A left circumflex aorta with a displaced thoracic duct in a 94-year-old male cadaver: a case report with discussion on embryology

A left circumflex aorta (LCA) is an extremely rare variation of the thoracic aorta. It is distinguished by a retroesophageal descending aorta that subsequently travels down the right side of the thoracic vertebrae towards the aortic hiatus. Nonetheless, its embryological origin ought not to be overly generalised, but each case should be considered individually due to its unique vascular patterns. This study presents a description of a LCA in a 94-year-old male cadaver. The dissection revealed the descending aorta posteriorly from the trachea and oesophagus and then laterally on the right from the thoracic vertebral bodies. The branching pattern of the aortic arch was typical, so was the course of the left and right recurrent laryngeal nerves. However, the thoracic duct was placed on the right, and drained into the right internal carotid vein. Due to the normal appearance of the ascending part and the arch of the aorta, it is safe to presume that the variation originated from the persistent right dorsal aorta, with the retroesophageal part from the persistent left dorsal aorta. Detailed understanding of the variations of the thoracic aorta, and the anomalies associated with the LCA, can help to improve management of these conditions, and with that, improve patients' overall outcomes. Patients with a LCA, or another vascular ring, can either be asymptomatic or present with oesophageal and/or tracheal compression symptoms. Management of this anomaly consists namely of ligation of the patent ductus arteriosus/ligamentum arteriosum and aortic uncrossing.

279 Preparing Foundation Trainees for Surgical On-Calls

Aim

Foundation trainee feedback has highlighted low levels of confidence with the prospect of surgical on-calls. Key areas of concern are assessing and managing the acute surgical patient, identifying which patients need an operation and having the technical skills to competently assist in theatre. This lack of confidence prevents trainees engaging in an educational and rewarding rotation. We have designed and facilitated a day of robust workshops, addressing these key educational needs.

Method

Pre and post course questionnaires assessed the efficacy of teaching. Lectures on the assessment and management of acute surgical patients in general surgery, urology and trauma and orthopaedics were delivered by core surgical trainees. A named consultant oversaw quality assurance. Addressing the technical skills development need, an afternoon of surgical skills workshops covered, suturing, knot tying, laparoscopic principles, and theatre etiquette. Small groups of trainees rotated through each workshop, delivered by senior specialty trainee registrars, to ensure high fidelity training

Results

Trainees rated themselves in key areas pre and post course on a scale from 1-5. Pre course, 66% of trainees scored 3+ in “confidence in managing a surgical patient on-call”. This rose to 100% post course. Similarly; “Confidence in decision making regarding whether a patient should proceed to theatre” increased from 37.5% to 93.7%. “Suturing skills” improved from 37.5% to 100%.

Conclusions

All trainees that attended the course displayed marked improvement in their confidence and competence. We feel this course or similar should be incorporated into the foundation teaching program locally and has scope to be expanded regionally.

Successful surgical treatment of a neonate with prenatal diagnosis of severe Ebstein's anomaly

We present a case of a patient with a severe form of Ebstein's anomaly diagnosed in a 36th week of gestation through prenatal echocardiographic evaluation. The emergency surgery consisted of closure of the tricuspid valve and creation of a residual atriventricular communication, enlargement of interatrial communication, closure of the pulmonary artery, and construction of an aortopulmonary shunt. Subsequently, the patient underwent the hemiFontan and Fontan operation. We conclude that prenatal echocardiographic diagnosis is crucial for the survival of children with a severe form of Ebstein's anomaly, which is a neonatal emergency and requires prompt decision mating to initiate surgical management.

Successful surgical treatment of a mycotic pseudoaneurysm of the ascending aorta in an infant after hypoplastic left heart complex repair

We describe a successfully treated pseudoaneurysm of the ascending aorta in a 2-month-old infant after a previous operation due to hypoplastic left heart complex. After a rapidly progressing respiratory tract obstruction as a first symptom, echocardiography revealed a huge aneurysmal formation originating from the anterior and right lateral wall of the ascending aorta. A patch aortoplasty was employed.

Hypoplastic left heart syndrome with an anomalous origin of the left coronary artery

Abnormal origin of the coronary artery in children with hypoplastic left heart syndrome is an extremely rare defect. We describe a newborn with concomitant hypoplastic left heart syndrome and abnormal origin of the left coronary artery arising from the right pulmonary artery. A Norwood procedure and direct reimplantation of the left coronary artery to the ascending aorta was performed.

