Search

Background Postoperative pericardial effusion (PPE) is a frequently occurring event after cardiac surgery, potentially leading to life-threatening cardiac tamponade. Unfortunately, no guidelines are currently available on this subject, possibly leading to unwarranted variations in care in clinical practice. Purpose The goal of our study was to determine the diagnostic and therapeutic preferences of cardiologists and cardiothoracic surgeons in the Netherlands regarding PPE, and to evaluate possible variations in this matter between specialties and centers. Methods A web-based questionnaire was sent to all interventional cardiologists and cardiothoracic surgeons in the Netherlands. Diagnostic preferences for the evaluation of PPE were examined. Additionally, clinical preferences were explored in response to 4 patient scenarios with each illustrating a combination of either high or low clinical suspicion of cardiac tamponade and either high or low echocardiographic suspicion. Each scenario was also stratified by 3 different amounts of PPE (2cm), leading to a total of 12 fictional patient cases (Figure 1). Results From 27 of the 31 contacted centers, a total of 94 clinicians responded to the survey, of whom 46 interventional cardiologists and 48 cardiothoracic surgeons. Cardiologists were more in favor of routine postoperative echocardiography in all patients (44%), whereas cardiothoracic surgeons preferred routine imaging after specific procedures, especially after mitral (85%) and tricuspid (79%) valve surgery. Overall, drainage of PPE (>48 hours postoperatively) was preferred through pericardiocentesis (83%) instead of surgical evacuation (17%). Regarding the patient scenarios, cardiothoracic surgeons were significantly more inclined to evacuate PPE compared to cardiologists for all scenarios combined (51% vs 37%, p Conclusions Our study highlights the significant variation of preferences in contemporary PPE management between cardiothoracic surgeons and interventional cardiologists in the Netherlands, sometimes even within the same center. These findings are the possible consequences of a current lack of general recommendations or guidelines. This could lead to unwarranted variation in care and additional research is necessary to provide general recommendations. Funding Acknowledgement Type of funding sources: None.

Background: Several animal studies suggested that the angiotensin II type 2 (AT2) receptor subtype mediates vasodilation, yet the results in human arteries are less well described and more inconsistent. Therefore, we evaluated the role of the AT2 receptor stimulation on the vasotonus of human internal mammary arteries. Methods: Internal mammary arteries were obtained from 50 patients undergoing coronary bypass surgery. The expression of angiotensin II type I (AT1) receptor and AT2 receptor mRNA was determined by using real-time polymerase chain reaction. In addition, angiotensin II and CGP42112A concentration-response curves (concentration range: 10(-10) M to 10(-6) M) were constructed in absence or presence of candesartan (10(-5) M) and/or the AT2 receptor-antagonist PD-123319 (10-6 M) and/or the a receptor antagonist phentolamine. Results: Both AT1 and AT2 receptor protein and mRNA were detected, and higher AT2 receptor mRNA expression levels were associated with increased contractile response to angiotensin II. Angiotensin II caused vasoconstriction up to 41.1 +/- 6.5% of the maximal response to phenylephrine, and PD123319 significantly reduced this response (28.6 +/- 9.6%, P

The QUO VADIS (the effects of QUinapril On Vascular Ace and Determinants of ISchemia) study was a randomized, double-blind, placebo-controlled trial designed to evaluate the effects of long-term angiotensin-converting enzyme (ACE) inhibition on angiotensin II formation in human vasculature. Patients (n = 187) scheduled for coronary artery bypass surgery used study medication 27 +/- 1 days before surgery. Segments of internal mammary arteries were exposed to increasing doses (0.1 nM-1 microM) of angiotensin I and II in organ baths. The rate of local angiotensin II formation is a function of the reciprocal of the difference between the pEC50's of the dose response curves to angiotensin I and II (-log/mol) and of the area between the curves (units). Quinapril (40 mg) and captopril (3 x 50 mg) similarly and significantly reduced mean blood pressure compared with placebo (p = 0.04). Difference between pEC50's was 0.90 +/- 0.08 in quinapril patients compared with 0.60 +/- 0.08 for placebo (p = 0.01); the area between curves was 91 +/- 8 for quinapril patients compared with 67 +/- 8 for placebo (p = 0.03). Angiotensin II formation was decreased to a lesser extent with captopril and was not statistically different from placebo (p = 0.3); the difference between pEC50's was 0.83 +/- 0.15; the area between curves was 84 +/- 12. This is the first randomized study to demonstrate that long-term oral treatment with an ACE inhibitor reduces vascular angiotensin II formation in humans.

