Higher Imported Food Patterns Are Associated with Obesity and Severe Obesity in Tuvalu: A Latent Class Analysis

Background

Tuvalu is a Pacific Island country within the small island developing states that has observed a significant and alarming increase in obesity rates over the past 40 years, affecting ∼60 %-70 % of the current population.

Objectives

This study aimed to investigate the association between food patterns and the proportion of obesity in a Pacific Island country.

Methods

The 2022 COMmunity-based Behavior and Attitude survey in Tuvalu (COMBAT) included 985 adults with complete data on sociodemographic information and the frequency of consumption of 25 common foods. A latent class analysis determined 4 food patterns. Bayesian multilevel logistic and linear regression models estimated the association between food patterns and the proportion of obesity [body mass index (BMI) ≥30 kg/m2], severe obesity (BMI ≥40 kg/m2), and weight (kg), adjusting for potential confounders and accounting for clustering by region.

Results

The latent class analysis revealed 4 food patterns with an entropy of 0.94 and an average posterior probability of class assignment for each individual of 0.97, described as follows: 1) local: locally produced foods with moderate food diversity (proportion of individuals = 28 %); 2) diverse-local: local with greater food diversity (17 %); 3) restricted-imported: more imported with restricted diversity (29 %); and 4) imported: heavily imported with high diversity (26 %). Compared to those following the diverse-local pattern, the odds of having obesity were greater for those classified with the imported pattern [odds ratio (OR): 2.52; 95 % credible interval (CrI): 1.59, 3.99], restricted-imported pattern (OR: 1.89; 95 % CrI: 1.59, 3.99), and local pattern (OR: 1.54; 95 % CrI: 0.94, 2.50). Similar trends were observed for severe obesity while body weight was positively associated with both restricted-imported and imported food patterns.

Conclusions

The high consumption of imported foods, together with the low consumption of plant-based foods and protein-rich foods, could be a relevant modifiable lifestyle factor explaining the high levels of obesity and severe obesity in Tuvalu, a Pacific Island country.

Pediatric neuroimaging findings and clinical presentations of COVID-19: A systematic review

OBJECTIVES

Symptoms from SARS-CoV-2 infection can involve multiple organ systems. Several reviews discussed the neurologic involvement and neuroimaging findings in adults but research on children is lacking. This study aimed to analyze the incidence of neurologic involvement in patients diagnosed with pediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS) or multisystem inflammatory syndrome in children (MIS-C); and also to summarize current literature on possible neuroimaging findings in SARS-CoV-2 infected children.

METHODS

A literature search in six electronic databases was performed to retrieve case series, cohort studies, and cross-sectional studies on neurologic involvement in COVID-19 patients younger than 21 years of age published between December 2019 to September 2023, including COVID-19 patients.

RESULTS

A total of 2224 patients with MIS-C from 10 cohorts and cross-sectional studies suggested that neurologic involvement in these subsets ranges from 8.5% to 32.1%. Symptoms included acute encephalitis, seizures, stroke, cranial nerve palsy, nausea/vomiting, and intracranial hypertension. Neuroradiology findings of 114 children from 50 case reports included splenial or acute disseminated encephalomyelitis (ADEM)-like lesions, cytotoxic brain edema, autoimmune demyelinating diseases, ischemic stroke and arteritis, venous thrombosis, intracranial hemorrhage, meningitis, posterior reversible encephalopathy syndrome, anti-N-methyl-D-aspartate receptor autoimmune encephalitis, acute hemorrhagic leukoencephalitis, hydrocephalus, olfactory bulb atrophy, cerebellitis, and acute necrotizing encephalitis.

CONCLUSION

Radiologic findings of SARS-CoV-2 infection in the pediatric population are diverse. Neuroimaging studies should be considered in critically ill patients to rule out neurologic involvement and facilitate early interventions.

Exploring the link between home garden use and severe obesity: Insights from a nationwide survey in Tuvalu

Background

Obesity is prevalent and increasing but understudied across Pacific Islanders. Tuvalu is a South Pacific country with a high obesity rate and faces multiple threats of food insecurity. Home garden serves as a sustainable food source and can be a possible intervention for the obesity pandemic in Tuvalu. This study investigated Tuvaluans' home garden use and obesity, and explored factors associated with increased use of home gardens.

Methods

We conducted a nationwide, cross-sectional study in Tuvalu during 2022. Structured questionnaires were administered during the in-person interviews, and trained interviewers measured the height and weight of each participant. The association between home garden use, obesity and severe obesity were tested with univariate and multivariable logistic regression. We also applied overlapping weights to balance the distribution of baseline demographic factors.

Results

The average body mass index was 34.87 kilogrammes (kg) / square metre (m2) among the study population of 1024 adults (630 from Funafuti and 394 from other islands in Tuvalu). Overall, people having home gardens was associated lower odds for severe obesity compared to those without a home garden in overlap weighting models (odds ratio (OR) = 0.946, 95% CI = 0.897-0.997, P = 0.039) and the association was stronger in Funafuti (OR = 0.927, 95% CI = 0.866-0.991, P = 0.027) than in the outlying islands (OR = 0.967, 95% CI = 0.889-1.052, P = 0.435). Furthermore, increased age was positively associated with having a home garden in Funafuti, and smoking showed an inverse association.

Conclusions

Having a home garden is associated with lower odds of severe obesity in Tuvalu, and the association is stronger in Funafuti. Smokers are less likely to have home gardens, and increased age is positively associated with having home gardens. These findings promote more home garden utilisation and provide evidence for targeted interventions in Tuvalu.

264The long noncoding RNA H19 modulates cardiac remodeling after infarction

Noncoding RNAs account for 80% of human transcripts, but functional studies on noncoding RNAs are relatively few and limited. Long noncoding RNAs (lncRNAs) are known to have an important role in cardiac development, and lately, high-throughput RNA sequencing has been extensively utilized to profile and explore the transcriptome landscape of lncRNAs in failing hearts. These studies have revealed that lncRNAs are mostly dysregulated in failing hearts and their expression signature can discriminate failing hearts of different etiologies.

H19 is abundantly expressed in failing human hearts and its polymorphism was shown to possess a significant correlation with the risk of coronary artery diseases. In our study using murine hearts, we discovered that H19 was significantly up regulated in the heart after ischemic injury, with predominant expression in cardiac fibroblasts. This finding piqued our interest to further investigate the function of H19 in the heart.

We demonstrated that ectopic overexpression of H19 using the AAV approach led to severe cardiac fibrosis in mouse hearts following myocardial infarction. In light of this finding, we generated H19 knockout mice to further investigate the functionality of H19 and we found that cardiac fibrosis was attenuated in these mice. Altogether, these findings suggested that H19 is a fibrosis regulator during cardiac remodeling process after infarction. Due to the multiple regulatory roles of lncRNAs, we then took advantage of chromatin isolation by RNA purification (ChIRP) to identify the H19-interacting protein, YB-1. Surprisingly, mice with YB-1 knockdown displayed severe cardiac fibrosis even without injury. Furthermore, we demonstrated that YB-1 is a transcriptional suppressor of collagen 1A1. Knockout of H19 in YB-1 knockdown partially suppressed Col1a1 expression, which suggests a negative regulatory role of H19 on YB-1 towards the expression of Col1a1.

