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PubMed2000

Surgical stress induces acute coronary release of tissue-type plasminogen activator in the pig.

BACKGROUND: Tissue-type plasminogen activator (t-PA) is an endothelium derived key enzyme in the initiation of endogenous fibrinolysis. Acute regulated release of active t-PA occurs within minutes in response to threatening thrombotic vessel occlusion. The aim of this study was to investigate the impact of surgical stimulation on the kinetics of t-PA release in the coronary vascular bed in the pig. METHODS: In anaesthetised pigs (n=16), arterio-venous concentration gradients of t-PA, and plasma flows (retrograde thermodilution) were obtained across the coronary vascular bed before (control) and at 1, 3, 5 and 10 min after sternotomy. RESULTS: At control, no significant coronary net flux (release or uptake) of t-PA was observed, while sternotomy induced a rapid net release of total t-PA (132.6 ng x min(-1)), with an associated increase in active t-PA (93.6 ng x min(-1)). This response, evident already after 1 min, showed a peak at 5 min and returned towards baseline levels within 10 min. No concurrent alterations in aortic levels of active t-PA were found and haemodynamic variables were unaltered. CONCLUSION: The rapidly increasing and transient net coronary release of t-PA after sternotomy suggests that the endothelium actively promotes local endogenous fibrinolysis during surgery. Such events could reflect a dynamic responsiveness to protect the coronary circulation during stress.

Animals↗
PubMed1997

Total intravenous anaesthesia using propofol, gamma-hydroxybutyrate or midazolam in combination with sufentanil for patients undergoing coronary artery bypass surgery.

Total intravenous anaesthesia (TIVA) using propofol, gamma-hydroxybutyrate (GHB) or midazolam in combination with sufentanil was investigated in 45 patients undergoing coronary artery bypass grafting (CABG). Anaesthesia was induced with sufentanil, etomidate and pancuronium. After endotracheal intubation, anaesthesia was continued with sufentanil (2 micrograms kg-1 h-1) for all patients. Patients were randomized to receive supplementary propofol (2 mg kg-1 h-1, n = 15), gamma-hydroxybutyrate (20 mg kg-1 h-1, n = 15) or midazolam (0.06 mg kg-1 h-1, n = 15). Haemodynamic measurements were performed after induction and at various times in the pre-bypass period. In the propofol group, a significant decrease in heart rate (HR 12% +/- 3%), cardiac index (CI 23% +/- 4%), mean arterial pressure (MAP 16% +/- 3%) and left ventricular stroke work index (LVSWI 17% +/- 4%) occurred until sternotomy was performed. With the exception of cardiac index, both midazolam and gamma-hydroxybutyrate produced similar haemodynamic effects: cardiac index was temporarily decreased (19% +/- 4%) by midazolam and remained unchanged after gamma-hydroxybutyrate. In both groups, sternotomy was followed by temporary hypertension, associated with a significant rise in systemic vascular resistance. No electrocardiographical signs of ischaemia were observed in any patient. In the case of propofol and midazolam, gamma-hydroxybutyrate showed adequate haemodynamic stability especially after induction of anaesthesia and may also be a suitable agent for total intravenous anaesthesia in patients with coronary artery disease. However, during sternotomy, supplementary administration of opioids was required.

Aged↗
PubMed2002

Video-assisted thoracoscopic thymectomy for myasthenia gravis.