Median sternotomy, currently the standard incision in open heart procedures, is rarely complicated by wound infection, but when present, it is associated with a high morbidity and mortality. Adequate treatment can be provided by means of transposition of the pectoralis major muscle. After thorough sternal wound debridement the muscle, based on the thoraco-acromial pedicle, is transposed into the defect. From September 1986 until December 1992 14 patients (mean age 67 years) with sternal infection were treated using this technique. Mean hospital stay after operation was 23 days; mean follow-up was 24 months. In 10 patients (72%) a successful treatment, i.e. a permanently cured infection, was achieved. Three patients (21%) developed a recurrence; one of them died during follow-up as a consequence of cardiac failure, the other two underwent reoperation and healing occurred at a later stage. In one patient (who died of a unknown cause 2 months after muscle transposition) the result was classified as unknown. In conclusion, transposition of the pectoralis major muscle is an adequate treatment for severe sternal infections. In comparison with conservative methods, mortality and morbidity can be reduced and hospital stay can be shortened.

A 69-year-old man with a history of coronary artery bypass grafting and a recent inferoposterior myocardial infarction presented to the hospital for diagnostic coronary angiography. Physical examination, laboratory analyses, coronary angiography, echocardiography, and CT scan were performed. A giant aneurysm of the aortocoronary venous bypass graft, associated with compression of the right side of the heart, was revealed. After surgical resection and replacement of the venous graft the patient died due to right ventricular failure. (Neth Heart J 2007;15:252-4.17923880Neth Heart J 2007;15:252-4.)

The feasibility of midsternal approach for closure of bronchopleural fistula is demonstrated in three patients who had previously undergone sternotomy for aortocoronary bypass grafting.

Aortitis with involvement of the aortic valve is rarely associated with vasculitis syndromes. We present a patient with antibodies to a neutrophil cytoplasmic antigen-associated (ANCA) vasculitis with renal failure who developed aortic incompetence as a result of aortitis which involved the aortic valve. Thickening of the aortic wall also caused stenosis of the left coronary ostium.

Patent coronary artery bypass grafts are at risk of injury during redo cardiac surgery. In particular, damage to a patent left internal mammary artery (LIMA) graft during repeat surgery is a well-described and potentially lethal complication [1]. Precise anatomical information is important for planning the surgical approach in reoperative cardiac surgery. The standard preoperative work-up including coronary angiography and chest X-ray may provide unsatisfactory information about the exact anatomical location of grafts [2]. This case report illustrates the value of preoperative computed tomography angiography (CT angiography) in patients undergoing repeat cardiac surgery after prior aortocoronary bypass surgery.

A 27-year-old man, two 54-year old men and a 64-year-old woman presented with aspecific symptoms: acute pain and tingling in the shoulders plus paraplegia; exertional dyspnoea and tingling in both feet for the past week; increasing shortness of breath and cold, pale legs and feet for the past week; acute retrosternal pain, incontinence and paraparesis. The cause was dissection of the ascending aorta (type A). Following the operation, the legs were amputated because of ischaemia. The 27-year-old man and one of the 54-year-old men died; the other two patients made a satisfactory recovery. Acute type-A aortic dissection is a life-threatening disease that must be recognised early because it is an absolute indication for emergency surgery. The initial manifestation of type-A dissection may be very aspecific. Post-operative lower limb ischaemia, as the first symptom of this disease, is rare and usually disappears after surgery for type-A dissection. In some cases, however, ischaemia persists and alters the post-operative course dramatically.

