Right ventricular rupture after coronary surgery

A 70-year-old woman suffered a fatal right ventricular rupture 12 h after uneventful coronary surgery. Post-mortem examination revealed that the rupture had occurred through an area of fatty infiltration. Myocardium had been replaced by fat cells. The literature is reviewed and pathology of this condition discussed.

Retrieval of broken left-atrial catheter using a rigid bronchoscope

Left-atrial pressure monitoring continues to be of value in cardiac surgery of the high-risk patient. Complications are fortunately low and include haemorrhage following catheter removal and retained catheter fragments. A simple and safe technique is presented to retrieve retained catheters using a rigid bronchoscope and avoiding the need for resternotomy.

Cardiopulmonary bypass in the early puerperium: possible new role for aprotinin

A case of successful emergency reoperation for mitral valve replacement 2 hours after a cesarean section is reported. The use of aprotinin (Trasylol; Bayer AG, Leverkusen, Germany) greatly simplified the surgical procedure and was in our opinion the most important factor in an uncomplicated outcome.

Emergency mitral valve replacement immediately following caesarean section

Cardiopulmonary bypass immediately post-partum could carry the risk of severe uterine bleeding. We report the case of a woman who successfully underwent emergency replacement of a thrombosed mitral prosthesis immediately after Caesarean section.

Straddle embolus--imminent paradoxical embolus diagnosed by echocardiography and treated surgically

Paradoxical embolus, the passage of an embolus from the right to the left side of the circulation, was formerly recognised as a postmortem diagnosis. More recently, survivors with paradoxical embolus have been described. A case of paradoxical embolus is described in which the diagnosis was made clinically, and an imminent further embolus visualised by transoesophageal echocardiography, which was successfully treated surgically. Treatment strategies are discussed.

Anticoagulation variability between centres: implications for comparative prosthetic valve assessment

One of the major determinants in the choice of a mechanical prosthetic valve is that valve's thromboembolic record but the thromboembolic (TE) rates may be substantially influenced by the levels of anticoagulation achieved. A detailed study of anticoagulation variability was undertaken in 834 patients who received one or more of a particular prosthesis (Medtronic-Hall) in one centre during a 7-year period from 1979 to 1987, but who attended 27 different anticoagulant clinics spread over a wide area. In addition, a questionnaire was sent to all 89 practising cardiac surgeons in the UK asking for their preferred range of International Normalised Ratio (INR) for patients with mechanical prosthetic valves. Both the local study (with 16,866 INR observations) and the national questionnaire (with a 53% response) revealed an enormous amount of variability. Median INR values (semi-interquartile range) varied from 2.2 to 3.9 (0.8-2.5) according to the anticoagulant clinic attended. The range of INR preferred by UK cardiac surgeons, but presumably not necessarily achieved, varied from 1.8-2.2 to 3.0-4.8, with 64% of surgeons preferring an INR less than 3.0. In comparison, standard US practice is to maintain prothrombin times equivalent to INR values of 4.0-5.0. Unless anticoagulant practice can be standardised internationally, comparison of TE complications between centres is meaningless, and casts doubt on the validity of TE rates quoted for particular prostheses, unless accompanied by a detailed analysis of anticoagulant control.

A comparative study of median sternotomy and standard thoracotomy wound skin closure methods

Complications from skin closure after median sternotomy or standard thoracotomy incision, although uncommon, may be the source of undesireable morbidity and even death. A prospective randomized study of 3 different methods of wound skin closure has been carried out in 205 patients undergoing cardiothoracic surgery. These methods were: 1. continuous nylon vertical mattress suture; 2. continuous subcuticular absorbable (Dexon) suture; 3. adhesive sutureless skin closure (Op-Site). All wounds were examined by independent observers at 5, 10 and 45 days after operation, and the findings were graded from 0 to 4. At 5 days, assessments were made of inflammation, edema, discharge and infection. At 10 days, attention was paid to the state of wound healing, and at 45 days to the final cosmetic appearance. The use of continuous subcuticular Dexon suture resulted in less discharge than Op-site (p less than 0.001) and less swelling or redness than nylon (p less than 0.001). Assessment of the final cosmetic appearance of the wound 6 weeks following surgery showed subcuticular Dexon to be superior to either nylon (p less than 0.01) or Op-site (p less than 0.01).

Pseudocoarctation of the aortic arch associated with bicuspid aortic valve lesion: is it a surgical entity?

Three patients with bicuspid aortic valve lesion associated with pseudocoarctation of the aortic arch are presented. At operation, 2 had a bicuspid calcified stenotic aortic valve, and one a bicuspid non-calcified incompetent aortic valve. All required replacement of the diseased aortic valve. The pseudocoarctation was not corrected because it caused no hemodynamic abnormality.

Right coronary artery occlusion by cloth from a Starr-Edwards aortic valve prosthesis

We report a case of sudden onset of angina 11 years after implantation of a No. 8 Model 2300 Starr-Edwards cloth-covered aortic valve prosthesis for aortic stenosis and insufficiency. At operation the cloth covering one strut of the metal cage was tenuously attached to the ring of the prosthesis, with its free end completely occluding the right coronary artery ostium. The valve was replaced and the obstructing foreign body removed, re-establishing the patency of the right coronary artery.