Taking into account all of these findings, we concluded that H19 mediates collagen expression in fibroblasts through the inhibition of YB-1 activity during cardiac remodeling.

Interference Effect between ϕ and Λ(1520) Production Channels in the γp→K^{+}K^{-}p Reaction near Threshold

The ϕ-Λ(1520) interference effect in the γp→K^{+}K^{-}p reaction has been measured for the first time in the energy range from 1.673 to 2.173 GeV. The relative phases between ϕ and Λ(1520) production amplitudes were obtained in the kinematic region where the two resonances overlap. The measurement results support strong constructive interference when K^{+}K^{-} pairs are observed at forward angles but destructive interference for proton emission at forward angles. Furthermore, the observed interference effect does not account for the sqrt[s]=2.1  GeV bump structure in forward differential cross sections for ϕ photoproduction. This fact suggests possible exotic structures such as a hidden-strangeness pentaquark state, a new Pomeron exchange, or rescattering processes via other hyperon states.

Versatile use of extra-corporeal life support to resuscitate acute respiratory distress patients

Extra-corporeal life support (ECLS) has been applied successfully to congenital respiratory defects but less optimally to acquired pulmonary failure. We extended this support to certain extreme complexities of patients with acute respiratory distress. From January 2003 to June 2005, 16 (nine men and seven women) patients refractory to ventilator support were treated with ECLS. Their median age was 32.4 years (1.5-70). The triggering events were pulmonary haemorrhage (n = 4), pneumonia (n = 7), aspiration (n = 2) and pancreatitis (n = 3). The indications for support were hypoxaemia in 13 and hypercapnia in three patients. Ten (63%) met the criteria of fast entry. Thirteen (81%) received veno-venous (V-V) mode support and the other three received veno-arterial mode support initially, but then converted to V-V mode after sufficient oxygenation stabilised haemodynamics. Initial pump flow was maximised to improve (mean 3250 +/- 1615 ml/min) to improve the oxygenation. Four patients with active pulmonary haemorrhage were heparin free in the first 12-24 h of support without complications. Excluding one prematurely terminated patient because of brain permanent damage, the duration of support was 162 +/- 95 h (67-363). Eleven (69%) weaned successfully from ECLS and 10 (63%) discharged and regained normal pulmonary performance in a median of 26.8 months follow-up. Pulmonary support using ECLS was feasible in selected patients with acute respiratory distress. Modification of guidelines for liberal use, early deployment before secondary organ damage and prevention of complications during support were the key to final success.

Cyclosporine enhances vasorelaxation in coronary but not pulmonary artery after 16-hour preservation with UW solution

Cyclosporine (CsA), a calcineurin inhibitor, has been associated with endothelial dysfunction in transplant patients. Human and in vitro studies suggest that CsA produces endothelial dysfunction by impairing vascular endothelium-dependent relaxation. However, little is know about the CsA effects to modulate the vasorelaxation after prolonged graft preservation. In this study using a protocol designed to eliminate the influences of infusion pressure and shear stress, we evaluated the effect of CsA on vasorelaxation of coronary and pulmonary arteries after 16-hour University of Wisconsin (UW) solution preservation.

Identification of a gene encoding a typical gamma-carboxyglutamic acid domain in the tunicate Halocynthia roretzi

We report the identification of a gene capable of encoding a novel Gla (gamma-carboxyglutamic acid) protein from the tunicate Halocynthia roretzi, a primitive member of the phylum Chordata. We call this new hypothetical protein Gla-RTK; it has a Gla domain typical of human vitamin K-dependent coagulation factors, a transmembrane domain, and a receptor tyrosine kinase domain. The receptor tyrosine kinase domain is very similar to the ARK (adhesion-related kinase) family of receptor tyrosine kinases. The ARK family includes Axl, Tyro3, and c-Mer. This gene also encodes a propeptide that binds to the human gamma-glutamyl carboxylase within a range of affinities observed for mammalian propeptides. The cDNA for this putative protein is found distributed throughout the oocyte and embryo but the cDNA is apparently not transcribed except during oogenesis. One of the most interesting aspects of this hypothetical protein is that its Gla domain is highly homologous to the Gla domain of Gas6, a ligand for Axl, while its receptor tyrosine kinase domain is highly homologous to Axl.

Thoracoscopic-assisted management of postpneumonic empyema in children refractory to medical response

BACKGROUND

Empyema frequently complicates the hospitalization of children; and in advanced stages, it often requires surgical intervention. In this study, we investigated the use of video-assisted thoracic surgery (VATS) for the management of postpneumonic empyema in children who have had an unsatisfactory medical response.

METHODS

We did a retrospective review of the medical records of 51 consecutive patients with loculated empyema (mean age, 5 years; range, 2 months to 15 years) hospitalized at Chang Gung Memorial Hospital between 1995 and 2000. All patients underwent debridement of the necrotic lung tissue and evacuation of the loculated empyema cavity using a VATS approach.

RESULTS

The mean operating time for the 51 patients was 90 min (range, 50-210); mean blood loss was 70 cc. Fever subsided within 72 h postoperatively in all patients. On average, chest tubing was removed on the 7th postoperative day (range, 4-18 days). However, in one patient who suffered from a prolonged air leak, the chest tube was not removed until day 18. The mean postoperative stay for all patients was 13.7 days (range, 9-23). No deaths occurred, and all of the children made a good recovery. A follow-up revealed that one of the 51 children patient suffered a left upper lung abscess 7 months after discharge. Left upper lobectomy was performed in this case, and the patient was discharged uneventfully 10 days after the operation.

CONCLUSIONS

VATS is a safe and effective treatment for pediatric empyema. Thoracoscopic-assisted surgery facilitates visualization, evacuation, and debridement of the necrotizing lung tissue. Early surgical intervention can avoid lengthy hospitalization and prolonged intravenous antibiotic therapy, and it can accelerate clinical recovery.

Minimal access thoracic surgery for esophageal hemangioma

Esophageal hemangioma is a rare tumor. This report describes the case of a 69-year-old woman with an esophageal tumor at the middle portion of the esophagus. The patient was successfully treated with minimal access thoracic surgery, and at the 6 month follow-up, the patient was free of any symptoms or recurrence.