To evaluate the initial experience with pulmonary thromboendarterectomy for cor pulmonale due to chronic pulmonary embolism.In the period 1 April 1996 to 31 October 2001, 18 patients with right ventricular failure due to chronic thromboembolic pulmonary hypertension were operated on. Their mean age was 54 (SD: 14) years. Preoperatively, all of the patients were in functional New York Heart Association (NYHA) class III or IV. Pulmonary angiography revealed pulmonary hypertension with an increased pulmonary vascular resistance, as well as typical angiographic signs of unresolved chronic emboli. Pulmonary thromboendarterectomy was performed via median sternotomy, using extracorporeal circulation and intermittent deep hypothermic circulatory arrest. The patients were monitored via the outpatients' department.From a technical viewpoint, the procedure was performed successfully in all of the patients. Initially the pulmonary thromboendarterectomy was performed unilaterally (n = 7), which did not decrease pulmonary artery pressure significantly. The following 11 patients were treated bilaterally; in them thromboendarterectomy required an average of circulatory arrest totalling 64 (SD: 30) min with 161 (SD: 35) min of myocardial ischemia. After bilateral pulmonary thromboendarterectomy, the pulmonary artery pressure decreased from 45 (SD: 13) to 28 (SD: 9) mmHg (p = 0.001). Reperfusion pulmonary oedema, requiring prolonged ventilation, occurred in 3 patients. There was no operative or later mortality. At a mean follow-up of 28 (SD: 19) months, all but one of the patients were in functional NYHA class I or II. Echocardiography revealed reduced right ventricular dimensions and pulmonary artery pressures. One patient, with mainly distally located obstructions, exhibited no substantial improvement.The initial experience with pulmonary thromboendarterectomy for patients with cor pulmonale due to chronic pulmonary emboli demonstrated satisfactory mid-term follow-up data.

To evaluate our initial experience with the reimplantation technique of the aortic valve.Retrospective.From January 1st 1998 to January 31st 2000, 13 patients were operated on by the technique as described by David. Mean age was 52.2 years (SD: 11). Median preoperative New York Heart Association (NYHA) functional class was 2/4 and median preoperative degree of aortic regurgitation was 3/4. Surgical indications were initially limited to aneurysmal disease of the aortic root (n = 6) and ascending aorta (n = 4), all complicated by aortic regurgitation. Later on, we also applied the technique in type A aortic dissection (n = 3). The repair was evaluated peroperatively by transoesophageal and postoperatively, by transthoracic echocardiography. The patients were followed postoperatively in the outpatient department.No technical problems arose that necessitated change or adjustment of the technique. Mean cardiac arrest time was 184 min (SD: 40) and cardiopulmonary bypass time 254 min (SD: 74). The primary aetiology on histopathological examination was medial necrosis in 5 patients and degenerative disease in the others. There was no early nor late mortality and none of the patients was reoperated upon the aortic root. Follow-up was complete at a mean of 12.3 months (SD: 8). Median aortic regurgitation at follow-up was 0.5 (p = 0.0001 versus preoperative) and median NYHA functional class at follow-up was 1 (p = 0.02 versus preoperative).David's aortic valve reimplantation technique was carried out with a low surgical risk and a low degree of residual aortic regurgitation in aneurysm of the aortic root, aneurysm of the ascending aorta and type A dissection with major destruction of the aortic root.

The QUO VADIS (the effects of QUinapril On Vascular Ace and Determinants of ISchemia) study was a randomized, double-blind, placebo-controlled trial designed to evaluate the effects of long-term angiotensin-converting enzyme (ACE) inhibition on angiotensin II formation in human vasculature. Patients (n = 187) scheduled for coronary artery bypass surgery used study medication 27 +/- 1 days before surgery. Segments of internal mammary arteries were exposed to increasing doses (0.1 nM-1 microM) of angiotensin I and II in organ baths. The rate of local angiotensin II formation is a function of the reciprocal of the difference between the pEC50's of the dose response curves to angiotensin I and II (-log/mol) and of the area between the curves (units). Quinapril (40 mg) and captopril (3 x 50 mg) similarly and significantly reduced mean blood pressure compared with placebo (p = 0.04). Difference between pEC50's was 0.90 +/- 0.08 in quinapril patients compared with 0.60 +/- 0.08 for placebo (p = 0.01); the area between curves was 91 +/- 8 for quinapril patients compared with 67 +/- 8 for placebo (p = 0.03). Angiotensin II formation was decreased to a lesser extent with captopril and was not statistically different from placebo (p = 0.3); the difference between pEC50's was 0.83 +/- 0.15; the area between curves was 84 +/- 12. This is the first randomized study to demonstrate that long-term oral treatment with an ACE inhibitor reduces vascular angiotensin II formation in humans.