BACKGROUND: Thymectomy is an effective, but radical therapy for myasthenia. Video-assisted thoracic surgery (VATS) may allow a minimally invasive alternative to the standard sternotomy approach. AIMS: To audit prospectively the outcome of VATS thymectomy for myasthenia gravis in a unit specializing in advanced VATS techniques. METHODS: Twenty-six patients underwent VATS thymectomy between 1997 and 2001. Most underwent preoperative plasma exchange therapy. Seventeen women and nine men with a median age of 36 years (range 17-71 years) had a right-sided VATS approach to remove all anterior mediastinal fat and thymic tissue. RESULTS: There was no perioperative mortality and all procedures were concluded successfully, with one patient requiring sternotomy. Twenty-five patients were extubated in theatre and one patient required 17 h of assisted ventilation. The other significant complication was a diathermy injury to the phrenic nerve, which recovered. Median postoperative stay was 4 days (range 2-6 days), with median postoperative chest drainage for 2 days (range 1-3 days). Three patients had progression of disease postoperatively. The remainder were asymptomatic (7), improved (14) or stable (2). CONCLUSION: In a dedicated unit with neurological and intensive care support, VATS thymectomy is a safe, effective method of obtaining remission or improvement in myasthenia gravis (MG). While achieving the same surgical goal, this approach offers advantages of improved cosmesis, shorter recovery time and minimal chest wall disruption over the gold standard of sternotomy. Better patient acceptance of this minimally invasive technique may result in wider application of the benefits of thymectomy in MG.

Adolescent↗
PubMed2003

DDD pacemaker implantation after Fontan-type operations.

Bradyarrhythmias developing after Fontan-type operations impair the function of the univentricular heart causing fatigue, headaches, ascites, and protein-losing enteropathy (PLE). Transvenous inaccessibility, requiring epicardial implantation, accounts for the reluctance to implant a pacemaker (PM). Between 1997 and 2000, 24 patients (mean age 9.5 years, range 6 months to 19 years) with Fontan-type operations received DDD pacing systems with atrial steroid-eluting stitch-on electrodes (mean capture threshold 1.9 V/0.5 ms, range 0.4-3.5 V) and ventricular screw-in electrodes (mean capture threshold 1.7 V/0.5 ms, range 0.1-3 V). The systems were implanted at the time of conversion from atrio- to cavopulmonary connections in 5 patients, at the time of a total cavopulmonary Fontan operation in 6, and 1-50 months thereafter (mean = 18) in 13 patients. A right ventricular anatomy was present in 13 (54%) of 24 of PM recipients, versus 35% of the overall population. After a mean follow-up of 3.5 years, the PM were functioning in DDD mode in 23 of the 24 patients. Length of hospital stay in the ten patients who underwent repeat sternotomy was 5 days, without procedure related complications. In three children a repeat sternotomy was avoided by implanting the atrial electrodes during the Fontan operation. All patients improved clinically, including resolution of PLE in four patients. Bradyarrhythmias may lead to significant morbidity after Fontan-type operations. Electrophysiological evaluation is advised at follow-up. The indication for implantation of a DDD pacemaker system should be liberal. Placing atrial electrodes during the Fontan operation, especially in the presence of a right ventricular anatomy, avoids repeat sternotomy.

Adolescent↗
PubMed2002

Anesthetic and perioperative outcome of teenagers and adults with congenital heart disease.

OBJECTIVE: To compare the perioperative outcome of patients >or=13 years old undergoing surgery for congenital heart disease in a children's hospital by a dedicated congenital heart surgery and anesthesia team with procedure-matched younger control patients. DESIGN: Retrospective medical record review study. From October 1997 to July 2000, medical records of all patients >12 years old requiring cardiopulmonary bypass were reviewed. A control group of patients <or=5 years old was reviewed, and 2 patients were matched to each older patient by diagnosis and surgical procedure. Data are reported as mean +/- SD. Older (study) patients were compared with younger (control) patients using t-test or chi square, with p <or= 0.05 significant. SETTING: Medical school-affiliated tertiary-care children's hospital. PARTICIPANTS: Patients undergoing congenital heart surgery. MEASUREMENTS AND MAIN RESULTS: The study group (older patients) comprised 85 patients, and the control group (younger patients) comprised 170 patients. There were no intraoperative deaths. All major complications-cardiopulmonary resuscitation, neurologic injury, massive hemorrhage with sternotomy, femoral cannulation for emergent bypass, and severe episodes of hypotension on induction of anesthesia-occurred in older patients undergoing repeat sternotomy. CONCLUSION: Mortality and major morbidity were low in both groups; however, all major intraoperative incidents occurred in older repeat sternotomy patients, suggesting increased perioperative risk for adverse outcomes in these patients.