Kinetic characteristics of bacterial azo-dye decolorization by Pseudomonas luteola

A Pseudomonas luteola strain expressing azoreductase activity was utilized to remove the color of an azo dye (reactive red 22) from contaminated solutions. The effects of substrate concentrations, medium compositions, and operation parameters (e.g., pH, temperature, dissolved oxygen, etc.) on decolorization of the azo dye by a P. luteola strain were systematically investigated to reveal the key factors that dominate the performance of azo-dye decolorization. The metabolites resulting from bacterial decolorization were analyzed by high-performance liquid chromatography (HPLC) and mass spectrometery (MS). The results show that the dissolved oxygen and glucose concentration retarded decolorization of reactive red 22 by P. luteola. The optimal azo-dye decolorization occurred at 37 degrees C, while more rapid decolorization took place over pH 7-9. Yeast extract and tryptone strongly enhanced the decolorization. The Michaelis-Menten model can satisfactorily describe the dependence of specific decolorization rate on the concentration of substrate (reactive red 22 or yeast extract). Decolorization of the azo dye by intact cells of P. luteola was essentially independent of the growth phase, whereas the azoreductase activity of the cell-free extract decreased in the order of late-stationary phase > early-stationary phase > mid-log phase. This suggests that mass transfer of the azo dye across the cell membrane may be the rate-limiting step. The HPLC and MS analyses suggest that both partial reduction and complete cleavage of the azo bond could contribute to decolorization of reactive red 22 by P. luteola.

Collagen as a drug carrier for deep sternal wound infection after open heart surgery

How to optimally treat deep sternal wound infection after open wound infection remains controversial. Biomaterial advances have made local antibiotics-releasing systems a promising alternative for treating deep sternal wound infection. Two patients with deep sternal wound complications were treated with radical wound debridement, sternal refixation, retrosternal suction drainage, bilateral pectoralis major muscle flaps and placement of collagenous drug carriers loaded with vancomycin underneath, above and between the sternal edges. No treatment failure and death occurred in these patients. There were no side effects, treatment failures or deaths after adjuvant treatment with collagenous vancomycin. Preliminary results of these 2 case studies demonstrate the feasibility of successfully treating deep sternal wound infections with collagenous vancomycin in combination with surgical debridement. This technique is easily performed, reliable and safe.

A new tool for benchmarking cardiovascular fluoroscopes

This article reports the status of a new cardiovascular fluoroscopy benchmarking phantom. A joint working group of the Society for Cardiac Angiography and Interventions (SCA&I) and the National Electrical Manufacturers Association (NEMA) developed the phantom. The device was adopted as NEMA standard XR 21-2000, "Characteristics of and Test Procedures for a Phantom to Benchmark Cardiac Fluoroscopic and Photographic Performance," in August 2000. The test ensemble includes imaging field geometry, spatial resolution, low-contrast iodine detectability, working thickness range, visibility of moving targets, and phantom entrance dose. The phantom tests systems under conditions simulating normal clinical use for fluoroscopically guided invasive and interventional procedures. Test procedures rely on trained human observers.

Thoracoscopic retrieval of metal rods after penetrating chest injury: case report

Thoracoscopy has been used for both diagnostic and therapeutic purposes. Its use in the trauma field is rapidly increasing. Here, we present a case of chest trauma that was successfully treated using the thoracoscopic approach. A 43-year-old male patient was brought to our emergency room with a severe right chest wall-penetrating metal-rod injury, which had occurred after falling from a height. The chest X-ray showed an upper right lung lobe injury. Video-assisted thoracoscopic surgery (VATS) was performed for diagnosis of any other associated injury and for management of the penetrating injury. The prognosis was good. We believe that minimal thoracoscopic surgery is an alternative way that provides a more rapid diagnosis, and a less-invasive and safe operation for acute chest trauma patients.

Paradoxical cerebral air embolism after removal of a central venous catheter: case report

Paradoxical cerebral air embolization through a residual tract after the removal of a central venous catheter is a serious complication of central venous cannulation. Air embolisms resulting from residual catheter tracts in general patients and in single lung transplant patients have been reported. The generally accepted mechanism of this complication is failure of a spontaneous collapse or thrombotic obliteration of a well-formed catheter tract. It may be related to the duration of catheter insertion, the patient's nutritional status, the diameter of the indwelling catheter, the upright position of the patient, deep inspiration or coughing, and improper wound dressing and catheter removal. Cardiovascular collapse, pulmonary or neurologic sequelae, and even death, are commonly noted in patients with air embolism. In this article, we report on cerebral air embolization as a complication with the removal with a central venous catheter in a patient with bullous emphysema. A high degree of suspicion and a prompt diagnosis are required for successful application of established therapy. Simple prophylactic procedures and constant awareness of the unusual mechanism of air embolism remain the best treatment.

Localization and activity of myosin light chain kinase isoforms during the cell cycle

Phosphorylation on Ser 19 of the myosin II regulatory light chain by myosin light chain kinase (MLCK) regulates actomyosin contractility in smooth muscle and vertebrate nonmuscle cells. The smooth/nonmuscle MLCK gene locus produces two kinases, a high molecular weight isoform (long MLCK) and a low molecular weight isoform (short MLCK), that are differentially expressed in smooth and nonmuscle tissues. To study the relative localization of the MLCK isoforms in cultured nonmuscle cells and to determine the spatial and temporal dynamics of MLCK localization during mitosis, we constructed green fluorescent protein fusions of the long and short MLCKs. In interphase cells, localization of the long MLCK to stress fibers is mediated by five DXRXXL motifs, which span the junction of the NH(2)-terminal extension and the short MLCK. In contrast, localization of the long MLCK to the cleavage furrow in dividing cells requires the five DXRXXL motifs as well as additional amino acid sequences present in the NH(2)-terminal extension. Thus, it appears that nonmuscle cells utilize different mechanisms for targeting the long MLCK to actomyosin structures during interphase and mitosis. Further studies have shown that the long MLCK has twofold lower kinase activity in early mitosis than in interphase or in the early stages of postmitotic spreading. These findings suggest a model in which MLCK and the myosin II phosphatase (Totsukawa, G., Y. Yamakita, S. Yamashiro, H. Hosoya, D.J. Hartshorne, and F. Matsumura. 1999. J. Cell Biol. 144:735-744) act cooperatively to regulate the level of Ser 19-phosphorylated myosin II during mitosis and initiate cytokinesis through the activation of myosin II motor activity.

Thoracoscopic removal of intrathoracic neurogenic tumors: a combined Chinese experience

OBJECTIVE

To review the surgical and clinical results of minimally invasive resection of intrathoracic neurogenic tumors using a video-assisted thoracoscopic technique.

SUMMARY BACKGROUND DATA

Thoracoscopy has emerged as a possible means for diagnosing and managing various intrathoracic disorders. Benign intrathoracic tumors often are ideal lesions for resection using a video-assisted technique. The authors report on their combined experience with the thoracoscopic resection of 143 intrathoracic neurogenic tumors.

METHODS

Between March 1992 and February 1999, 143 patients with intrathoracic neurogenic tumors were diagnosed and underwent resection using video-assisted thoracoscopic techniques in three teaching centers. Case selection, surgical technique, and clinical results were reviewed.

