Interactive CardioVascular and Thoracic Surgery recent issues

[Work in progress report - Experimental] Total endovascular aortic arch reconstruction via fenestration in situ with cerebral circulatory support: an acute experimental study

Numan, F., Arbatli, H., Bruszewski, W., Cikirikcioglu, M. — 2008-07-29

The aim of this experimental study is to evaluate the feasibility of endovascular repair of the complete aortic arch by using novel fenestration devices with simultaneous support of the cerebral circulation. Two fresh human cadavers and five Yorkshire pigs were used for the experiments. In human cadavers the thoracic aorta was pressurized using a roller pump to simulate the circulation. In animal experiments right femoral artery to right distal carotid artery bypass circuit was achieved in order to support the cerebral circulation during the stent graft deployment, fenestration and conduit fixation procedures. Commercially available Valiant Thoracic Stent Grafts, covered stents, steerable guiding catheters and dilatation balloons were used. Stent grafts were deployed successfully and two fenestrations and one conduit implantation were achieved in each cadaver. All animals survived the stent graft implantation, fenestration and conduit implantation procedures. Cadaver dissection and necropsy of the animals revealed good fixation of the conduits into the fenestrated segments of the stent graft. Endovascular repair of the total aortic arch via in situ fenestration of the stent graft using cerebral circulatory support seems to be feasible and safe. Further studies are required before clinical adoption of this procedure.

[Work in progress report - Cardiac general] Short-term transcutaneous electrical nerve stimulation after cardiac surgery: effect on pain, pulmonary function and electrical muscle activity

Cipriano, G., Camargo Carvalho, A. C., Bernardelli, G. F., Tayar Peres, P. A. — 2008-07-29

This study aimed to evaluate the effectiveness of transcutaneous electrical nerve stimulation (TENS) for treatment of postoperative pain in patients who underwent cardiac surgery. In addition, we sought to determine whether TENS would be related to improved pulmonary function and muscle electrical activity in this patient population. Forty-five patients, 32 males and 13 females, aged 41–74 years were randomly allocated to receive TENS (n=23) or sham treatment (n=22) during 4 h on the third postoperative day. A 0–10 visual analogic scale was used to assess pain; lung function was evaluated by spirometry and surface electromyography (n=10 in each group) was used to quantify electrically-induced muscle activity (trapezius and pectoralis major). TENS was associated with significant reductions on spontaneous and cough-induced postoperative pain as compared to sham (P<0.05). There was also improvement in chest wall-pulmonary mechanics after TENS with proportional increases in tidal volume and vital capacity (P<0.05). In addition, electrical activity of both muscle groups was enhanced after TENS, but not post sham (P<0.05). TENS is a valuable strategy to alleviate postoperative pain following cardiac surgery with positive effects on pulmonary ventilatory function and electrical activity of thoracic and girdle muscles.

[Work in progress report - Experimental] Human parietal pleura present electrophysiology variations according to location in pleural cavity

Kouritas, V. K., Hatzoglou, C., Foroulis, C. N., Gourgoulianis, K. I. — 2008-07-29

The aim of the study was to investigate if human pleura from different anatomical locations presents electrophysiology differences. Specimens were stripped over the 2nd–5th rib (cranial), 8th–10th rib (caudal), and mediastinum during open surgery and were mounted between Ussing chambers. Amiloride and ouabain were added towards mesothelial surface and trans-mesothelial potential difference (PD_TM) was measured after 1, 5, 10 and 20 min. Trans-membrane resistance (R_TM) was calculated from Ohm's law. R_TM increased after amiloride addition, for cranial (net increase of 0.40 ·cm²) and caudal (1.16 ·cm²) pleural pieces. Mediastinal pleura R_TM remained unchanged (0.09 ·cm²). R_TM increase was higher for caudal than cranial (P=0.029) or mediastinal tissues (P=0.002). R_TM increased after ouabain addition for caudal (1.35 ·cm²) and cranial (0.56 ·cm²) pleural pieces. Mediastinal pleural tissue did not respond (0.20 ·cm²). Caudally located pleura responded greater than cranial (P=0.043) or mediastinal (P=0.003) pleural tissues. Human pleura shows electrophysiology differences according to the location within the pleural cavity. Surgeons may waste mediastinal pleura when needed but should leave intact caudal parietal pleura, which seems to be electrophysiologically the most important part of the pleural cavity.

[Work in progress report - Valves] Sorin Solo stentless valve: extended adaptability for sinotubular junction mismatch

Weltert, L., De Paulis, R., Maselli, D., Scaffa, R. — 2008-07-29

Stentless valve continence is affected by the implantation technique, annular symmetry and dilatation of the sinotubular junction. We tested in vitro how the Sorin Solo stentless pericardial valve adapts to a slightly dilated sinotubular junction. Stentless Sorin Solo aortic valves (25 mm) were sutured into a 32-mm Valsalva graft suspending the commissures into the expandable region of the graft. The neo-aortic root was pressurized and sinotubular junction size progressively decreased by wrapping the neocommissural ridge with Dacron rings. Direct endoscopic view and ultrasound imaging were used to observe geometry and morphology of leaflets, regurgitation, height and level of leaflets coaptation. Fresh porcine valves of the same annular size were used as controls. Solo valves had mild regurgitation at baseline, became continent at 32 mm sinotubular junction size and remained continent at any size of reduction, with optimal coaptation height and level. Porcine valves had severe regurgitation at baseline, became continent at 30 mm and showed mild insufficiency and reduction of the coaptation level at a sinotubular junction of 28 mm. The Solo valve prevents residual valve regurgitation for a wider range of sinotubular junction mismatch when compared with natural porcine valves. This extended tolerance to sinotubular junction mismatch suggests a safe use of stentless valves even in suboptimal geometry roots.

[Work in progress report - Vascular thoracic] New vascular graft for simplification of the aortic valve reimplantation technique

Urbanski, P. P., Frank, S. — 2008-07-29

Achievement of optimal valve geometry in valve-sparing aortic root repairs is a prerequisite for favorable valve function and, therefore, the simplification of these procedures is of utmost importance. The aim of the study was to determine the feasibility of the new vascular graft for aortic valve reimplantation technique and evaluate the early and intermediate functional results. Five patients with different aortic root and valve pathologies (1 acute aortic dissection, 4 chronic aneurysms, and 1 bicuspid valve) of whom two patients suffered from severe (4+) aortic regurgitation, underwent valve-sparing aortic root repair using the reimplantation technique with the new graft. Three patients required, in addition to the aortic root repair, other procedures on the valve cusps. In all patients, optimal root restoration with no or slight valve insufficiency could be achieved, and these results remained unchanged over the follow-up time of up to two years. The new aortic root graft simplifies aortic root repair using the valve reimplantation technique, and despite its straight form, allows easy restoration of the aortic root, which fits perfectly with patients' anatomy.