Adolescent↗
PubMed2000

Vascular control for resection of suprahepatic intracaval Wilms' tumor: technical considerations.

The surgical resection of Wilms' tumor can be complicated by tumor thrombus extension into the inferior vena cava. In cases of suprahepatic Wilms' tumor thrombus that may extend into the right atrium, a median sternotomy and cardiopulmonary bypass (CPB) are used to facilitate tumor resection. However, if the tumor can be localized and controlled below the atrium, resection without the use of cardiopulmonary bypass may limit morbidity. The authors describe a novel approach to tumor thrombectomy for a Wilms' tumor extending to the suprahepatic vena cava without the use of CPB. The authors used transesophageal echocardiography to localize the tumor thrombus and detect any tumor or air embolization and a minimal lower sternotomy to obtain intrapericardial control of the inferior vena cava. This technique may be useful in selected cases of Wilms' tumor as an alternative to median sternotomy and use of cardiopulmonary bypass.

Child, Preschool↗
PubMed2000

Sternal closure with resorbable synthetic loop suture material in children.

PURPOSE: The reliability of poly-p-dioxanone (PDS) suture for sternal closure was tested on 264 consecutive sternotomies in the authors' department from April 1987 to May 1998. METHODS: The reason for sternotomy was tetralogy of Fallot in 65 cases (24.6%), ventricular septal defect (VSD) in 38 cases (14.4%), atrial septal defect (ASD) in 77 cases (29.2%), ASD + VSD in 23 (8.7%), mitral valve replacement in 22 cases (8.3%), aortic valve replacement in 10 cases (3.8%), and other cardiac disorders in 29 cases (11.0%). RESULTS: Sternal wound infection, sternal dehiscence, and mediastinitis occurred in 1.5% of patients (4 of 264). The overall hospital mortality rate related to the mediastinitis was 1.1% (3 of 264) in the early postoperative period. CONCLUSION: This absorbable suture and our different technique are a safe alternative to standard sternotomy closure after pediatric open cardiac surgery.

Adolescent↗
PubMed2002

Off pump coronary surgery in Argentina.

Benetti and Buffolo repopularized off pump surgery (OPCAB), developing the technique and using it in all arteries of the heart with veins and arteries in the different clinical situations inclusive in patients with acute myocardial infarction. Despite my personal experience with more than 2500 cases of off pump conducted in my country and different places of the world during the teaching and education process. In 1997, we started a new approach (xiphoid) to perform the ambulatory off pump surgery (ie, discharging the patient after 24 hours of the operation). Between October 1997 and December 2001, 78 patients were operated on through the xiphoid (lower sternotomy approach). The mean age of the patients was 64.2 years (range 45-78), there were 70% males, and all were class 3-4 according to the Canadian Association. The mortality of the 78 patients was 1% (1 patient), conversion to complete sternotomy was 1% (1 patient), and perioperative infarction was 1% (1 patient). From the 16 patients restudied immediately the patency rate was 100% G A anastomosis. Six patients from this group were discharged during the next 24 hours after the operation. The mortality was 0% and perioperative infarction 0%. With the xiphoid (lower sternotomy approach) we had good initial experience in discharging the patients during the first day. Using the technology that already exists, it is possible to perform multiple arterial grafts with this approach and in the future expand the concept of ambulatory coronary surgery in multiple vessels.

Aged↗
PubMed2004

Changes in sternal blood flow after different methods of internal thoracic artery harvesting.