RESULTS

The average age of the patients was 40.8 years; 57.3% were male. Thirty-eight patients (27%) had symptoms attributable to the masses. Seventy-two masses were neurofibromas, 33 were neurilemmomas, 7 were paragangliomas, and 31 were ganglioneuromas. All but seven tumors were located in the posterior mediastinum. The masses were on average 3.5 cm in greatest diameter. The mean surgical time was 40 minutes, and the average hospital stay was 4.1 days. There were no major postoperative complications or recurrences to date. Nine patients reported paresthesias over the chest wall during a mean follow-up of 29 months.

CONCLUSIONS

Resection of intrathoracic neurogenic tumors using a thoracoscopic technique based on standard surgical indications would seem to be appropriate. Most of these masses are benign and readily removed. For dumbbell tumors, a combined thoracic and neurosurgical approach is mandatory.

Cost-effective approach of video-assisted thoracic surgery: 7 years experience

BACKGROUND

Cost containment is the driving force behind current health care reform. While video-assisted thoracic surgery (VATS) permits a less invasive approach to surgical diseases of the chest, cost is one aspect that is seldom discussed. In Asia, cost-effectiveness essential for the survival of this approach. We present our cost-effective experience with VATS in 2300 patients over a 7-year period.

METHOD

Between 1992 and 1999, 2300 patients underwent video-assisted thoracic surgery at Chang Gung Memorial Hospital. The mean age was 53.2 years (range, 22 days to 102 years); 67% (1541 patients) were men. The VATS technique was mainly performed based on traditional surgical principles. Conventional instruments and the fundamental surgical techniques of dissection, suturing, hemostasis, and tissue approximation that are familiar in the open setting were modified and used to enhance cost savings during VATS.

RESULTS

Surgery was performed on 41 patients on an emergency basis (24 with impending cardiac tamponade and 17 with hemothorax). The mean hospital stay of the patients treated by VATS was 4.5 days. The majority of the patients were operated on successfully using conventional instruments under video vision. The overall operative cost was decreased as compared to common VATS techniques. No delayed morbidity was noted in our patients after a mean follow-up period of 39 months (range, 1 to 68 months).

CONCLUSION

It is our experience that VATS procedures should be performed with the same expertise as open surgery. Conventional instruments similar to those used in open thoracotomy can be incorporated in VATS, and with a more natural hand manipulation. Only through stringent use of expensive endoscopic consumables and application of modified techniques based on traditional surgical principles can VATS be performed efficaciously and economically for a wide range of thoracic conditions.

Catamenial hemoptysis: report of a case treated with thoracoscopic wedge resection

Catamenial hemoptysis is a rare form of hemoptysis. It is a term for the condition of hemoptysis associated with menses. Few cases have been reported in the literature. Only one case, treated by video-assisted thoracoscopic wedge resection, has been described. We report the case of a 26-year-old woman who suffered from catamenial hemoptysis for 7 months and was treated successfully with a video-assisted thoracoscopic (VATS) wedge resection of the lesion. No evidence of recurrence was noted in the postoperative follow-up period of 48 months. We suggest that VATS is the good choice for single focus catamenial hemoptysis.

Composite graft tear and aortico-left ventricular tunnel after aortic root replacement using Cabrol's technique

Woven graft tera is a very rare complication after aortic root replacement using Cabrol's technique. In this report, we present a 40-year-old man with aortic annular ectasia and severe aortic regurgitation who underwent four revisional aortic valve operations because of recurrent paravalvular leakage after valve repair and/or replacement. The Bentall operation with translocated aortic valve and Cabrol's coronary artery anastomosis were performed in the fifth operation, because of progressive dilatation of the aortic root and ascending aorta. Unfortunately, aortico-ventricular tunnel developed 2 years after aortic root replacement using Cabrol's technique. Graft tear and proximal anastomotic leakage were found to be the cause of the tunnel during the sixth operation. The patient died of myocardial failure 8 days after the seventh aortic root replacement operation. The devastating result of this complication should alert cardiovascular surgeons to the possibility of graft failure after the Bentall operation.

Blunt trauma-induced internal thoracic artery injury: case report

We report the case of a 54-year-old male motorcyclist with an apparent grade IV liver injury and life-threatening hemomediastinum and right hemothorax following blunt deceleration trauma. Massive hemothorax and an unstable hemodynamic status even under copious blood volume replacement made emergent surgical intervention mandatory. A midline laparotomy was performed at first to rule out abdominal bleeding accompanied by a diaphragmatic tear, but the procedure was soon converted to a thoracotomy after finding an intact diaphragm and persistent bleeding from the chest tube. An isolated internal thoracic artery (ITA) transection was identified. It was actively bleeding and causing a huge anterior mediastinal hematoma and had ruptured into the right pleural cavity. The bleeder was controlled with suture ligation and the hemodynamic status was soon stabilized. The patient recovered without significant sequelae. The rarity of this kind of presentation is discussed, including both the ITA injury mechanism and the problems posed in making an early and correct diagnosis.

Video-assisted endoscopic removal of infected endocardial pacemaker lead with large floating vegetation

The best management of pacemaker lead related endocarditis is complete surgical or percutaneous removal of the pacemaker system. Although the traditional surgical approach is via median sternotomy, we present two cases in which the lead and vegetations were removed using a video-assisted endoscopic technique through a limited right submammary incision. In each case the patient was supported by partial extracorporeal perfusion. Additional tricuspid valve repair and atrial septal defect closure was performed in one case. The postoperative courses were uneventful, illustrating that, when compared to the conventional open heart surgical approach, the less invasive approach can be a safe and effective way to remove an infected foreign body from the right heart with increased comfort, fast recovery, and a better cosmetic result.

Thoracoscopic surgery for spontaneous pneumothorax

Spontaneous pneumothorax in apparently healthy individuals is a relatively common occurrence. The management of patients with spontaneous pneumothorax remains controversial. With the advances in thoracoscopic techniques and instrumentation, video-assisted thoracic surgery (VATS) is now accepted by many as the procedure of choice for surgical treatment of spontaneous pneumothorax. We report our combined experience with 757 patients who suffered from recurrent or persistent spontaneous pneumothorax treated by VATS over a 5-year period. Surgical indications included persistent air leak (n = 165), recurrence (n = 325), radiologically demonstrated huge bulla (n = 12), spontaneous hemopneumothorax (n = 13), incomplete expansion of the lung (n = 212), and bilateral involvement (n = 30). Several surgical procedures were undertaken, based on the thoracoscopic findings: endoscopic stapled bullectomy (n = 312), argon beam coagulation (n = 6), endoscopic suturing (n = 52), and endoloop ligation (n = 352). In 49 cases, mechanical or chemical pleurodesis was the only procedure performed. There were no mortalities or intraoperative hazards. Complications consisted of wound infections (n = 16), localized empyema (n = 2), chest wall bleeding (n = 1), and persistent air leaks (bulla type III) (n = 31). The median duration of the operation was 55 minutes (15-160 minutes), and the average postoperative hospital stay was 4.5 days (range 0-27 days). There were 16 recurrences (2.1%), after a mean follow-up of 30 months (range 1-60 months). Seven patients had recurrence from 9 to 17 months after stapled bullectomy. All the remaining patients had recurrence after failed pleurodesis. On the basis of our results, we conclude that video-assisted thoracoscopic management allows effective, safe performance of standard surgical procedures, avoiding a formal thoracotomy incision. We consider thoracoscopy the treatment of choice for patients with pneumothorax requiring surgical therapy.