[eComment] eComment: New vascular graft for simplification of the aortic valve reimplantation technique

Bockeria, L. A., Malashenkov, A. I., Muratov, R. M. — 2008-07-29

[Work in progress report - Experimental] Non-robotic thoracoscopic internal mammary artery preparation in the pig. A training model

Demertzis, S. D., Laschke, M. W., Siclari, F. P.A., Menger, M. D. — 2008-07-29

Notwithstanding non-robotic, thoracoscopic preparation of the internal mammary artery (IMA) is a difficult surgical task, an appropriate experimental training model is lacking. We evaluated the young domestic pig for this purpose. Four domestic female pigs (30–40 kg body weight) were used for this study. Bilateral thoracoscopic preparation of the IMA was carried out under continuous, pressure controlled CO₂ insufflation. A 30° rigid thoracoscope was inserted through a 10-mm port in the 5th/6th intercostal space (ICS) dorsally to the posterior axillary line. The dissection instrument (Ultracision Harmonic Scalpel) was inserted (5-mm port) in the 7th ICS at the posterior axillary line and the endo-forceps (5-mm port) in the 5th ICS at the posterior axillary line. Thoracoscopic IMA preparation in pig resulted more difficult than in man. A total of seven IMAs were prepared in their full intrathoracic length. A change in the preparation technique (lateral detachment of the endothoracic muscle) improved the safety of the procedure, allowing all four respective IMAs to be prepared safely, while the initial technique ensued an injury for 2 out of 3 vessels. The described young domestic pig model is suitable for experimental training of bilateral thoracoscopic IMA preparation.

[Protocol - Cardiopulmonary bypass] Heparin induced thrombocytopenia diagnosis in cardiac surgery: is there a role for thromboelastography?

2008-07-29

The aim of the present protocol is to investigate the potency of thromboelastography (TEG) to screen postcardiac heparin induced thrombocytopenia (HIT) patients suspicious for HIT type II, and to differentiate which of them are subject to suffer thrombotic complications from those who will suffer hemorrhagic complications.

[Institutional report - Coronary] EuroSCORE predicts health-related quality of life after coronary artery bypass grafting

2008-07-29

Three hundred and two patients were evaluated for the EuroSCORE risk and health-related quality of life (HRQoL) during three years after CABG as assessed by the 15D instrument. Both additive and logistic EuroSCORE correlated significantly with the 15D score at 6, 18 and 36 months. A clinically important increase ≥0.03 in the 15D score was achieved by 50.6% of patients at 6 months, 40.0% at 18 months and 35.9% at 36 months. The rates were similar among patients with increasing EuroSCORE at 6 and 18 months, but tended to decrease at 36 months in the highest EuroSCORE group (EuroSCORE 0–2: 46.8%; 3–5: 34.8%; and 6–14: 33.3%, respectively, P=0.13). Both additive (area under the receiver operating characteristic curve, AUC: 0.582, P=0.024) and logistic EuroSCORE (AUC: 0.575, P=0.039) were predictors of a significant increase of the 15D score. The best cut-off value of the additive EuroSCORE for prediction of a clinically important improvement of the 15D score during 3-year follow-up was 3, as 46.7% of patients with EuroSCORE 0–3 and 30.1% of patients with a score >3 (P=0.006) improved clinically. The present study showed that the EuroSCORE also predicts long-term HRQoL after CABG.

[eComment] eComment: Even the elderly post-CABG patients have a better HRQoL postoperatively

Apostolakis, E., Merkouris, A., Koniari, I. — 2008-07-29

[Institutional report - Thoracic general] Should surgical pleurectomy for spontaneous pneumothorax be always thoracoscopic?

Qureshi, R., Nugent, A., Hayat, J., Qureshi, M., Norton, R. — 2008-07-29

Fifty-seven patients were studied over a period of three years to analyse the efficacy of surgical pleurectomy for spontaneous pneumothorax. Thirty-one and 26 patients underwent open and video-assisted thoracoscopic surgery (VATS) pleurectomy, respectively. VATS was the main modality used for primary spontaneous pneumothorax (PSP) (21 vs. 8). However, secondary spontaneous pneumothorax (SSP) was mainly managed with open pleurectomy (23 vs. 5). The median operating time was significantly longer in open group (72.4 vs. 55 min; P=0.005). The amount of analgesia required in the first five days was significantly more in open group (108 mg vs. 46.9 mg; P=0.02). Chest drainage was significantly more in open group (1027.1 ml vs. 652.8 ml; P=0.04). However, chest drain duration and hospital stay had no significant difference. VATS emerged as a cost-effective modality (£1770 vs. £3226). The ability to return to work was significantly earlier in VATS group in PSP patients (6 weeks vs. 10 weeks; P=0.007). There were 3 (5.27%) recurrences in VATS group for patients with SSP. This experience suggests that VATS pleurectomy is an appropriate modality for PSP. However, open pleurectomy is a viable alternative to treat SSP.

[Institutional report - Thoracic general] Postoperative radiotherapy for patients with completely resected pathological stage IIIA-N2 non-small cell lung cancer: focusing on an effect of the number of mediastinal lymph node stations involved

2008-07-29

Postoperative radiotherapy (PORT), especially using modern technology, for patients with stage IIIA-N2 non-small cell lung cancer (NSCLC) is controversial. We retrospectively investigated 112 patients with stage IIIA-N2 NSCLC who underwent complete resection of the lung tumor in our institution from 1986 through 2003. Among the 91 patients determined suitable candidates for PORT postoperatively, 45 patients received PORT (PORT group) and 46 did not (non-PORT group). We analyzed the correlation between PORT use and clinicopathological characteristics, number of involved mediastinal lymph node stations, recurrence, and survival. Five-year and 10-year survival rates of PORT group were 53.2% and 40.0%, which were superior, however, not statistically different, to those (39.3% and 27.5%) of non-PORT group (P=0.6284). According to the number of mediastinal lymph node stations, PORT was more effective for multiple station metastasis than single station metastasis. The disease-free survival of PORT group was significantly better than that of non-PORT group among the patients with multiple station metastasis. Five-year disease-free survival rate of PORT group and non-PORT group were 41% and 5.9%, respectively (P=0.0220). PORT using modern techniques can reduce local recurrence and improve overall survival especially for patients with multiple station N2. Prospective randomized control trials are warranted.