OBJECTIVE: The study was designed to assess the early changes in sternal perfusion after midline sternotomy and different (skeletonized versus semiskeletonized) techniques of internal thoracic artery (ITA) harvesting. METHODS: The experiments were performed in the swine model. After midline sternotomy, ITA harvesting (skeletonized technique) was performed unilaterally in Group I (6 animals). The ITA and the internal thoracic vein (ITV) were harvested (semiskeletonized technique) in Group II (5 animals). The contralateral sternal half served as a control. Using a thermographic camera with a 0.06 degrees C sensitivity, sternal perfusion was assessed 2 and 5 hours after surgery. RESULTS: Midline sternotomy alone did not affect sternal blood flow. A statistically significant ( p < 0.05) reduction in perfusion of the involved sternal half in comparison to the control side was detected at 2 and 5 hours after surgery. The degree of perfusion deficit was not related to the harvesting technique. CONCLUSIONS: Skeletonized and semiskeletonized ITA harvesting techniques caused a similar acute reduction in sternal perfusion during the early postoperative period and this effect lasted for at least 5 hours.

Animals↗
PubMed2005

[The ECG-gated 4-row multidetector CT of the heart in preoperative imaging minimal invasive coronary artery bypass grafting].

PURPOSE: Minimal invasive direct coronary artery bypass grafting (MIDCAB) or off-pump coronary artery bypass grafting (OPCAB) on the beating heart with full or mini-sternotomy are becoming more common in coronary bypass surgery of the left anterior descending (LAD). In the decision, which surgical approach (MIDCAB, OPCAB or conventional surgery with cardiopulmonary bypass) will be best used, knowledge of the anatomical field is of major importance. The aim of the study was to evaluate retrospective ECG-gated 4-row multidetector CT (MDCT) in patients planned for MIDCAB as additional imaging to coronary angiography. MATERIAL AND METHODS: The study included 25 consecutive patients. MSCT was performed as unenhanced (collimation 4 x 2.5 mm) and contrast-enhanced examination (140-170 ml, 300 mg Iodine/ml, collimation 4 x 1 mm). The evaluation included presence of LAD calcifications, distance of LAD and left internal mammarian artery (LIMA), course of LAD and LIMA, the presence or absence of bridging through myocardium or epicardial fat and the presence of pleural fibrosis. The MDCT results were correlated with intra-operative findings. RESULTS: All MDCTs could be assessed with reference to the demands. In 20/25 operations, MDCT had direct influence as to the selection of the surgical approach (11 MIDCAB, 7 OPCAB with mini-sternotomy and 5 with full sternotomy, 2 conventional surgeries). The distance of LAD and LIMA varied from 0.9 to 4.5 cm in MDCT. As to calcifications, 3/25 correlated patients had calcifications and 10 patients had no calcifications in the middle LAD. Seven patients had intraoperative fibrosis of the vessel wall without calcification of the middle LAD, which could not be detected with MDCT. Another 5 patients had single calcified plaques in the middle LAD, 4 of these had a fibrosis of the vessel and 1 had a normal vessel at surgery. In these cases, the anastomosis was done between the calcified plaques. No myocardial bridging was detected by MDCT and at surgery. Bridging of epicardial fat was shown by MDCT and at surgery in 9/25 patients and was excluded in 15 patients. In 1 patient, the LAD seemed to run superficially in MDCT, but was covered with fat as seen during surgery. The course of the LIMA was inconspicuous in all cases, no pleural fibrosis was found. CONCLUSIONS: The 4-row MDCT has proven to be adequate in addition to coronary angiography for preoperative evaluation in patients scheduled for MIDCAB and provides the surgeon with relevant information for the selection of the operative approach.

Aged↗
PubMed2006

[The importance of vacuum therapy in the treatment of sternal osteomyelitis from the plastic surgeons point of view].