The use of multiplane transesophageal echocardiography to evaluate residual patent ductus arteriosus during video-assisted thoracoscopy in adults

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) has emerged as an innovative and popular procedure for interruption of patent ductus arteriosus (PDA), while intraoperative transesophageal echocardiography (TEE) has proven to be an effective monitor in the evaluation of residual patency. Previous reports on the adequacy of surgical interruption of PDA under VATS and TEE are available for pediatric patients, but only limited information is available for adults with PDA. MATEIALS AND METHODS: Between August 1995 and October 1997, we monitored 35 adult patients undergoing PDA interruption via VATS with Hewlett-Packard color Doppler multiplane TEE throughout the procedure. The average PDA diameter was 10.2 +/- 1.8 mm. All the PDA were completely ligated.

RESULTS

Thirty-two patients showed no ductal flow after double ligation. In the other three patients, residual flow was detected intraoperatively after double ligation, but it was quickly abolished by the third ligation. One patient showed faint ductal flow by transthoracic echocardiography at postoperative follow-up, but no reintervention was needed.

CONCLUSIONS

Our study showed that, with the refinement of adult PDA interruption via VATS, intraoperative multiplane TEE provides higher resolution for direct evaluation of the entire course of PDA ligation without interrupting the surgical procedure and minimizes the incidence of complications.

Emphysema surgery--loop ligation approach

OBJECTIVES

To demonstrate the efficacy of using thoracoscopic endoloop ligation of bullae in patients with bullous emphysema.

METHODS

From 1992 to 1997, 93 advanced age (mean age, 66 years) and oxygen dependency patients underwent thoracoscopic procedure using endoloop ligation for treatment of bullous emphysema. Clinical data were collected from chart review. Thoracoscopic loop ligation of bulla was carried out under general anesthesia with double lumen endotracheal tube and single lung ventilation.

RESULTS

Eighty-two patients (88%) exhibited subjective improvement in their symptom status at 3-month follow-up (from grade 2 or 3 to grade 1 or 2) according to the modified Medical Research Council dyspnea scale. The mean duration of chest drainage was 7.5 days (range, 4-19 days). Average hospital stay was 9.5 (range, 5-26) days. There was no post-operative death. A comparison of pre-operative and post-operative functional evaluation was available in 27 patients who showed an average increase in FEV1 (from 0.89 to 1.12 l) and declined in residual volume after operation. Complications include persistent airleak over 10 days in nine patients (9.7%), wound infection in three patients and localized empyema in five patients. There was no recurrent after a mean follow-up of 37 months.

CONCLUSION

Thoracoscopic loop ligation of bulla has proven to be a safe, reliable and cost effective means of technique for bullous emphysema.

Blunt trauma with flail chest and penetrating aortic injury

Blunt chest trauma with flail chest is common. The mortality attributes initially to the associated pulmonary contusion, massive hemothorax and later to the occurrence of adult respiratory distress syndrome. We report a case of flail chest with segmental fractures near the costovertebral junction and delayed hemothorax attacked 14 h later. The final diagnosis of the penetrating aortic injury by detached rib fragment was appreciated by aortogram. Unfortunately, active aortic hemorrhage made prompt thoracotomy in vain for life salvage.

"I" ministernotomy for aortic valve replacement

BACKGROUND

Minimally invasive surgical approaches have been applied recently in the management of valvular heart disease. In this report, we reviewed our preliminary experience of minimally invasive aortic valve replacement.

METHODS

Eighteen patients were operated on by means of an "I" ministernotomy, and 16 patients were operated on by means of a full median sternotomy during the same period. There was no difference between these two groups in term of age, sex, and preoperative left ventricular ejection fraction. In patients of the ministernotomy group, the operations were approached through an "I" median sternal split, from the second to the fifth intercostal space, 8 to 10 cm in length, with transverse division. Cardiopulmonary bypass was established through aorto-right atrial cannulation with aortic cross-clamping and antegrade or retrograde delivery of blood cardioplegia.

RESULTS

Under direct vision, aortic valve replacement was performed successfully in patients of both groups. The duration of cardiopulmonary bypass time and aortic cross-clamp time was significantly longer in the ministernotomy group than in the full sternotomy group. However, the length of incision, duration of endotracheal intubation, intensive care unit stay, pain score, postoperative length of stay, and return to normal activity interval were significantly shorter and lower in patients of the ministernotomy group than in those of the full sternotomy group. All patients recovered from the operation rapidly. Follow-up was complete in all patients with no late complications. Echocardiographic examination showed good function of aortic prostheses.

CONCLUSIONS

Our experience demonstrates that the "I" ministernotomy provides good exposure, reduced wound pain, enhanced recovery, shortened hospital stay, and good cosmetic healing. It may be a good alternative for surgical correction of aortic valve lesions.

The propeptides of the vitamin K-dependent proteins possess different affinities for the vitamin K-dependent carboxylase

The vitamin K-dependent gamma-glutamyl carboxylase catalyzes the modification of specific glutamates in a number of proteins required for blood coagulation and associated with bone and calcium homeostasis. All known vitamin K-dependent proteins possess a conserved eighteen-amino acid propeptide sequence that is the primary binding site for the carboxylase. We compared the relative affinities of synthetic propeptides of nine human vitamin K-dependent proteins by determining the inhibition constants (Ki) toward a factor IX propeptide/gamma-carboxyglutamic acid domain substrate. The Ki values for six of the propeptides (factor X, matrix Gla protein, factor VII, factor IX, PRGP1, and protein S) were between 2-35 nM, with the factor X propeptide having the tightest affinity. In contrast, the inhibition constants for the propeptides of prothrombin and protein C are approximately 100-fold weaker than the factor X propeptide. The propeptide of bone Gla protein demonstrates severely impaired carboxylase binding with an inhibition constant of at least 200,000-fold weaker than the factor X propeptide. This study demonstrates that the affinities of the propeptides of the vitamin K-dependent proteins vary over a considerable range; this may have important physiological consequences in the levels of vitamin K-dependent proteins and the biochemical mechanism by which these substrates are modified by the carboxylase.

