Asian Cardiovascular and Thoracic Annals

Between October 1996 and August 1997, 56 endoscopic vein harvests were performed with video monitoring. Incisions of 2 to 3 cm in length were made at the groin and above or below the knee. The harvested veins were used for coronary artery bypass grafting. The complication rate was 1.8%. The average hospital stay for patients undergoing the endoscopic procedure was 7.2 days. All incisions had healed well at the 12-week follow-up. Endoscopic saphenous vein harvest provides a minimally invasive alternative to the open procedure. It gives a good cosmetic result, promotes early ambulation, and may reduce postoperative pain.

Minimally invasive techniques for repair of extracardiac anomalies in congenital heart disease have evolved over the last 5 years and laid the foundation for the next phase: the repair of intracardiac defects. Fifteen patients (9 females and 6 males) with a median age of 9.8 years (range, 5.2 to 54 years) underwent closure of a secundum atrial septal defect through a small right anterior thoracotomy. The right external iliac artery was cannulated through a small groin incision and the atrial septal defect was repaired during hypothermic fibrillatory arrest for a mean period of 14 ± 5 minutes. The mean length of the thoracotomy was 4.9 ± 0.8 cm (range, 4.5 to 8.8 cm) while the mean length of the groin incision was 3.9 ± 0.5 cm (range, 2.9 to 5.3 cm). In the 3 youngest patients, the external iliac artery was cannulated with an 8F arterial cannula. Direct closure of the atrial septal defect was possible in all patients. The mean operative time was 109 ± 39 minutes. There was no perioperative or late mortality and no morbidity except for a tear in the right femoral artery of a 19-year-old girl. No residual atrial septal defect was observed in any of the patients. Although minimally invasive techniques for repair of intracardiac defects are not fully developed with regard to indications, the procedure described here provided secure closure of the defects with excellent cosmetic results.

Thrombolytic therapy for left-sided prosthetic valve occlusion is a viable alternative to surgery. The phenomenon of delayed opening of a bileaflet valve is a peculiar feature of thrombolytic therapy. Of 64 patients who received thrombolytic therapy and presented on 71 occasions, partial success was observed in 28 patients on completion of treatment. Of these 28 patients, delayed opening of the leaflets was observed in 14 (50%) over a period of 3 to 12 months. We suggest that this unique feature of bileaflet valves might delay or avoid reoperation. The need for frequent follow-up of patients with partially successful thrombolytic therapy is emphasized.

From October 1989 to September 1997, 14 patients underwent repair of a thoracic aortic aneurysm or dissection using deep-hypothermic circulatory arrest. There were 10 males and 4 females with a mean age of 58 years (range, 43 to 82 years). The diagnoses included one ascending aortic aneurysm, one ascending aortic and arch aneurysm, 2 aortic arch and descending aortic aneurysms, 4 descending aortic aneurysms, 2 chronic aortic dissections of type A and 4 of type B. The involved aortic segment was replaced with a woven Dacron tube graft in 11 patients and repaired with a patch of woven Dacron in the other 3. Concomitant procedures were coronary artery bypass grafting in 2 cases; one aortic valve replacement, and one wedge resection of the left-upper lobe of the lung. A median sternotomy approach was used in 6 patients of whom 5 had right atrial-femoral artery bypass and 1 had right atrial-ascending aortic bypass. In addition to sternotomy, one patient had a left anterolateral thoracotomy. Seven patients had a left posterolateral thoracotomy with femorofemoral bypass. The mean circulatory arrest time was 35 minutes (range, 13 to 59 minutes). The lowest perfusion temperature ranged from 7°C to 16°C. Retrograde cerebral perfusion was used in 5 patients. There was one operative death from massive bleeding. Early complications included stroke in 2 patients, vocal cord paralysis in one, prolonged ventilatory support in one, reoperation for bleeding in one, and pleural effusion in 3 patients. There were 2 late deaths and the 11 surviving patients (78%) have been followed up for a mean period of 18 months. Deep-hypothermic circulatory arrest was found to be a useful technique in the repair of aortic aneurysm and dissection. We consider retrograde cerebral perfusion to be safe and easily performed. It probably decreased the incidence of stroke in patients with involvement of the aortic arch.

Aortoesophageal fistula is an uncommon and lethal clinical condition. We operated on 2 cases of aortoesophageal fistula between 1991 and 1996. The operations were uneventful. However, both patients died from fatal hemorrhage at 7 and 30 days postoperatively, respectively. The management of aortoesophageal fistula is still a challenging problem for cardiac surgeons.

Analyses of lymphocyte subsets using flow cytometry were conducted to determine the significance of these cells in the pathogenesis of chronic rheumatic heart disease. Lymphocytes (B cells, T cells, CD4 cells, CD8 suppressor or cytotoxic T cells, activated T cells, and natural killer cells) were measured in blood and left atrial appendage samples of 30 patients with rheumatic heart disease and 10 patients with acyanotic congenital heart disease. Monoclonal fluorescent-labeled antibodies were used to identify various cells by flow cytometry. There was a significant increase in CD4 cells and activated T cells with a significant decrease in B cells in the left atrial appendage tissue of patients with rheumatic heart disease compared to those in the control group. There was no significant difference between the two groups in the distribution pattern of T lymphocytes in peripheral blood. These changes in rheumatic heart disease reflect an abnormal immunoregulatory mechanism with an ongoing enhanced immunological process continuing into the chronic phase of the disease. In our opinion, this persistent T cell response may lead to fresh damage to the myocardium and deformation of the heart valves.