BACKGROUND: Since its introduction in 1997 the vacuum assisted closure therapy has gained widespread and is for its indications international accepted. It is also well established in the treatment of sternal infections a dreaded complication after median sternotomy in cardiac surgery. The well known positive effects of the vacuum therapy act as a dignified cleaning procedure between debridement and plastic coverage or as a temporarily closure method if the first debridement was properly not sufficient. METHOD AND PATIENTS: Between January 2003 and December 2005 twenty eight patients with advanced sternal infection after median sternotomy were treated by radical debridement, vacuum assisted closure therapy and definitive plastic coverage by muscle flaps. In this article three patients are exemplarily introduced. RESULTS: In all patients a sufficient plastic coverage was achieved after radical debridement an vacuum assisted closure therapy. The patients received a pedicaled muscle flap. Stable wound condition with no signs of a recurrent sternal infection were observed in all patients. DISCUSSION: Vacuum assisted closure therapy acts as a link between radical Debridement and definitive plastic coverage in prolonged sternal infection after median sternotomy. Before the invention of V.A.C.(R) dressing changes were obliged every day in patients with deep sternal infection. The V.A.C.(R) therapy reduces the frequency of this painful dressing changes significantly and on this behalf makes life more comfortable for this mostly multi-morbid patients.

Aged↗
PubMed1999

Coronary bypass grafting without cardiopulmonary bypass--technical considerations, clinical results, and follow-up.

BACKGROUND: Coronary bypass surgery can be performed less invasively by avoiding cardiopulmonary bypass (CPB). We present our early 'off pump' coronary bypass surgery experience in combination with a minithoracotomy or sternotomy. METHODS: Between 11/1996 and 12/1997 312 patients were included in a prospective study, 223 (Group A) underwent an antero-lateral minithoracotomy (MIDCAB) and 89 (Group B) had a full sternotomy (OPCAB). ITA harvesting and anastomosis was performed under direct vision in all cases. Different devices for local mechanical immobilization were used to perform the anastomosis. RESULTS: In 212 patients of group A revascularization was by a single ITA graft and in 11 patients by a double graft using the radial artery as a T graft. Conversion to sternotomy and cardiopulmonary bypass was necessary in 12 (5.3%) patients. Intraoperative myocardial infarction was observed in 5 patients (2.2%). Early-postoperative reoperation due to graft failure was necessary in 5 patients (2.2%). Mortality was 0.4% (one patient). The early postoperative graft patency rate was 97.1% as confirmed by angiography. In group B, 25 patients had single graft and 64 patients multiple graft revascularization. Intraoperative conversion to CPB was necessary in 10 patients (11.2%). Intraoperative myocardial infarction occurred in 1 patient (1.1%), postoperative low output syndrome in 2 patients (2.2%). Early postoperative reoperation due to graft failure was necessary in 1 patient (1.1%). Mortality was 1.1%. Angiographic control of 48 patients after 6 months confirmed a patency rate of 92.6%. CONCLUSION: Coronary bypass surgery without using cardiopulmonary bypass is safe to achieve good early and mid-term results. MIDCAB is a minimally invasive technique. Experienced surgeons should be ready to compete with PTCA techniques.

Cardiopulmonary Bypass↗
PubMed1984

Revival of right thoracotomy to approach atrio-ventricular valves in reoperations.

A right thoracotomy was used to approach the atrio-ventricular (AV) valves in 8 patients who had previously undergone a cardiac operation through a midline sternotomy. Due to an extremely enlarged right heart, to a dilated ascending aorta, or to the presence of anteriorly placed aorto-coronary bypass-grafts, a repeated midline sternotomy was considered to involve the risk of massive hemorrhage in this group of patients. Cardiopulmonary bypass was instituted after cannulation of the right femoral artery and of the right atrium or venae cavae. The ascending aorta was controlled when deemed necessary. Since minimal dissection was required and the exposure of the AV valves was excellent, the operative procedure was uneventfully and expeditiously carried out in all cases. A right thoracotomy provides a convenient way to approach the AV valves in selected patients who have had previous heart surgery through a midline sternotomy.

Adolescent↗
PubMed2002

Doppler tissue velocity, strain, and strain rate imaging with transesophageal echocardiography in the operating room: a feasibility study.