[Institutional report - Aortic and aneurysmal] The use of statins and fate of small abdominal aortic aneurysms

2008-07-29

The aim of this study was to evaluate the value of statins in reducing abdominal aortic aneurysm (AAA) growth rate and improving freedom from aneurysm repair or rupture. One hundred and twenty-one patients with AAA undergoing ultrasonographic surveillance for at least one year were included in this retrospective study. Patients treated with statins had a decreased linear aneurysm growth rate than those not receiving statins (1.9±1.8 mm/year vs. 2.6±2.4 mm/year, P=0.27), but this difference did not reach statistical significance. Statin users had a better survival freedom from aneurysm repair or rupture (at 5 years: 72.3% vs. 52.5%, P=0.048). The impact of treatment with statins was even more evident in patients with a baseline aneurysm diameter<40 mm (at 5 years: 84.0% vs. 58.8%, P=0.022). When adjusted for age, coronary artery disease and baseline aneurysm diameter, treatment with statins had significantly better survival freedom from aneurysm repair or rupture (P=0.012, RR 0.34, 95% CI 0.14–0.78). The use of statins seems to slightly decrease the AAA growth rate and to significantly improve freedom from aneurysm repair and rupture.

[eComment] eComment: Approaching the beneficial impact of statins in patients with abdominal aortic aneurysms

Koniari, I., Apostolakis, E. — 2008-07-29

[eComment] eComment: Statins and ACE-inhibitors

Hudorovic, N. — 2008-07-29

[Institutional report - Cardiac general] Intraoperative graft flow measurements during coronary artery bypass surgery predict in-hospital outcomes

Herman, C., Sullivan, J. A., Buth, K., Legare, J.-F. — 2008-07-29

Transit-time flowmetry enables immediate intraoperative assessment of blood flow parameters in coronary artery bypass grafts (CABG). The present study assesses the predictive value of measured graft flows on early and medium-term outcomes. All cardiac surgery patients with measured graft flows were included. The last intraoperative flow measurements recorded using the Medtronic Butterfly Flowmetry system were used for analysis. Patients were separated into two groups: patients with normal flow in all grafts or patients with abnormal flow ≥1 graft. Any pulsatility index (pulsatility index=min–max flow/mean flow) ≤5 was determined to be normal flow. The study population included 985 patients. Nineteen percent of patients had abnormal flow in ≥1 graft. Overall in-hospital mortality was 4.7% and not significant between the two groups. After adjusting for covariates, the in-hospital composite outcome for adverse cardiac events was more prevalent in the abnormal flow group (31% vs. 17%; P<0.0001) with an odds ratio of 1.7 (CI 1.1–2.7). Survivors to discharge had a mean follow-up of 1.8 years. However, abnormal flow was not an independent predictor of the medium-term mortality and readmission to hospital for cardiac reason following discharge. Our findings suggest that abnormal flows measured intraoperatively are independently associated with short-term in-hospital adverse outcome.

[eComment] eComment: Flow measurements are extremely useful in CABG

Benetti, F. — 2008-07-29

[Institutional report - Transplantation] Cardiac allograft systolic function. Is the aetiology (ischaemic or idiopathic) a determinant of ventricular function in the heart transplant patient?

2008-07-29

The natural history of the LV systolic function (LV-SF) and functional capacity of survivors of heart transplantation (Htx) has not been defined. Some investigators suggest that SF may be different in recipients with different pre-transplant aetiologies: ischaemic or dilated, idiopathic disease. Routine transthoracic echocardiograms (TTE) were performed during a 1-year follow-up in 48 Htx recipients (total 864 examinations; mean 18/patient). Patients were divided into two groups based on pre-transplant diagnosis: ischaemic (CAD-CMP: n=13, age 54±1.7 years, 23% females) and idiopathic dilated cardiomyopathy (ID-CMP: n=35, age 51±2.3 years, 26% females). Patients with valvular and toxic aetiology were excluded. All patients underwent left ventriculography (VENT) 12–15 months after Htx. The majority of 1-year survivors of Htx maintained normal LV-SF: mean LVEF 65±4% by echocardiography and 68±3% by ventriculography, but in the ID-CMP group LVEF was significantly higher: 67±4% vs. 62±4% (TTE) and 77±4% vs. 60±4% (VENT), without significant differences in functional capacity (NYHA). 82.9% of ID-CMP patients had LVEF >65% vs. 39% in CAD-CMP. The incidence of acute cellular rejection, freedom from cardiac vasculopathy, renal failure, diabetes, hypertension and pre-transplant alloantibody level was similar. Our study shows a strong correlation between pre-transplant heart disease and the systolic function of the cardiac allograft at 1-year follow-up.

[Institutional report - Cardiac general] Expedient pulmonary embolectomy for acute pulmonary embolism: improved outcomes

2008-07-29

Indications regarding surgical pulmonary embolectomy for treatment of submassive/massive acute pulmonary embolism remain controversial. An institutional experience with pulmonary embolectomy for acute pulmonary embolism (APE) was reviewed. A retrospective analysis of all patients undergoing pulmonary embolectomy for APE from September 2004 to January 2007 was conducted. Demographic data, clinical presentation and outcomes were analyzed. Fifteen patients underwent surgery for APE over a period of 27 months [average age 59.6 (range 35–89) years, (seven male, eight female)]. Six (40%) patients were admitted with known APE and nine patients exhibited post admission APE (seven – after surgical procedures, two – after cerebrovascular accident). Clinical presentation included dyspnea (86.67%), hemodynamic instability requiring continuous vasopressor support (40%), echocardiographic evidence of right ventricular dilatation (80%). Ten patients undergoing early/expedient embolectomy all survived while delayed surgery in the other five patients (>24 h) was associated with 60% mortality. Expanding indications for early surgical pulmonary embolectomy has stemmed from reliable echocardiographic identification of right ventricular compromise and recognition of these findings as harbingers of subsequent hemodynamic embarrassment. Our series underscores the benefit of early consideration and performance of pulmonary embolectomy in these critically ill patients.