Rupture of the ventricular wall is a highly lethal complication of acute myocardial infarction that is diagnosed more frequently with the increased use of two-dimensional echocardiography. External patching techniques were used to treat 4 patients with ventricular rupture, thus avoiding resection of necrotic myocardium. Three of the patients survived. One patient developed a large left ventricular pseudoaneurysm requiring reoperation. The other 2 patients had intact repairs on follow-up echocardiogram obtained after 5 weeks and 3 years, respectively. With prompt recognition and treatment, patient survival and excellent short-term results can be achieved.

To investigate the effectiveness of using a free pericardial fat pad to control air leaks from residual raw parenchymal surfaces after pulmonary resections, 30 consecutive patients were studied. There were 23 males and 7 females with a median age of 69 years. The indication for this technique was any alveolar air leak from a residual raw parenchymal surface which could not been controlled by suturing. There were 25 lobectomies with incomplete fissure and 5 cases of segmentectomy. None of the patients exhibited air leaks beyond 2 days, post-operative space problems, or infections. All patients had chest drains removed within 2 days after the operation. The application of a free pericardial fat pad is a promising new method of treating air leaks from residual raw parenchymal surfaces after pulmonary resections.

Although coronary artery bypass surgery has become a common procedure, there were no data available regarding this type of surgery in the United Arab Emirates. Therefore, we undertook this retrospective study of the first 522 consecutive patients undergoing coronary artery bypass graft surgery between October 1992 and July 1997. The mean age was 49.1 years at operation with a 97.1% male predominance. Patients of Asian origin accounted for 75.8%, Arabs 22.4%, and Europeans 1.7%. Chronic stable angina was the most frequent presenting symptom (70.4%) and 62.1% patients had at least one prior myocardial infarction. There was a 44.6% incidence of hypertension and 32.9% of patients were diabetic. Other prominent risk factors were smoking (55.7%), hyperlipidemia (53.9%), and family history of ischemic heart disease (10.7%). Left main coronary artery obstruction was evident in 6.5% of patients. An average of 3.4 grafts per patient were performed using reverse saphenous vein and endarterectomies were needed in 2.2%. The early mortality rate in elective cases was 2.4%. This study suggests that in spite of a high incidence of multiple risk factors, our patients tolerated coronary artery bypass surgery well. Our findings highlight the trend towards more urgent operations and the decreasing age of patients with severe coronary artery disease.

A 50-year-old male who developed subclavian vein thrombosis following insertion of a demand pacemaker was treated with a short period of high-dose recombinant tissue plasminogen activator (100 mg over 3 hours). Total thrombolysis was achieved without complications.

Mural thrombi are common in patients with acute myocardial infarction and can cause refractory left ventricular failure as a rare complication. We report a case of large postinfarction ventricular thrombus resulting in left ventricular failure resistant to medical therapy. After echocardiographic diagnosis, thrombectomy and coronary bypass grafting were performed and the symptoms subsided.

A 70-year-old man with acute inferolateral and posterior myocardial infarction presented with congestive heart failure. The 12-lead electrocardiogram showed a discordant pattern consisting of very low limb-lead QRS voltages and tall R waves in leads V₂ and V₃.

We report the case of a 39-year-old male with hypertrophic cardiomyopathy who complained of angina pectoris. The patient was treated with a beta blocker and a calcium antagonist without effect. Myocardial scintigraphy revealed anterior ischemia. Cardiac catheterization and ventriculography revealed severe systolic narrowing of the left anterior descending coronary artery and no significant pressure gradient across the left ventricular outflow tract. Myotomy was performed on a muscular bridge over the left anterior descending coronary artery and the patient's angina was relieved. In young patients with hypertrophic cardiomyopathy who develop angina refractory to medical therapy, a coexisting muscular bridge should be sought.

We report a rare case of congenital saccular aneurysm of the right cervical aortic arch in a 16-year-old girl. There were no branches arising from the aortic arch but 3 branches arose from the ascending aorta: the left innominate artery, the right common carotid artery, and the right subclavian artery. The aneurysm was successfully repaired with a plasma-preclotted woven Dacron interposition graft during profound hypothermic cardiopulmonary bypass without total circulatory arrest.

We report a case of extracardiac unruptured aneurysm of the noncoronary sinus of Valsalva presenting with massive aortic regurgitation and high fever. The preoperative evaluation, echocardiographic and cardiac catheterization findings, and surgical management of this rare condition are discussed.

Membranous obstruction of the inferior vena cava is a rare congenital anomaly that results in the primary type of Budd-Chiari syndrome. We describe the case of an 8-year-old boy initially diagnosed with intrahepatic portal hypertension, who underwent percutaneous transluminal balloon dilatation of an inferior vena cava membrane located in the suprahepatic inferior vena cava, which resulted in successful palliation of his symptoms.

We describe a simple safe technique of left heart bypass using cannulation of the posterior aspect of the left inferior pulmonary vein for repair of an aneurysm in the distal aortic arch.

A technique for ligating the end of a running polypropylene suture or for securing inadvertent loops is described. This method was used in 700 pediatric cardiac procedures without failure of ligation.