Thoracoscopic retrieval of foreign body after penetrating chest injury: report of two cases

Video-assisted thoracic surgery has proved to be valuable in many settings in thoracic surgery. The use of video-assisted thoracic surgery in trauma has recently rapidly increased. It is useful in acute or delayed management of patients with blunt and penetrating chest trauma. It is safe for removal of clotted hemothorax, treatment of thoracic empyema, treatment of persistent pneumothorax, treatment of chylothorax, and for diagnosis of diaphragmatic injury. We report two cases using thoracoscopy to remove intrathoracic metal fragments and avert the need for thoracotomy. In the first patient, a metal fragment injury was sustained via a penetrating wound from the supraclavicular notch to the right upper lung. The metal fragment was retrieved and the lung was repaired thoracoscopically using conventional suturing techniques. A second patient sustained a broken pin injury to the left upper mediastinum via a low neck wound. The pin was successfully removed under videothoracoscopy. Both patients recovered uneventfully and had shortened hospital stays. We feel that thoracoscopy offers a therapeutic as well as diagnostic benefit in stable patients with penetrating chest trauma.

Myosin light chain kinase: functional domains and structural motifs

Conventional myosin light chain kinase found in differentiated smooth and non-muscle cells is a dedicated Ca2+/calmodulin-dependent protein kinase which phosphorylates the regulatory light chain of myosin II. This phosphorylation increases the actin-activated myosin ATPase activity and is thought to play major roles in a number of biological processes, including smooth muscle contraction. The catalytic domain contains residues on its surface that bind a regulatory segment resulting in autoinhibition through an intrasteric mechanism. When Ca2+/calmodulin binds, there is a marked displacement of the regulatory segment from the catalytic cleft allowing phosphorylation of myosin regulatory light chain. Kinase activity depends upon Ca2+/calmodulin binding not only to the canonical calmodulin-binding sequence but also to additional interactions between Ca2+/calmodulin and the catalytic core. Previous biochemical evidence shows myosin light chain kinase binds tightly to actomyosin containing filaments. The kinase has low-affinity myosin and actin binding sites in Ig-like motifs at the N- and C-terminus, respectively. Recent results show the N-terminus of myosin light chain kinase is responsible for filament binding in vivo. However, the apparent binding affinity is greater for smooth muscle myofilaments, purified thin filaments, or actin-containing filaments in permeable cells than for purified smooth muscle F-actin or actomyosin filaments from skeletal muscle. These results suggest a protein on actin thin filaments that may facilitate kinase binding. Myosin light chain kinase does not dissociate from filaments in the presence of Ca2+/calmodulin raising the interesting question as to how the kinase phosphorylates myosin in thick filaments if it is bound to actin-containing thin filaments.

Minimally invasive cardiac surgery for intracardiac congenital lesions

OBJECTIVE

Minimally invasive cardiac surgery has recently been applied to the correction of intracardiac lesions. This report reviews our experience of minimally invasive cardiac surgery in 119 patients with intracardiac congenital lesions.

METHODS

From October 1995 to April 1997, 119 patients (48 male and 71 female, aged 0.9-65 years old, 18.5+/-17.8) received elective minimally invasive cardiac surgery at Chang Gung Memorial Hospital, Taipei, Taiwan for repair of atrial septal defect (96 patients) or ventricular septal defect (23 patients). The operations were performed through right submammary incision (ASD) or left parasternal minithoracotomy (VSD), under femoro-femoral or femoro-atrial cardiopulmonary bypass with fibrillatory arrest.

RESULTS

All of the defects were repaired successfully. The bypass time was 25-125 min (46+/-18). The operation time was 1.5-5.2 h (2.8+/-0.8). The postoperative course was uneventful in all patients. Follow-up (1.0-18.2 months, mean 7.3) was complete, with no late deaths or residual shunt. All patients were found to be in NYHA functional class I or II.

CONCLUSION

Our experience demonstrate that minimally invasive cardiac surgery is a technically feasible, safe, and effective procedure in surgical correction of selective simple intracardiac congenital lesions, yielding good short-term results.

Video-assisted cardiac surgery for intracardiac tumors

OBJECTIVE

To present our experience in surgical excision of intracardiac tumors in three patients using video-assisted cardiac surgical techniques.

METHODS

Three patients received emergency video-assisted cardiac surgery for excision of right atrial or left atrial tumors. These surgeries were performed through right anterior submammary minithoracotomies and guided by video-assisted endoscopic techniques by projected images on a video monitor while under femoro-femoral cardiopulmonary bypass. The myocardium was protected by continuous coronary perfusion with fibrillatory arrest. Conventional instruments were used.

RESULTS

All but one of the tumors were excised completely. The bypass time was 88-148 min. The operation time was 3.5-4.4 h. There were no operative deaths. Pathological examination of the tumors showed left atrial myxoma, metastatic left atrial choriocarcinoma, and right atrial lymphoma. One patient died from non-cardiac origin 5 weeks after discharge. Follow-up was completed with the two survivors. Transthoracic echocardiographic examination showed good ventricular function without any residual tumors. They were both in New York Heart Association functional class I or II. They were satisfied with the cosmetic healing of their incisions.

CONCLUSION

Video-assisted cardiac surgery is technically feasible and can be performed in surgical excision of intracardiac tumors.

Totally minimally invasive cardiac surgery for coronary artery disease

OBJECTIVE

We report our experience using minimally invasive techniques both to perform coronary artery bypass and harvesting of saphenous vein grafts in 25 patients with left main or triple vessels disease.

METHODS

From March 1997 to June 1997, 25 patients received elective coronary artery bypass grafting using minimally invasive surgical techniques for left main or triple vessels disease. Saphenous vein grafts were harvested using minimally invasive techniques under direct vision. The coronary artery bypass grafting was performed through a limited left anterior parasternal minithoracotomy under femoro-femoral or aorto-atrial cardiopulmonary bypass. The myocardium was protected by antegrade infusion of cold blood cardioplegic solution while the aorta was cross-clamped.

RESULTS

Three to four distal anastomoses were performed with the saphenous vein graft and the left internal thoracic arterial graft. The aortic cross-clamp time was 60-135 min. The duration of cardiopulmonary bypass was 89-172 min. The postoperative course was uneventful for all patients. All patients were found to be in New York Heart Association functional class I or II on follow-up from 3-7 months after surgery.

CONCLUSIONS

Minimally invasive coronary artery surgery is technically feasible and can be performed in left main or triple vessel disease safely and effectively for complete revascularization.

Video-assisted minimal access in excision of left atrial myxoma

BACKGROUND

Minimal access surgery with video-assisted endoscopy has been applied to the correction of intracardiac lesions. We report our experience using this technique in surgical excision of left atrial myxoma in 3 patients.

METHODS

From November 1995 to March 1997, 3 female patients, ages 45 to 80 years (mean, 62.7 years), received emergency operations for excision of left atrial myxoma. These operations were performed through a right anterior submammary minithoracotomy or right parasternal incision with the assistance of endoscopy during femoro-femoral cardiopulmonary bypass. The myocardium was protected by continuous coronary perfusion with fibrillatory arrest or cardioplegic arrest with aortic cross-clamping.

RESULTS

All the tumors were excised completely through the right atrial approach. The bypass time was 92 to 148 minutes (mean, 111 minutes). The operation time was 3.2 to 4.4 hours (mean, 3.7 hours). There were no hospital deaths. Follow-up, which ranged from 6 to 19 months (mean, 10.5 months), was complete in all patients. Transthoracic echocardiographic examination showed good ventricular function without any residual tumors. Patients were found to be in New York Heart Association functional class I or II. They were satisfied with the good cosmetic healing of the incision.

