid annuloplasty for mild functional tricuspid insufficiency at the initial double valve replacement.

We reviewed our surgical experience, over a 7-year period, of 38 patients with congenitally corrected transposition of the great arteries with ventricular septal defect and pulmonary stenosis, who were anatomically well-suited for a biventricular repair. Follow-up ranged from 2 to 9 years (mean 5.3 years). One group of patients underwent a univentricular repair; there were 2 early deaths (8%) among the 24 patients who underwent a Fontan-type repair and 5 patients had prolonged pleural effusion. There was no early mortality in the 3 patients who underwent a bidirectional Glenn anastomosis but there was 1 late death. Patients undergoing a biventricular repair comprised 6 who had closure of a ventricular septal defect and pulmonary valvotomy, and 5 who had ventricular septal defect closure and conduit repair. There was 1 early death (9%) and 2 patients developed iatrogenic complete heart block in this group but there was no late mortality. None of these patients had a double switch procedure. With the advent of the double switch procedure, there are now 3 modes of management for these defects. Determining which of these provides the best long-term result is still a matter for debate.

Between 1968 and 1995, a total of 153 patients who were between 35 and 63 years of age (mean 49.8 years), underwent surgery for secundum type atrial septal defect. There were 78 (50.9%) males and 75 females (49.1 %). Mean left-to-right shunt ratio was calculated as 2.49. Mean pulmonary artery pressure was 50.15 mm Hg. Three patients died within 30 days of surgery, giving a hospital mortality of 1.96%. Long-term follow-up was available in 135 cases (90%). Total follow-up was 967.3 patient-years and ranged from 3 months to 11.3 years (mean 7.16 years). There were no late deaths reported. Four patients were readmitted with atrial fibrillation and 2 with pericardial effusion. In our experience, surgical closure of atrial septal defect in adults was found to be successful, safe, and with low morbidity in patients with pulmonary hypertension and congestive heart failure.

Residual shunt was determined by postoperative echocardiogram after hemoclip closure of patent ductus arteriosus in 22 neonates, and compared with the findings in 15 neonates who had conventional ligation of the ductus between January 1992 and December 1994. There were no significant postoperative complications related to the surgery. The study showed no residual shunt across the ductus by color and pulsed wave Doppler echocardiography in either group, with the exception of one patient who required a second hemoclip operation. We conclude that the method of closure with a hemoclip is safe and effective.

Severe restrictive lung pathology following long-standing valvular disease is not uncommonly seen in developing countries. Acute restrictive pulmonary conditions, corrective surgery, and the effects of cardiopulmonary bypass add to the preexisting lung pathology. This may lead to a difficult postoperative respiratory management culminating in an inability to wean such a patient from the ventilator. We present the successful respiratory management of 3 frail patients with rheumatic heart disease and severe respiratory lung pathology, who underwent valve replacement surgery.

A 32-year-old housewife was treated for recurrent pericardial effusion with repeated pericardiocentesis and pleuropericardial window formation after a diagnosis of tuberculous pericarditis. The biopsied pericardium revealed nonspecific inflammation. In spite of continuing antituberculosis medication, she did not improve and the pericardial effusion increased with emerging signs of progressive right heart failure. A pericardiectomy was performed and multiple masses with a cobblestone appearance were found on the entire epicardium and the great vessels. The partially excised masses showed mesothelial hyperplasia and capillary hemangioma. The pericardial effusion continued and radiation therapy (2,000 cGy/2 weeks) was given with corticosteroid to control immune thrombocytopenic purpura. On the 87th postoperative day, a left posterolateral thoracotomy was performed to remove a large pleural hematoma which was compressing the left atrium and the left ventricle. We found extensive spread of the hemangioma into the pleural cavity along the intercostal vessels. The patient died 3 days later from massive uncontrollable hemorrhage.

We report a case of bullet penetration into the left iliac vein, with embolus into the inferior vena cava and migration up to the junction of the inferior vena cava and the right atrium. The bullet was subsequently extracted through laparotomy from the infrarenal segment of the inferior vena cava, just above its bifurcation.

A modified technique for the repair of tetralogy of Fallot with absent pulmonary valve syndrome and stenosis at the origin of the lobar or segmental pulmonary artery branches is described. This consists of generous reduction plasty of the redundant anterior and posterior walls of the aneurysmally dilated branches of the pulmonary artery, resection of the main pulmonary artery, pericardial patch augmentation of the stenotic origins of the lobar or segmental pulmonary artery branches, insertion of a valved pulmonary allograft, and closure of the ventricular septal defect. The advantages of this technique, in addition to relief of the left-to-right shunt, consist of complete decompression of the tracheobronchial structures, and restoration of the capacitance of the central pulmonary arteries. This may result in a reduced tendency for postoperative respiratory insufficiency as well as long-term preservation of right ventricular compliance. The technique was successfully performed on 2 critically ill neonates and a 3-month-old infant.

Bilateral partial anomalous pulmonary venous connection is a very rare malformation; its association with intact atrial septum is even more unusual. This report concerns a 5-year-old girl with this condition who underwent successful surgical repair.

A 4-month-old infant with an anomalous left coronary artery underwent a surgical correction in the form of tubular reconstruction of the anomalous coronary artery using a cuff of the main pulmonary artery and creation of a viable two-coronary artery system. Subsequently, mitral valve repair was performed for severe mitral insufficiency, which had not abated after the repair of the anomalous coronary artery. This case demonstrates the difficulties in diagnosing such patients, along with the advantage of creating a viable two-coronary artery system in such sick infants.

A clamshell incision allows simultaneous correction of aortic coarctation and intracardiac defects. This incision combines the benefits of a single incision with those of excellent exposure of the heart and the entire thoracic aorta as well as a superior cosmetic result.