OBJECTIVE: Transesophageal echocardiography (TEE) is increasingly used to monitor regional myocardial function during cardiac operation. Doppler myocardial imaging (DMI) indices can potentially provide new information on regional radial and longitudinal myocardial motion and local deformation. This study examined the feasibility of TEE acquisition of regional radial and longitudinal velocity, displacement (D), strain, and strain rate data during cardiac operation and evaluated the effects of sternotomy and pericardial opening on these indices. METHODS: After a baseline transthoracic echocardiographic study, TEE was performed in 22 patients (age 64 +/- 7 years) before sternotomy, after sternotomy with intact pericardium, and after pericardial opening. Regional DMI velocity analysis was performed for the transgastric anterior and inferior walls midpapillary segment (radial function) and the 4-chamber septum and 2-chamber inferior walls basal, mid, and apical segments (longitudinal function). For each segment, systolic and diastolic velocity were derived and D, strain, and strain rate calculated. RESULTS: Transthoracic echocardiographic study and TEE provided similar data from an equivalent number of interpretable segments. In the basal and mid septum, maximum longitudinal systolic D decreased with pericardial opening (basal septum pericardium closed: 6.6 +/- 1.5 mm, open: 4.6 +/- 1.8 mm, P =.007; midseptum pericardium closed: 4.7 +/- 2.5 mm, open: 2.7 +/- 1.5 mm, P =.028). No changes were evident in systolic or diastolic DMI indices in all other segments. CONCLUSION: DMI with TEE is feasible during cardiac operation. During pericardial opening, longitudinal D decreases in the septum, but not in the inferior wall. DMI requires further evaluation in the assessment of ventricular function and the detection of ischemia in the operating room.

Aged↗
PubMed2002

Repair of atrial septal defects via limited right anterolateral thoracotomy.

INTRODUCTION: Right thoracotomy is a well known alternative for median sternotomy to gain access to the right atrium. The Port-Access technique is a surgical option to reduce the skin incision to 5 cm and have a considerable gain in cosmesis and post-operative rehabilitation. PATIENTS AND METHODS: From February 1997 to May 2000, 50 patients (19M/31F) had Port-Access atrial septal defect repair (ASD) with the Heartport Endo-CPB and Endo-aortic clamp system. Mean age was 46 years (range 10.5-74 years). Forty-nine patients had a type II ASD. Most of the patients were asymptomatic (48 were NYHA class I-II). Five patients underwent combined procedures: two mitral valve repairs, one mitral valve replacement, one plasty of the superior vena cava and one mini Cox-Maze. Direct closure was obtained in 34 patients (68%). Mean aortic cross clamp time was 56 minutes (range 24-134 min) and mean perfusion time was 102 minutes (range 32-196 min). RESULTS: There were no conversions to sternotomy. The procedure was complicated in six patients: revision for bleeding (n = 1), stenting of the iliac vein (n = 1), enlargement plasty of the femoral artery (n = 1), transient renal failure (n = 1), sick sinus syndrome requiring pacemaker implantation (n = 1) and one lymphocoele. No thromboembolic or peripheral ischaemic complications were noted. Per- and postoperative echocardiography showed no leakage in any patients. There was no hospital mortality. Mean ICU and hospital stay were 1.14 days (range 1-3 days) and 6.41 days (range 4-10 days) respectively. CONCLUSION: The Port-Access approach of ASD closure constitutes a valid alternative to sternotomy with the same standards of results and quality.

Adolescent↗
PubMed1994

Comparison of desflurane and fentanyl-based anaesthetic techniques for coronary artery bypass surgery.