CONCLUSIONS

Our experience demonstrates that minimal access surgery is a technically feasible, safe, and effective procedure in surgical excision of left atrial myxoma.

Frequency of Epstein-Barr virus-associated gastric adenocarcinoma in Taiwan

Eighty-two gastric adenocarcinomas (32 intestinal and 50 diffuse type) were investigated for the presence of Epstein-Barr virus (EBV) DNA by amplifying the 78-bp fragment from the EBNA1 gene with polymerase chain reaction. EBV was detected in 17 (20.7%) of the 82 gastric tumorous specimens. Of these 17 EBV-positive cases, only one was EBV-positive in the adjacent non-tumorous tissue. EBV-positive gastric adenocarcinoma was present in 15.6 and 24.0% of the intestinal and diffuse type tumors, respectively, but within the two classes there was significant non-homogeneity by type. EBV was found more frequently in adenocarcinomas of the tubular (25%) and poorly differentiated (30.3%) types. EBV involvement was found more in male than in female patients. Eighty of the 82 tumors were also checked for the prevalence of p53 gene mutation. Of the 17 EBV-positive gastric adenocarcinomas, only two showed p53 gene mutations. The p53 mutation rate was lower in EBV-positive tumors (11.8%) than in EBV-negative tumors (25.4%).

Surgical closure of atrial septal defect. Minimally invasive cardiac surgery or median sternotomy?

BACKGROUND

Closure of ostium secundum atrial septal defect (ASD) vis median sternotomy (MS) is a simple procedure for most cardiac surgeons. Minimally invasive cardiac surgery (MICS) has recently been applied in the management of intracardiac lesions.

METHODS

We report our experience in surgical closure of isolated ASD via MICS in 60 patients and via MS in 58 patients. There was no difference between these two groups in gender, age, body weight, ratio of systemic to pulmonary blood flow, and pulmonary arterial pressure.

RESULTS

The duration of cardiopulmonary bypass was significantly longer in the MICS group than in the MS group [27 to 126 min (42 +/- 12) and 14 to 158 min (27 +/- 11), respectively; (p < 0.001]. However, the length of incision, incidence of temporary pacemaker wire insertion rate, duration of endotracheal intubation, timing of oral intake, postoperative day drainage amount, incidence of parenteral analgesic injection, postoperative length of stay, and return to normal activity interval were significant shorter and lower in patients of the MICS group than in those of the MS group. All the patients recovered rapidly from the surgery. Follow-up was complete in all patients, with no late complications and no residual shunt.

CONCLUSION

Our results suggest that MICS is a good option for surgical closure of ASD.

Predictors of systemic embolism in patients with mitral stenosis. A prospective study

BACKGROUND

Most studies of the predictors of systemic embolism in patients with mitral stenosis have been retrospective.

OBJECTIVE

To prospectively study factors associated with systemic embolism in mitral stenosis.

DESIGN

Prospective cohort study.

SETTING

University-affiliated medical institution with 3000 beds.

PATIENTS

534 consecutive patients with a mitral valve area of 2.0 cm2 or less; 132 patients were in sinus rhythm, and 402 were in atrial fibrillation.

MEASUREMENTS

Nine clinical and 10 echocardiographic variables were assessed for prediction of systemic embolism over a mean (+/- SD) follow-up of 36.9 +/- 22.5 months. Diagnosis of systemic embolism was based on symptoms and signs (sudden onset of peripheral arterial ischemic or neurologic manifestations without prodromes) and on findings on computed tomography, angiography, and surgery.

RESULTS

For patients in sinus rhythm, age (relative risk [RR], 1.12 [95% CI, 1.04 to 1.21]), the presence of a left atrial thrombus (RR, 37.1 [CI, 2.82 to 487.8]), mitral valve area (RR, 16.9 [CI, 1.53 to 187.0]), and the presence of significant aortic regurgitation (RR, 22.4 [CI, 2.72 to 184.8]) were positively associated with embolism. For patients in atrial fibrillation, previous embolism (RR, 3.11 [CI, 1.66 to 5.85]) was positively associated with embolism; percutaneous balloon mitral commissurotomy (RR, 0.37 [CI, 0.18 to 0.79]) was a negative predictor.

CONCLUSIONS

It may be prudent to give anticoagulants not only to patients in atrial fibrillation and patients with previous systemic embolism but also to those showing a left atrial thrombus or significant aortic regurgitation on echocardiography. Early percutaneous balloon mitral commissurotomy may also help prevent systemic embolism in patients with mitral stenosis.

Video-assisted cardiac surgery: preliminary results in Chang Gung Memorial Hospital

OBJECTIVE

To summarize the experience of utilization of video-assisted endoscopy in 91 patients operated on at Chang Gung Memorial Hospital, Taipei, China.

METHODS

From October 1995, through August 1996, 91 patients (44 male and 47 female) received video-assisted cardiac surgery (VACS). Their ages ranged from 1 year to 79.5 years (25.7 +/- 21.7). Indications for surgery were atrial septal defect (59 patients), ventricular septal defect (15), coronary artery disease (4), severe mitral regurgitation (4), severe tricuspid regurgitation (3), thrombosis of mitral mechanical prosthesis (3), left atrial tumor (2), and left ventricular thrombus with dilated cardiomyopathy (1). The VACS was performed through right or left anterior minithoracotomy and guided by video-assisted endoscopic techniques by means of projected images on the video monitor under extracorporeal circulation. The aorta was not cross-clamped and the myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest (rectal temperature 22.6 +/- 4.0 degrees C). Conventional instruments were used.

RESULTS

All lesions were corrected successfully. The bypass time was 27 to 335 minutes (72.8 +/- 52.7). The operative time was 1.3 to 8.5 hours (3.0 +/- 1.7). There were no operative deaths and 3 late deaths. Follow-up was complete in all survivors (6 to 16 months, mean 8.7). Most of them were found to be in NYHA functional I or II.

CONCLUSION

Our preliminary experiences demonstrate that VACS is simple and effective in surgical correction of selected cardiac lesions. Short-term results show good outcomes.

Minimally invasive coronary surgery in women

OBJECTIVE

To evaluate the minimally invasive surgery in coronary artery bypass grafting and the feasibility for revascularization of triple vessel coronary artery disease.

METHODS

Nine female patients, aged 49.1 to 81.6 years (mean 64.3), were operated on for triple vessel disease through minimally invasive surgical techniques. The surgeries were performed through limited left parasternal incision under femorofemoral extracorporeal circulation. The myocardium was protected by antegrade infusion of cold blood cardioplegic solution while the aorta was cross-clamped. Under direct vision, the left saphenous vein grafts were connected sequentially to the diagonal branch, obtuse marginal branch and posterior descending branch, and the left internal thoracic arterial graft was anastomosed to the left anterior descending artery in each patient.