[Institutional report - Vascular thoracic] Endovascular repair of lesions involving the descending thoracic aorta. Mid-term morphological changes

Attia, C., Farhat, F., Boussel, L., Villard, J., Revel, D., Douek, P. — 2008-07-29

Thoracic aortic lesions are often life-threatening conditions with significant morbidity and mortality after open surgical repair. If preliminary results suggest that endovascular therapy is an effective and advantageous treatment, long-term effectiveness remains questionable. We analysed 75 consecutive patients who underwent endovascular stent-grafting of lesions involving the descending thoracic aorta (32 emergent, 43 elective). Aortic pathologies were aneurysms (n=31), chronic (n=8) or complicated (n=6) type B dissections, penetrating ulcers (n=4) or aortic ruptures (n=26). Follow-up was performed using magnetic resonance angiography. In three cases, the procedure was stopped due to inappropriate arterial access calibre. The hospital mortality and morbidity were 8% and 12%, respectively. One patient of the chronic group presented a type I endoleak, treated by embolisation. After 1.5 months, the mortality and morbidity rates were 10.6% and 10.6%, respectively. The secondary endoleak rate was 16%. One patient died of aortic rupture 24 months after the procedure. In the aneurysm group, the regression of the aortic calibre was significant in 23 and stable in 28 patients. Thus, and despite encouraging early outcomes, mid-term results suggest a trend toward increased re-intervention and late complication rates in these high surgical risk patients. Therefore, continued surveillance of patients treated with stent-grafts is necessary.

[Institutional report - Congenital] Children subjected to cardiac surgery for congenital heart disease. Part 1 - Emotional and psychological outcomes

Menahem, S., Poulakis, Z., Prior, M. — 2008-07-29

This study investigated the psychological and emotional functioning of children with congenital heart disease (CHD) subjected to surgery. Children aged 2–12 years with CHD who underwent cardiac surgery were enrolled. Information was collected prior to surgery and 12 months or later following surgery. Measures included assessment of the child's receptive vocabulary, adaptive behaviour skills, emotional and behavioural development, temperament and parent quality of life, as well as surgical data. Similar information was collected from a control group prior to undergoing non-cardiac surgery. Of the 69 children contacted to enrol, completed pre- and post-surgical data were obtained from 39 children, and pre-surgical data from 12 controls. Children with CHD subjected to surgery displayed psychological and emotional functioning indistinguishable from normative populations or the control group. These findings persisted at reassessment 12–50 months after surgery. Psychological functioning at follow-up was most closely related to functioning prior to surgery. Significant residual defects and the need for further surgery were associated with poorer functioning. The results suggest an optimistic psychological and emotional outcome following cardiac surgery. This study may assist in identifying children most at risk of adverse outcomes after cardiac surgery and help guide therapeutic interventional programmes.

[Institutional report - Congenital] Children subjected to cardiac surgery for congenital heart disease. Part 2 - Parental emotional experiences

Menahem, S., Poulakis, Z., Prior, M. — 2008-07-29

Parents experience considerable distress when their children are subjected to cardiac surgery. This study investigated their psychological and emotional experiences. As part of a prospective study reviewing the emotional and psychological outcomes of children aged 2–12 years subjected to cardiac surgery, that age group being chosen to allow for objective testing following infancy and before adolescence, their parents were assessed prior to and 12–50 months following the surgery. The measures reviewed their mental health, locus of control, family functioning and social support. There were 39 children. Most of the parental information was obtained from the mothers, who reported increased anxiety, and a tendency to attribute events to luck and/or chance greater than published norms, irrespective of the cardiac anomaly, whether the surgery was ‘curative’, or if further surgery was required. At follow-up, their ratings approximated to norms, except for a continued perception that life events were a function of fate and beyond one's control. The results confirmed that a substantial increase in the emotional distress of mothers at the time of surgery essentially resolved by 12 months or later. In contrast, they still seemed not to feel in ‘control’ when reviewed on follow-up.

[Institutional report - Pulmonary] Surgical treatment of bronchiectasis: early and long-term results

2008-07-29

Management of bronchiectasis remains controversial and information on long-term results of surgical treatment is poor. Clinical records of 45 patients, who underwent surgery for bronchiectasis in an 8-year period, were retrospectively reviewed. Bronchiectasis focus was isolated in 24 cases, associated with a limited homolateral or controlateral focus in 9 and 11, respectively; two patients had bilateral evident foci. Bronchiectasis was responsible for lobe destruction in 23 cases. All patients had symptoms: haemoptysis (n=7), recurrent pneumonia (n=7), persistent bronchorrea with recurrent infection (n=15), hemoptysis and recurrent infection (n=16). A total of 23 lobectomies, 11 lobectomies+segmentectomies, 2 bi-lobectomies, 9 segmentectomies and 1 pneumonectomy were carried out. There were no perioperative deaths; complications occurred in 5 patients (postoperative pneumonia in 2, prolonged air-leak, residual air-space and bronchial infection 1 each). Symptoms disappeared in 32 patients, 10 patients experienced a significant improvement. Exercise tolerance remained stable or improved in 33 and 2 cases, respectively, a slight impairment was observed in 9. Out of 32 evaluable patients 11 had an unchanged FEV₁, 15 had a limited FEV₁ lowering (<15%), and 9 had a more important functional loss. Surgical treatment of bronchiectasis obtains satisfactory long-term results, with acceptable morbidity rates.

[Institutional report - Thoracic general] Prognostic impact of thrombocytosis in resectable non-small cell lung cancer

Tomita, M., Shimizu, T., Hara, M., Ayabe, T., Onitsuka, T. — 2008-07-29

Relationship between thrombocytosis and poor prognosis has been reported in lung cancer. However, the majority of previous studies included many advanced stage and small cell lung cancer patients. Few studies focused on resectable non-small cell lung cancer patients. In the present study, therefore, consecutive 240 non-small cell lung cancer patients who received surgical resection were reviewed retrospectively, and investigated the survival impact of preoperative platelet count. In our results, the frequency of preoperative thrombocytosis was only 5.83% (14/240). The 5-year survival of patients with and without thrombocytosis was 28.87% and 63.73%, respectively. Both univariate and multivariate analyses indicated the independent prognostic impact of thrombocytosis. The present study is the first evaluation of prognostic effect of thrombocytosis in patients with resectable non-small cell lung cancer. Preoperative platelet count was a prognostic factor for resectable non-small cell lung cancer patients.