Surgical correction of pectus deformities was mainly performed for cosmetic and psychologic reasons but eventual cardiopulmonary symptoms improved. Whether this results from alterations in cardiopulmonary physiology is still controversialIn 25 years 662 patients underwent correction (390 for pectus excavatum-funnel chest, 235 for pectus carinatum-chicken chest, 37 for pectus arcuatum-pouter pigeon chest). Surgical correction was mainly performed for cosmetic and psychologic reasons. Sternochondroplasty was performed without prosthetic materialClinical results for funnel chest were satisfactory in 83.6% (excellent 44.1%, good 39.5%) and were always good for protrusion deformities if enough deformed cartilages were resected. In a retrospective study the pulmonary function tests performed on 152 patients with funnel chest before surgery and at long-term follow-up demonstrated an eventual increased restriction at follow-up, despite symptomatic improvement and increased anteroposterior chest diameter on the X-ray, but restricted anterior chest wall motion. In a prospective study the exercise cardiorespiratory function tests on 35 patients with funnel chest before and one year after operation suggested unchanged work performance, but an increased oxygen consumption and acidification due to a higher work of breathing after operation, caused by decreased chest wall compliance.The subjective physical improvement after operation cannot be explained by changes in static lung volumes or in cardiorespiratory function at exercise, but is due to other unexplained factors. Satisfactory subjective long-term results of most patients justify surgical correction. Both physical as well as psychologic and cosmetic factors may allow operative correction.

The use of circulatory arrest with selective antegrade cerebral perfusion is described in a 59-year-old man who underwent thrombendarterectomy for chronic thromboembolic pulmonary hypertension. The postoperative course was uneventful. The described surgical technique may prevent the patient from cerebral sequelae especially in more complex cases.

The use of circulatory arrest with selective antegrade cerebral perfusion is described in a 59-year-old man who underwent thrombendarterectomy for chronic thromboembolic pulmonary hypertension. The postoperative course was uneventful. The described surgical technique may prevent the patient from cerebral sequelae especially in more complex cases.

Thirteen patients with a pectus excavatum deformity, without associated cardiopulmonary symptoms, were treated by implantation of a custom made silicone prosthesis. The postoperative results are reported and the indications for this operation are discussed.

We describe a case of spontaneous coronary artery dissection in a 38-year-old woman presenting with anterior myocardial infarction who was initially treated with thrombolysis. During the administration of thrombolytics the clinical symptoms and the electrocardiogram (ECG) deteriorated. Coronary angiography revealed a major dissection in the proximal left descending coronary artery. A spontaneous dissection was hypothesized to have extended by thrombolytic-induced bleeding into the dissected vessel wall. Therefore, we advocate that, especially in young female patients presenting with an acute myocardial infarction and without cardiac risk factors, direct coronary angiography be considered, rather than thrombolytic therapy, in order to decide for the optimal therapeutic strategy. © Wiley-Liss, Inc.