RESULTS

The number of distal anastomoses was 3 to 4 with a mean of 3.7. The aortic crossclamp time was 52 to 130 minutes (82 +/- 25 minutes). The duration of extracorporeal circulation was 78 to 151 minutes (115 +/- 29 minutes). The postoperative course was uneventful in all patients. The postoperative length of stay was 4 to 12 days (7.2 +/- 2.0 days). Follow-up (4.2 to 8.7 months, mean 6.4) was complete in all patients and there were no late deaths or angina. Coronary angiography of 2 patients showed patent grafts. All patients were satisfied with the good cosmetic healing of the incision.

CONCLUSION

Our experience demonstrates that minimally invasive surgery in coronary artery bypass grafting is technically feasible and may be an alternative approach in surgical revascularization of triple vessel coronary artery disease, especially in female patients.

Endothelium-dependent relaxation of canine pulmonary artery endothelium after prolonged preservation

OBJECTIVE

Experiments were designed to investigate the effect of Euro-Collins (EC) solution and University of Wisconsin (UW) solution on function of pulmonary arterial endothelium.

METHODS

Third order canine pulmonary artery segments were preserved in cold (4 degrees C) UW (group 1, n = 8) or EC (group 2, n = 9) solutions for 16 hours. The preserved (group 1 and 2) and control (group 3, n = 7) pulmonary arterial segments with and without endothelium were studied in vitro in organ chambers to measure isometric tension.

RESULTS

The endothelium-dependent relaxation to acetylcholine and adenosine diphosphate of group 1 and 3 were significantly better than those of group 2.

CONCLUSIONS

We concluded that endothelium-dependent relaxation of canine pulmonary arterial endothelium to receptor-dependent acetylcholine and adenosine diphosphate were impaired after preservation with Euro-Collins solution. However, endothelium-dependent relaxation of pulmonary segments were well maintained after preservation with University of Wisconsin solution.

One-stage sternal stenting with homograft bone after cardiac operation in pediatric patients

Low cardiac output after open heart operations in neonates and infants carries a high mortality. Delayed sternal closure may be life-saving but may prolong hospital stay and increase costs. To circumvent these issues, we shaped homograft bone and interposed it between the sternal edges to allow primary wound closure in 2 pediatric patients. Midterm results are satisfactory.

On-line multiplane transesophageal echocardiography for balloon mitral commissurotomy

This study describes in detail the technique and results of on-line multiplane transesophageal echocardiographic guidance of balloon mitral commissurotomy in 150 consecutive patients with symptomatic mitral stenosis. The mitral valve area improved significantly and there were no in-hospital deaths, strokes, or emergency valve operations.

Minimal access surgical techniques in coronary artery bypass grafting for triple-vessel disease

BACKGROUND

Minimal access surgical techniques in coronary artery bypass grafting have been used mainly in the management of single-vessel disease.

METHODS

Fifteen patients, 11 men and 4 women with a mean age of 64.1 years (range, 35.7 to 78.0 years), underwent operation for triple-vessel disease using minimal access techniques. The procedures were performed through a limited left parasternal thoracotomy using femorofemoral extracorporeal circulation. The myocardium was protected by the antegrade infusion of cold blood cardioplegic solution while the aorta was cross-clamped.

RESULTS

Under direct vision, the left saphenous vein grafts were connected sequentially to the diagonal branch, obtuse marginal branch, and posterior descending branch, and the left internal thoracic artery graft was anastomosed to the left anterior descending artery in each patient. The mean aortic cross-clamp time was 86 +/- 17 minutes (range, 67 to 125 minutes). The mean duration of extracorporeal circulation was 112 +/- 22 minutes (range, 82 to 162 minutes). The postoperative course was uneventful in all patients. Follow-up was complete in all patients at a mean of 7.4 months (range, 6.0 to 8.5 months), and there were no late deaths or angina. Coronary angiography in 8 patients showed patent grafts.

CONCLUSIONS

Our experience demonstrates that minimal access surgical techniques in coronary artery bypass grafting are technically feasible and may be an alternative approach in the surgical revascularization of triple-vessel disease.

Video-assisted thoracoscopic surgery for spontaneous hemopneumothorax

We operated on 403 patients with spontaneous pneumothorax between 1992 and 1996. Among these cases, 11 (2.7%) were spontaneous hemopneumothorax. The patients were all men, with ages ranging from 19 to 28 years (mean 23.8 years). The amount of blood drainage ranged from 650 to 2300 ml. Video-assisted thoracoscopic surgery was performed on these patients within 1 day after admission. The sources of bleeding were in the parietal and visceral pleurae of ruptured bullae (n = 6), the parietal pleura (n = 4), or the visceral pleura (n = 1). During operation, the ruptured bullae can be managed by an endoscopic linear stapler for a bullectomy, and the bleeding parietal pleura of the torn adhesion can be coagulated directly. Postoperative recovery of the 11 patients was uneventful, and they were discharged 4 to 10 days after the operation. No recurrence of spontaneous hemopneumothorax or any other complications occurred during follow-up. Thus spontaneous hemopneumothorax can be readily managed by cauterizing a bleeding site where appropriate, excising the apicocystic disease, and pleurodesis. As a minimally invasive method, video-assisted thoracoscopic surgery may be considered an initial treatment procedure in patients with spontaneous hemopneumothorax.

Minimally invasive cardiac surgical techniques in the closure of ventricular septal defect: an alternative approach

BACKGROUND

Minimally invasive cardiac surgical techniques recently have been applied in the management of a variety of intracardiac lesions.

METHODS

Fourteen patients (6 boys and 8 girls; age, 8.9 +/- 5.5 years; body weight, 29.0 +/- 13.5 kg) were operated on using minimally invasive cardiac surgical techniques for the closure of a ventricular septal defect (subarterial in 11 patients and perimembranous in 3 patients). The operations were performed through a left anterior minithoracotomy and were guided by video-assisted endoscopic techniques under femorofemoral cardiopulmonary bypass. The myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest. The right ventricular outflow tract was entered after pericardiotomy was performed.

RESULTS

Closure of the defect (directly in 4 patients and by patch in 10 patients) was performed successfully in all patients. A right ventricular outflow tract obstruction and ruptured sinus of Valsalva aneurysm also were repaired in 1 patient each. The duration of cardiopulmonary bypass was 41 +/- 10 minutes (range, 28 to 100 minutes) and the total operative time was 2.2 +/- 0.8 hours (range, 1.3 to 3.5 hours). All the patients recovered rapidly from their operation and had an uneventful postoperative course. Follow-up (mean, 6.2 months; range, 6 to 9 months) was complete in all patients. There were no late deaths. Transthoracic echocardiographic examination showed no residual shunt and no aortic regurgitation in all patients.

CONCLUSIONS

Our experience demonstrates that minimally invasive cardiac surgical techniques are technically feasible and an alternative option for the repair of a ventricular septal defect.