[Institutional report - Valves] Thrombocytopenia after aortic valve replacement with the Freedom Solo stentless bioprosthesis

2008-07-29

Stentless bioprostheses have been considered to achieve superior hemodynamics over stented bioprostheses for aortic valve replacement with improved long-term performance. We observed severe thrombocytopenia in patients who received the Sorin Freedom Solo aortic stentless pericardial bioprosthesis within the first days after implantation. Absolute and relative platelet counts within 2 weeks after implantation of either a stentless (Sorin Freedom Solo) or a stented (Sorin Mitroflow) bovine pericardial bioprosthesis were compared in a matched-pairs analysis in 40 patients. Except the preoperative values, absolute platelet count was higher at all time points in the Mitroflow group. In the Mitroflow group, the mean platelet count moderately dropped to a minimum of 60% of the initial value on POD 3 and fully recovered by POD 8. In the Freedom Solo group, platelet loss was significantly more severe (minimum relative value 25% on POD 4) with no recovery during follow-up (60% on POD 13). Eight patients of the Freedom Solo group experienced a critical platelet drop towards <20% of their initial values, in five of them absolute numbers decreased below 30,000/µl. No bleeding complications or other morbidity occurred. Attention should focus on the platelet count after implantation of the Freedom Solo bioprosthesis, especially in patients who are supposed to receive platelet inhibitors. However, the described phenomenon remains unexplained.

[Institutional report - Thoracic general] The role of muscle flap in preventing bronchus stump insufficiency after pneumonectomy for malignant pleural mesothelioma in high-risk patients

Beshay, M., Carboni, G., Hoksch, B., Reymond, M. A., Schmid, R. A. — 2008-07-29

Bronchus stump insufficiency (BSI) is one of the major complications after pneumonectomy; we analyzed all patients who underwent extra pleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM) in order to detect the role of muscle flap (MF) on preventing early and late stump insufficiency. From January 2000 until December 2005, there were 42 patients admitted with MPM for further intervention at our institution. Thirty patients were suitable for surgery and thus received a multimodal treatment with neo-adjuvant chemotherapy using Cisplatin^® and Gemcitabin (Gemzar^®), EPP followed by 54 Gray (Gy) adjuvant radiotherapy. Data were collected from the surgical and oncological records. There were 37 male patients (88%), the median age was 65 years (range 40–83 years). Seven (17%) patients had concomitant diseases. Forty patients (95%) had asbestos exposition. The operative procedures were EPP with muscle flap through an anterolateral thoracotomy. Univariate and multivariate analyses were done. One patient (3%) died on the 2nd postoperative day due to lung embolism. Mild complications were noticed in the early postoperative phase in 8 (25%) patients. There was no early or late stump insufficiency during the 15-month follow-up. Surgical techniques using muscle flap seems to play a major role in the prevention of bronchus stump insufficiency especially after neo-adjuvant chemotherapy.

[eComment] eComment: Skin isle as a potential bronchoscopic monitoring isle in latissimus dorsi flap surgery for bronchus stump insufficiency

Knobloch, K., Gohritz, A., Spies, M., Vogt, P. M. — 2008-07-29

[eComment] eComment: Routine or selective reinforcement of bronchial stump after pneumonectomy?

Apostolakis, E., Panagopoulos, N. D., Dougenis, D. — 2008-07-29

[Institutional report - Thoracic general] Elastofibroma of the thoracic wall

Freixinet, J., Rodriguez, P., Hussein, M., Sanroman, B., Herrero, J., Gil, R. — 2008-07-29

Soft tissue tumors of the chest wall are rare. Between 1998 and 2007 we treated eight cases of elastofibroma of the thoracic wall, an infrequent primary tumor of the chest. Seven females and one male between 44 and 62 years presented with dorsal subscapular tumors of months and even years of evolution. One case was a relapse from previous interventions and in three cases the tumor was bilateral. A surgical excision was performed in all cases, confirming the source of the tumor. There were no postoperative complications or relapses. We concluded that elastofibroma is a tumor that appears most frequently in middle aged women, and that diagnosis can be established through the use of imaging and fine needle aspiration biopsy. Given its benign character and slow growth, in cases where it is asymptomatic, its evolution can be controlled without surgical intervention.

[Institutional report - Thoracic general] Clinical spectrum of pulmonary inflammatory myofibroblastic tumor

Takeda, S.-i., Onishi, Y., Kawamura, T., Maeda, H. — 2008-07-29

We retrospectively describe clinicopathological characteristics of five patients with surgically resected pulmonary inflammatory myofibroblastic tumor (IMT), and discuss in the light of present-day concepts regarding this disease entity. During the past 15 years, five patients with an age ranging from 21 to 74 years underwent surgery for IMT of the lung, and the resected lesions were studied histologically and immunohistochemically. Three asymptomatic patients referred as X-ray suspicious lung cancer, one patient complained of recurrent hemoptysis, and one presented with fever and dyspnea. The three patients were treated by lobectomy (n=3) including chest wall resection, one segmentectomy and one wedge resection, two of whom were diagnosed as pulmonary sarcoma by frozen section at surgery. The tumor size ranged from 1.5 to 5.5 cm in diameter and histologically characterized by myofibroblasts that are mixed with chronic inflammatory cells, including plasma cells, lymphocytes, and histiocytes. There was no recurrence in these patients, and all of them are in good health. Complete surgical resection can be chosen for both diagnostic and therapeutic for IMTs, which remains the best treatment.

[Institutional report - Experimental] Epicardial coronary artery Doppler: validation in the animal model

2008-07-29

The aim of the study was to validate a newly-designed epicardial coronary artery Doppler probe and test its detection of changes in coronary blood flow velocity. Left anterior descending (LAD) coronary blood flow and flow velocity were evaluated in four pigs with a pericoronary transit time flow (TTF) probe and a newly-designed epicardial Doppler micro-probe. Four consecutive measurements were taken for each of the following conditions: basal, partial stenosis, occlusion, and reperfusion of the LAD. Mean TTF value (ml/min) was 23.2±6.6 in basal condition, 16.2±5.7 after partial LAD stenosis, 0.1±0.3 during LAD occlusion, and 67.4±23.3 at reperfusion (P<0.001). Similar patterns were recorded in terms of Doppler velocity (cm/s) with values of 4.0±1.9 in basal condition, 3.5±2.3 after partial LAD stenosis, 0.5±1.4 during LAD occlusion, and 11.1±5.5 at reperfusion (P<0.001). No significant differences in both TTF and Doppler velocity were detected between basal condition and partial LAD stenosis (P=ns). Epicardial coronary arterial Doppler represents a valuable tool to detect coronary arterial flow velocity in basal condition. Although changes in flow velocity are easily recorded after coronary occlusion and reperfusion, modifications after partial coronary stenosis are not clearly defined.