In 35 patients with pectus excavatum (aged 17.9 +/- 5.6 years) pulmonary function and maximal exercise test results were compared before and at 1 year after operation. The lower posteroanterior chest diameter on the lateral x-ray film was significantly smaller than normal (p0.0001) and increased significantly after operation (p0.0001). Preoperatively, total lung capacity (86.0% +/- 14.4%; p = 0.0001) and inspiratory vital capacity (79.7% +/- 16.2; p = 0.0001) were significantly smaller than predicted and further decreased after operation (-9.2% +/- 9.2%; p = 0.0001 and -6.6% +/- 10.7%; p = 0.0012, respectively). Arterial blood gas values displayed normal patterns with increasing exercise both before and after operation. Only the arterial pH decreased more after operation than before (p = 0.0026). After operation there was a significant increase in maximal oxygen uptake (oxygen uptake; p = 0.0002 and oxygen uptake per kilogram; p = 0.0025) and oxygen pulse (oxygen uptake/heart rate approximates an indirect parameter for stroke volume; p = 0.0333) during exercise, whereas the maximal work performed was unchanged. Efficiency of breathing (ratio of tidal volume/inspiratory vital capacity) at maximal exercise improved significantly after operation (p = 0.0005). Ventilatory limitation of exercise (defined by an increase in carbon dioxide tension during exercise) was found in 43.9% of the patients before operation. A tendency of improvement was noted (not significant) after operation (difference in carbon dioxide tension 0.6 +/- 0.4 kPa before versus 0.3 +/- 0.5 kPa after operation). However, the group with normal preoperative carbon dioxide elimination had a ventilatory limitation of exercise after operation (difference in carbon dioxide tension -0.4 +/- 0.3 kPa before versus -0.1 +/- 0.3 kPa after operation; p = 0.0128) with a significant increase in oxygen consumption (p = 0.0007). In conclusion the subjective physical improvement after operation is not explained by changes in cardiorespiratory function at exercise. The data suggest a higher work of breathing after operation.

The treatment of superior pulmonary sulcus (Pancoast) tumor is not uniform and is still discussed. Literature data and our retrospective study are presented. Fourteen patients were operated for a Pancoast tumor. Nine patients underwent mediastinoscopy followed by preoperative radiotherapy. Five patients received adjuvant radiotherapy after incomplete resection. Five patients who did not have preoperative radiotherapy, received postoperative irradiation. All three patients who survived five years or more, had preoperative radiotherapy and two of them underwent a complete resection. Literature data are discussed and emphasis is laid on the importance of preoperative staging, including mediastinoscopy, preoperative radiotherapy and complete "en bloc" resection.

Two cases of congenital bronchial atresia with pectus excavatum are reported. Costosternal retraction during the efforts to overcome the airway obstruction due to encroachment on normal lung tissue by the hyperinflated segments may play a part in causing pectus excavatum.

Between 1972 and 1987, 192 patients have been operated upon for pectus excavatum of which 152 patients were included in the study (79%). Mean age at operation was 15.3 +/- 5.5 years; 117 were male. Mean follow-up was 8.1 +/- 3.6 years. The deformity was noted before the age of 5 in 90%. Type I symmetrical and localized deformity was seen in 33.2%, type II symmetrical but diffuse depression in 23.7% and type III localized or diffuse asymmetrical deformity in 43.1%. It was considered severe in 68.9%, fair in 16.9% and mild in 14.2%. There were significantly more asymmetrical defects in the older age groups. The operation consisted of subperichondral chondrectomy, transverse sternotomy and division of the intercostal bundles at the outer limit of the chondrectomy and suturing the edge of this broad sheet of muscle and perichondrium to the anterior surface of the chest wall more laterally and under tension, elevating and stabilizing the sternum. Results were satisfactory in 83.6% (excellent 44.1%, good 39.5%). Results were not significantly influenced by age, sex, severity, type, symmetry, the extent of cartilage resection or follow-up. Results were inversely influenced by the occurrence of wound problems. The optimal age for operation is considered to be between 5 and 10 years. Both physical as well as psychological cosmetic factors may serve as an indication for operation.

Between 1975 en 1988, 16 patients underwent pulmonary embolectomy because of massive pulmonary embolism. Three of these patients, in whom shock and cardiac arrest had occurred prior to operation, died. The role of surgery in the treatment of massive pulmonary embolism is a topical issue, also in view of the rise of thrombolytic therapy and its acceptable results. For patients whose haemodynamic condition deteriorates in spite of thrombolytic treatment and for patients in whom thrombolytic therapy is contraindicated, pulmonary embolectomy remains an effective form of treatment.