We have compared, in 51 ASA II and III patients undergoing coronary artery bypass surgery, an inhaled anaesthetic technique based on desflurane, supplemented with low-dose (10 micrograms kg-1) fentanyl, with an i.v. technique using high-dose (50 micrograms kg-1) fentanyl with midazolam for induction. Satisfactory records were available for analysis in 50 patients. There were no differences between groups in operating time, cardiopulmonary bypass time, aortic cross-clamp time or duration of stay in the intensive care unit after surgery. Desflurane maintained mean systemic arterial pressure at the awake level during incision and sternotomy (end-tidal concentrations 3.7% and 4.6%, respectively) but decreased it significantly at all other times. With fentanyl, mean systemic arterial pressure was unchanged from awake values during induction and laryngoscopy but increased significantly at incision and sternotomy by 8% and 12.8%, respectively, to exceed the desflurane group at sternotomy by 20 mm Hg (P < 0.001). With desflurane, heart rate remained at 60-67 beat min-1 at all times before cardiopulmonary bypass. This was always lower than the fentanyl group by 5-15 beat min-1 and the difference was significant at induction, during skin preparation and before aortic cannulation. In comparison with the desflurane group, cardiac index was significantly greater in the fentanyl group at induction, laryngoscopy and during skin preparation, but was significantly less before aortic cannulation. The need for vasodilator intervention was significantly more common in the fentanyl group before, during and after cardiopulmonary bypass and for beta adrenoceptor block before cardiopulmonary bypass.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1990

Results of salvage surgery for metastatic sarcomas.

Between January 1970 and December 1988, 105 consecutive patients underwent complete resection for lung metastases from sarcoma, 33 of them in the years from 1970 to 1983 and 72 between 1984 and 1988. In the latter period, new criteria consisting of early bilateral surgical staging and lung resection through median sternotomy were adopted for the management of lung metastases, in all patients with purely intrathoracic relapse. There was no operative mortality, follow-up was updated in August 1989, and actuarial survivals were calculated by the logrank method at 36 months from the time of first lung resection. During the second period, the overall actuarial survival at three years improved significantly (24% vs. 50%, P less than 0.02), notwithstanding the higher incidence of patients with unfavourable prognostic factors. The three-year survival was also significantly better in the subset of patients with a disease-free interval less than or equal to 12 mos. and/or multiple pathological lesions (9% vs. 45%, P less than 0.05). Contralateral occult metastases were resected in 10 of 29 subjects who underwent sternotomy for monolateral clinical lesions. Of 26 patients with further intrapulmonary recurrence, 16 (62%) were amenable to re-operation and eventual surgical rescue. These data suggest that median sternotomy and early management of occult contralateral disease may contribute to an improvement in the long-term survival of patients with metastatic sarcomas. On the other hand, it is possible that the effectiveness of salvage surgery is related to the higher activity and wider application of adjuvant and salvage chemotherapy.

Adolescent↗
PubMed2001

Pulmonary arterial pressure can be estimated by transesophageal pulsed doppler echocardiography.

We examined whether pulmonary arterial pressure can be estimated on the basis of pulmonary arterial flow velocity determined via intraoperative pulsed Doppler transesophageal echocardiography (TEE) in 20 patients undergoing cardiac surgery. Standard pulmonary artery measurements were taken as well. Measurements were taken before sternotomy, after pericardiotomy, after cardiopulmonary bypass, and after sternum closure. The variables obtained by TEE included preejection period (PEP), acceleration time (AT), right ventricular ejection time (RVET), and R-R interval (RR). Five ratios were calculated as indices of pulmonary arterial pressure--PEP/AT, PEP/RVET, AT/RVET, PEP/ square root of RR, and AT/ square root of RR--and were compared with pulmonary artery catheterization findings, i.e., systolic pulmonary arterial pressure (sPAP), log sPAP, mean PAP (mPAP), and log mPAP. Before sternotomy, PEP/AT, PEP/ square root of RR, and AT/ square root of RR showed significant correlation with all pulmonary artery catheterization values. AT/RVET showed correlation with all pulmonary artery values except log mPAP. PEP/AT showed the closest correlation with sPAP (r = 0.771) and log sPAP (r = 0.789). PEP/AT also showed close correlation with mPAP (r = 0.764) and log mPAP (r = 0.777). Significant agreement between sPAP and mPAP values calculated from a regression equation and values measured via pulmonary artery catheter was observed by plotting the differences against the mean values of the two measurements. We therefore conclude that noninvasive estimation of pulmonary arterial pressure is feasible via intraoperative TEE when sternotomy is not involved.

Adult↗