[Institutional report - Thoracic general] The posterior membranous flap technique for bronchial closure after pneumonectomy

Kakadellis, J., Karfis, E. A. — 2008-07-29

Bronchopleural fistula after pneumonectomy is a life-threatening complication which is associated with the surgical technique and the experience of the surgeon. We evaluated the incidence of bronchopleural fistula using the posterior membranous flap technique, as originally described by G. Jack in 1965. The surgical technique of bronchial closure proximal to the carina is described and discussed. From 1999 to 2005, 45 consecutive patients underwent pneumonectomy in our hospital using the posterior membranous flap technique for bronchial closure. Twenty-nine patients (64.5%) underwent left pneumonectomy and 16 patients (35.5%) right pneumonectomy. Patients were operated on for non-small cell lung cancer (41 patients – 89%), small cell lung cancer (one patient – 2.2%), mixed and other types of cancer (two patients – 4.4%), and non-neoplastic etiology (one patient – 2.2%). In the follow up of the patients no bronchopleural fistula was identified after pneumonectomy, right or left. Thirty-day mortality was 6.6% (three patients), all because of cardiorespiratory insufficiency. Using the posterior membranous flap technique, we eliminated the two major factors of the occurrence of BPF: (a) the tension in the suture line; and (b) the remaining stump from the resected bronchus. This bronchial closure technique offers a safe method of prevention of bronchopleural fistula.

[eComment] eComment: Manual closure of bronchial stump during pneumonectomy: an obsolete method for only selective cases

Apostolakis, E., Panagopoulos, N. D., Dougenis, D. — 2008-07-29

[eComment] eComment: The latissimus dorsi flap surgery for bronchus stump insufficiency - an alternative?

Knobloch, K., Gohritz, A., Vogt, P. M. — 2008-07-29

[eComment] eComment: Pedicled pericardial flap for prevention of postpneumonectomy bronchopleural fistula. A safe alternative

Barbetakis, N., Samanidis, G., Tsilikas, C. — 2008-07-29

[Proposal for bail-out procedures - Assisted circulation] Circulatory support with right ventricular assist device and intra-aortic balloon counterpulsation in patient with right ventricle failure after pulmonary embolectomy

Lango, R., Kowalik, M. M., Klajbor, K., Rogowski, J. — 2008-07-29

Severe pulmonary embolism may lead to acute right ventricular failure despite immediate surgical embolectomy, which is regarded as the treatment of choice after recent CABG surgery. We report a case of a patient with massive pulmonary thromboembolism which resulted in acute right ventricular failure following early surgical embolectomy. Pulmonary embolism developed two days after an elective off-pump CABG surgery. We observed severe circulatory collapse which resulted in cardiac arrest and proved refractory to pharmacological treatment after immediate cardiopulmonary resuscitation. Intra-aortic balloon pumping was used in an attempt to improve hemodynamic performance during surgical skin preparation. After the completion of the embolectomy and failure to wean the patient from CPB, upon clinical signs of low cardiac output and akinetic right ventricle, the decision was made to support its function with a centrifugal pump. The substantial improvement of the right ventricular function observed in the next 24 h allowed weaning the patient from right ventricle support. In spite of hemodynamic recovery, the patient remained in a coma on discharge from the cardiac-surgical ICU after 18 days, and died 10 days later from systemic infection.

[Proposal for bail-out procedures - Vascular thoracic] Extraanatomical ascending-abdominal aorta bypass with stump closure for aortic graft infection

Aizawa, K., Ohki, S.-i., Konishi, H., Misawa, Y. — 2008-07-29

A 42-year-old man, who 25 years previously underwent grafting of the descending aorta because of traumatic rupture after a traffic accident, was admitted to our hospital complaining of fever and hemoptysis. Computed tomography (CT) scans showed a low density area around the prosthetic graft. We diagnosed a graft infection. We undertook extraanatomical ascending-abdominal aorta bypass with stump closure of the descending aorta, with omentopexy around the stump. Postoperative course was uneventful and he has been free from infection for one year. Extraanatomical bypass was an effective strategy for treatment of a graft infection.

[Proposal for bail-out procedures - Arrhythmia] Rescue peri-operative management of the patient with giant electrical storm and severe left ventricular dysfunction: support by levosimendan and intraaortic balloon counterpulsation

Vanek, T., Kolesar, M., Nejedly, M., Jirmar, R. — 2008-07-29

We present a case of a 62-year-old male patient (coronary heart disease, and stenosis of aortic valve) with severe left ventricular dysfunction (left ventricular ejection fraction 20%, left ventricular end-diastolic diameter 80 mm, end-diastolic volume 329 ml) who developed giant electrical storm (on the whole 115 episodes of pulseless ventricular tachycardia treated by antiarrhythmics and electrical discharges) with low-elevation of cardiac biomarkers. The patient was referred to emergent cardiac surgery (double coronary bypass grafting, aortic valve replacement, and implantation of left ventricular epicardial electrode). Levosimendan and intraaortic balloon counterpulsation were used for successful weaning from the cardiopulmonary bypass; no other arrhythmia appeared in the post-bypass period. Postoperatively no arrhythmic events were detected, and repeated echocardiographic examinations of the patient in good general condition showed gradual improvement of left ventricular ejection fraction (30–35%), likewise in other parameters (left ventricular end-diastolic diameter 72 mm, end-diastolic volume 285 ml).