In a retrospective clinical study of 25 knees in 22 patients treated for patellofemoral pain using the technique of Fulkerson in which anteriorization of the tibial tuberosity was combined with medialization, the results were evaluated at an average of 12 months and 30 months postoperatively. At the first evaluation, the results were satisfactory in 84%. In the follow-up period up to 38 months after surgery, this percentage decreased to 70%. The patients were placed in four groups based on preoperative roentgenographic findings. Only in the relatively young group of patients without signs of patellofemoral arthritis did the results remain satisfactory in all cases. At the late evaluation, there were satisfactory results in 60% of the patients with patellofemoral arthritis and/or lateralization. The rather extensive consolidation time and the long period of revalidation are disadvantages as are the difficulties with kneeling and hypoesthesia around the scar.

A retrospective study was made of eight patients who underwent operation in the period 1974-1987 because of a Pancoast (pulmonary sulcus) tumour. Of the five patients still alive, three have had no local recurrences for 15, 4 and 2 years, respectively, after the operation. Data from this investigation and from the literature confirm that the absence of metastases in mediastinal lymph nodes, and use of preoperative irradiation may have a favourable effect on the prognosis. The best result is achieved with preoperative irradiation followed by 'en bloc' resection of the affected pulmonary lobe, the tumour-infiltrated chest wall and, if necessary, part of the sympathetic trunk and the plexus brachialis inferior. Emphasis is laid on the importance of early recognition of the tumour in case of aspecific shoulder and arm symptoms.

A case is reported of an intramural oesophageal cyst. Acute dyspnoea, due to compression of the trachea, was an indication for exploratory sternotomy.

A malignant fibrous histiocytoma of the mediastinum was successfully treated by surgery and radiotherapy. Magnetic resonance imaging was able to show the site of invasion, the two different components of the tumour, and the blood supply.

In a retrospective clinical study of 25 knees in 22 patients treated for patellofemoral pain using the technique of Fulkerson in which anteriorization of the tibial tuberosity was combined with medialization, the results were evaluated at an average of 12 months and 30 months postoperatively. At the first evaluation, the results were satisfactory in 84%. In the follow-up period up to 38 months after surgery, this percentage decreased to 70%. The patients were placed in four groups based on preoperative roentgenographic findings. Only in the relatively young group of patients without signs of patellofemoral arthritis did the results remain satisfactory in all cases. At the late evaluation, there were satisfactory results in 60% of the patients with patellofemoral arthritis and/or lateralization. The rather extensive consolidation time and the long period of revalidation are disadvantages as are the difficulties with kneeling and hypoesthesia around the scar.

The blood ordering practice in a general hospital was evaluated for 22 types of frequently scheduled elective surgical procedures. The following parameters were used: the C/T ratio (crossmatched/transfused ratio) for appraising the tendency to over-order in terms of frequency, the BOQ (blood ordering quotient) to establish whether the appropriate amount is ordered, and the transfusion probability to establish whether the risk accompanying the procedure warrants crossmatching blood. Using the results a list was compiled grouping the procedures as follows: 1. transfusion probability greater than 30%: typescreen and crossmatching of blood before the surgical procedure; 2. transfusion probability less than 30%: typescreen; 3. transfusion probability = 0%: no typescreen (remaining procedures). The number of units crossmatched for surgical procedures in the first group is in accordance with actual expected needs. Owing to the use of this list of expected haemotherapy requirements the number of patients for whom blood is crossmatched preoperatively has diminished from 76.5% to 29.8%. Furthermore, the C/T ratio has decreased from 3.33 to 1.45 with a practically unchanged transfusion probability (the mean for 22 types of surgical procedures). The number of crossmatches for these procedures has shown a 56% decrease. The use of the list of expected requirements has led to an annual saving of Dfl. 20,000-on laboratory expenses.

Intraoperative angioscopy was performed in three patients who underwent pulmonary embolectomy for massive pulmonary embolism. Angioscopy followed conventional techniques such as extracting the clot by a gallstone forceps, using a Fogarty catheter in the pulmonary tree or squeezing of the lungs. The rationale for angioscopy was to assess the result of these usual "blind" techniques. In two patients residual thrombus was detected and removed under direct visual control. Our initial experience suggests that intraoperative angioscopy appears to be useful in the detection of residual thrombus material, especially in the asanguinous, arrested heart. The small size of the angioscope allows easily access to the secondary, and up to the tertiary pulmonary branches. Clots can be visualized and extracted under direct visual control.