[Proposal for bail-out procedures - Assisted circulation] A novel use of the implantable ventricular assist device for isolated right heart failure

Osaki, S., Edwards, N. M., Johnson, M. R., Kohmoto, T. — 2008-07-29

Isolated right heart failure after cardiac surgery is uncommon and the prognosis remains poor. Additionally, managements for these patients are difficult. Profound postcardiotomy right heart failure developed in a 45-year-old woman after aortic root replacement for critical aortic stenosis with small aortic root. Although maximum medical therapy, intraaortic balloon counterpulsation and extracorporeal membrane oxygenator were attempted, severe right heart failure remained. Finally, an implantable right ventricular assist device (RVAD) was utilized because an immediate myocardial recovery was unlikely. The patient was discharged from the hospital at 17 days after the RVAD implantation. After 79 days of support, right ventricular function had recovered, the fully rehabilitated patient was successfully weaned from the RVAD, and the RVAD was explanted. The patient has no recurrence of heart failure 668 days after RVAD explantation.

[Negative results - Vascular general] Graft repair of tracheo-innominate artery fistula following percutaneous tracheostomy

Jamal-Eddine, H., Ayed, A. K., Al-Moosa, A., Al-Sarraf, N. — 2008-07-29

Tracheo-innominate fistula (TIF) is a rare complication following percutaneous dilatational tracheostomy (PDT), occurring in ≤1% of cases. It usually develops three days to six weeks after the procedure and is fatal in the majority of cases, even after successful initial repair. We present a successfully treated case of TIF using a Goretex graft to replace the severely destroyed segment of the innominate artery.

[Negative results - Cardiac general] Serotonin syndrome following cardiac surgery

Shanmugam, G., Kent, B., Alsaiwadi, T., Baskett, R. — 2008-07-29

Selective serotonin reuptake inhibitors (SSRIs) are widely used to treat depression. We report a case of serotonin syndrome following cardiac surgery. This syndrome is rare in the cardiac literature. The clinical features, diagnosis and management of this unusual syndrome are described. In patients with polypharmacy, it is important to take cognisance of serotonergic antidepressants and anticipate their potential interactions with drugs used peri-operatively. Early recognition and treatment is important as this condition is potentially fatal.

[eComment] eComment: Serotonin syndrome: pharmacogenomics and treatment

Koniari, I., Tsigkas, G., Apostolakis, E. — 2008-07-29

[Negative results - Coronary] Carbon dioxide embolism during endoscopic vein harvesting

Tamim, M., Omrani, M., Tash, A., El Watidy, A. — 2008-07-29

Endoscopic vein harvesting (EVH) is becoming common for the patients undergoing coronary artery bypass grafting. Using carbon dioxide insufflations during the vein harvest can produce rare but catastrophic CO₂ embolism. We report a case of massive right atrial CO₂ embolism due to femoral vein injury which occurred during the performance of a routine EVH procedure.

[Negative results - Assisted circulation] Hemodynamic collapse during pulmonary embolectomy due to loss of venous return from acute occlusion of the cardiopulmonary venous cannula with thromboembolus

Augoustides, J. G.T., Plappert, T., Bavaria, J. E. — 2008-07-29

We report a case of hemodynamic collapse during pulmonary embolectomy with cardiopulmonary bypass. The hemodynamic collapse was due to complete loss of venous return due to thromboembolic occlusion of the atrial cannula. The diagnosis was made during focused intraoperative transesophageal echocardiography.

[eComment] eComment: Surgical options in emergency pulmonary embolectomy

Lentini, S., Tancredi, F., Monaco, F., Gaeta, R. — 2008-07-29

[Negative results - Congenital] Right ventricular aneurysm following modified Norwood-Sano operation for hypoplastic left heart syndrome

Karimi, M., Farouk, A., Stork, J., Hennein, H. A. — 2008-07-29

Hypoplastic left heart syndrome is a rare congenital heart defect characterized by underdevelopment of left-sided heart structures, including the aortic arch. The contemporary surgical management of this anomaly includes the Norwood procedure and provision of pulmonary blood flow by either a modified Blalock-Taussig shunt (MBTS) or a right ventricle-to-pulmonary artery (RV-PA) conduit, commonly referred to as the Sano shunt. We report on an unusual complication of the Sano shunt, that of a giant right ventricular pseudoaneurysm occurring at the shunt insertion site.

[Negative results - Cardiac general] Mobile biatrial thrombus in a patient with mitral stenosis under heparin infusion

Tasdemir, K., Sarli, B., Kaya, M. G., Gunebakmaz, O. — 2008-07-29

A 58-year-old female patient with complaints of sudden presenting pain and pallor on her left foot was referred to our clinic for urgent embolectomy. On her cardiovascular examination there was an apical grade 2/6 systolic murmur and a grade 2/4 diastolic murmur. The presenting electrocardiography revealed atrial fibrillation with rapid ventricular response. She underwent emergent femoro-popliteal embolectomy. Transthoracic echocardiography showed a mobile 1.4x1.7-cm sized left atrial thrombus, mild mitral regurgitation and 9 mmHg mean gradient on mitral valve after embolectomy. Unfractioned (UF) heparin infusion was initiated immediately after surgery. After three days, the control transthoracic echocardiography revealed left atrial thrombus and also a large ‘snake-like’ thrombus waving in right atrium. The patient underwent biatrial thrombectomy and mitral valve replacement. When she became haemodynamically stable, a bilateral lower limb venous Doppler ultrasonographic study was performed. This study indicated a thrombus formation in the deep veins of the left leg. The origin of the right atrial thrombus was probably a snapped piece of thrombus from the calf deep-veins after the initiation of intravenous UF heparin. In summary, we have reported an extremely rare case of biatrial thrombus in a patient under UF heparin infusion.

[Follow-up papers - Cardiac general] Successful six-year follow-up of a sutureless device for proximal anastomoses in a severely calcified ascending aorta

Puehler, T., Fraund-Cremer, S., Cremer, J., Boening, A. — 2008-07-29

Background: Aortic connector devices (ACDs) for proximal anastomoses of vein grafts during coronary artery bypass grafting (CABG) have widely failed during recent years. As a consequence ACDs have been withdrawn from the market. Method: We report on an 81-year-old patient who had undergone CABG for three-vessel disease. The proximal anastomosis was accomplished with an ACD (St Jude Medical) due to a highly calcified ascending aorta. Six years later the patient underwent aortic valve replacement, which offered the opportunity of visual inspection of the previous ACD anastomosis. Result: Coronary angiography demonstrated a perfectly patent ACD anastomosis with a sufficient sequential vein graft to the marginal and the postero-lateral branches. Intraoperatively, the nitinol stent of the ACD anastomosis was perfectly incorporated, and covered with a thin layer of endothelial cells. Discussion: Though poor, short- and mid-term results have led to the abandonment of ACDs, our case demonstrates a perfect anastomosis after a six-year follow-up.

[eComment] eComment: Aortic connectors in coronary artery surgery

Ricci, M., Salerno, T. A. — 2008-07-29

[Best evidence topic - Thoracic general] Does video-assisted thoracoscopic pleurectomy result in better outcomes than open pleurectomy for primary spontaneous pneumothorax?

Vohra, H. A., Adamson, L., Weeden, D. F. — 2008-07-29

The question addressed by a best evidence topic approach using a structured protocol was whether pleurectomy using video-assisted thoracoscopic surgery (VATS) resulted in better outcomes than open pleurectomy for primary spontaneous pneumothorax. Altogether 45 relevant papers were identified of which nine papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that VATS pleurectomy has been shown to be comparable to open pleurectomy in the treatment of spontaneous pneumothorax, with a meta-analysis and several RCTs showing reductions in length of hospital stay and analgesic requirements. Postoperative pulmonary dysfunction has also been shown to be reduced after VATS pleurectomy in two RCTs, although a third study found no significant difference. A concern may be a four-fold increase in the recurrence of pneumothorax following VATS pleurectomy as compared to open pleurectomy reported in a recent meta-analysis of four randomised and 25 non-randomised studies performed in 2007 and published in the Lancet, although a second meta-analysis of only the randomised trials did not show this difference.

[Best evidence topic - Valves] Is a port-access mitral valve repair superior to the sternotomy approach in accelerating postoperative recovery?

Richardson, L., Richardson, M., Hunter, S. — 2008-07-29

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether port-access mitral valve repair reduces the recovery period of patients compared to the conventional sternotomy approach. Using the reported search, 778 papers were identified. Thirteen papers represented the best evidence on the subject and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. The 13 papers demonstrated that patients who undergo minimally invasive mitral valve repair have a shorter ICU and total hospital stay than those who undergo the sternotomy approach. Results vary but mean hospital stays range from 5.6 to 13 days in port-access groups compared to 6.25–15 days in sternotomy groups. Other advantages over the sternotomy approach were reduced postoperative bleeding and pain, shorter time to extubation and a quicker return to daily activities. However, it is consistently reported that operative time is longer, with the increase in bypass time being around 30 min. We conclude that in several cohort studies minimally invasive mitral valve repair is reported to result in a shorter ICU and hospital stay, reduced postoperative bleeding and pain and a shorter time to resuming normal activities. This is at the expense of longer bypass and operative times.

[eComment] eComment: Port-access mitral valve repair in re-do surgery

Gaeta, R., Tancredi, F., Monaco, F., Lentini, S. — 2008-07-29

[Best evidence topic - Valves] Do statins slow the progression of aortic valve stenosis?

Tourmousoglou, C. E., Lalos, S., Psarros, T. — 2008-07-29

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether therapy with statins significantly slows the progression of aortic valve stenosis. Altogether 226 papers were found using the reported search, of which twelve represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The results of the reported studies provided conflicting results. There are twelve studies. Ten retrospective studies and one prospective had been promising with a slower rate of hemodynamic progression in patients taking statins. One retrospective and one randomized controlled trial did not halt the progression of calcific aortic stenosis or induce its regression. The data are discrepant as to whether this effect is related to serum lipid levels or to other effects of statins. While the data are not yet strong enough to change clinical practice, two large randomized controlled trials (ASTRONOMER and SEAS) which have recruited 272 and 1873 patients, respectively, will provide important new evidence in this area in the near future.

[eComment] eComment: Statins decelerate the sclerosis progression of senile aortic valves in only selected cases

Apostolakis, E., Koniari, I. — 2008-07-29

[Best evidence topic - Aortic and aneurysmal] Is it safe to cover the left subclavian artery when placing an endovascular stent in the descending thoracic aorta?

Dunning, J., Martin, J. E., Shennib, H., Cheng, D. C. — 2008-07-29

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the left subclavian artery may be safely covered with a descending thoracic aortic stent without a prior carotid-subclavian artery bypass or transposition procedure. Altogether 2612 abstracts were identified. Forty-five non-randomized control trials and 213 non-controlled papers were found using the reported search and all these were read in full to search for coverage of the left subclavian artery. From these papers, 20 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We identified 20 studies with more than 10 cases of left subclavian artery coverage without prior revascularisation. Aggregating the data from all these studies we found 498 covered left subclavian arteries. Complications included 13 strokes (2.6%), 8 cases of paraplegia or paraparesis (1.6%) and 6 endoleaks due to subclavian backflow (1.2%). Of note there were 51 cases of ischaemia or other symptoms attributable to poor blood flow (10%), which resulted in 20 post-procedural revascularisations (4%). In three studies the mean pressure drop in the left arm was between 36 and 48 mmHg after left subclavian occlusion. We conclude that coverage of the left subclavian artery has a low, but not insignificant, incidence of side-effects. This incidence must be balanced with the urgency of the procedure and may be acceptable in emergency or salvage situations. However, in non-emergency cases we recommend that the carotid arteries, the vertebral arteries and the Circle of Willis are fully assessed by tests such as duplex ultrasound, angiography, CT or MRI scanning. An absent right vertebral artery, diseased carotid arteries or an incomplete Circle of Willis is a contraindication to left subclavian artery coverage without prior transposition or bypass grafting of the left subclavian artery.

[Best evidence topic - Congenital] Is early primary repair for correction of tetralogy of Fallot comparable to surgery after 6 months of age?

Vohra, H. A., Adamson, L., Haw, M. P. — 2008-07-29

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether early primary repair for correction of tetralogy of Fallot (TOF) resulted in better outcomes than surgery after 6 months of age. Altogether 650 relevant papers were identified using the below mentioned search, eight papers represented the best evidence to answer the specific question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that early primary repair of TOF has been shown to be comparable to later repair, with several retrospective series concluding that there is no increase in mortality with children under 6 months of age. Freedom from reintervention has also been shown to be similar irrespective of the age primary repair is undertaken. However, it has been observed that length of intensive care unit stay, period of mechanical ventilation and the need for inotropes is increased in patients undergoing primary repair at <3 months of age.

[eComment] eComment: Correction of tetralogy of Fallot

Tirilomis, T. — 2008-07-29