Solid-phase extraction and simplified high-performance liquid chromatographic determination of 10-deacetylbaccatin III and related taxoids in yew species

Solid-phase extraction was accomplished with specially prepared cartridges filled with silanised silica gel (RP-2) for the purpose of 10-deacetylbaccatin III (10-DAB III) and related taxoids extracts purification obtained from different yew materials. In the first method, the analysed taxoids eluted in 75% methanol, but in the second method, the preliminary elution with 30% methanol was made. DAB III and its six derivatives were separated from co-extractives in merely acetonitrile-water gradient mode during 25 min on Waters Symmetry C-18 column with photodiode array (PDA) detection. The total recoveries for 10-DAB III and paclitaxel in the first SPE method (all compounds were applied in amounts of 80 microg) were about 98 and 94%, respectively. Almost 100% recoveries for paclitaxel and baseline separation of 10-DAB III and co-extracted compounds were obtained when preliminary elution with 30% methanol was performed. This method can be applied as a routine, inexpensive and uncomplicated procedure for 10-DAB III and related taxoids determination in yew material.

Surgical treatment of aortopulmonary window with tetralogy of Fallot

An association between aortopulmonary window and tetralogy of Fallot is rare. We report a case of the combined anomalies in which, possibly for the first time, the diagnosis was made by echocardiography alone, and in which successful surgical treatment was performed in early infancy.

Screening for pharmaceutically important taxoids in Taxus baccata var. Aurea corr. with CC/SPE/HPLC-PDA procedure

Needles of 'the golden yew' Taxus baccata var. Aurea Corr. were extracted with methanol followed by pre-purification of the crude extract and column chromatographic (CC) separation on florisil in gradient mode (an increasing concentration of acetone in dichloromethane). The obtained fractions were concentrated and purified on silanized silica gel SPE cartridges and taxoids eluted with 75% methanol were analysed by HPLC-PDA procedure using Waters Symmetry C(18) column with gradient elution. The applied method enabled not only determination of four taxoids commonly occurring in yew extracts (10-deacetylbaccatin III, baccatin III, paclitaxel and cephalomannine), but also, on the basis of chromatographic behaviour and UV spectrum, 10-deacetylated taxoids (10-deacetylpaclitaxel, 10-deacetylcephalomannine, 7-xyloside-10-deacetylpaclitaxel and 10-deacetyltaxol C) could be detected together with 7-epi-10-deacetylpaclitaxel. From the needles of Taxus baccata var. Aurea Corr. the largest amounts isolated were of 10-deacetylbaccatin III, then 10-deacetylpaclitaxel and 7-xyloside-10-deacetylpaclitaxel, all compounds considered to be paclitaxel precursors in semisynthesis. The efficient mechanism of the separation of 10-acetylated taxoids from their 10-deacetylated derivatives on florisil on the basis of electron acceptor-electron donor interactions is discussed.

Screening for pharmaceutically important taxoids in Taxus baccata var. Aurea corr. with CC/SPE/HPLC-PDA procedure

Needles of 'the golden yew' Taxus baccata var. Aurea Corr. were extracted with methanol followed by pre-purification of the crude extract and column chromatographic (CC) separation on florisil in gradient mode (an increasing concentration of acetone in dichloromethane). The obtained fractions were concentrated and purified on silanized silica gel SPE cartridges and taxoids eluted with 75% methanol were analysed by HPLC-PDA procedure using Waters Symmetry C(18) column with gradient elution. The applied method enabled not only determination of four taxoids commonly occurring in yew extracts (10-deacetylbaccatin III, baccatin III, paclitaxel and cephalomannine), but also, on the basis of chromatographic behaviour and UV spectrum, 10-deacetylated taxoids (10-deacetylpaclitaxel, 10-deacetylcephalomannine, 7-xyloside-10-deacetylpaclitaxel and 10-deacetyltaxol C) could be detected together with 7-epi-10-deacetylpaclitaxel. From the needles of Taxus baccata var. Aurea Corr. the largest amounts isolated were of 10-deacetylbaccatin III, then 10-deacetylpaclitaxel and 7-xyloside-10-deacetylpaclitaxel, all compounds considered to be paclitaxel precursors in semisynthesis. The efficient mechanism of the separation of 10-acetylated taxoids from their 10-deacetylated derivatives on florisil on the basis of electron acceptor-electron donor interactions is discussed.

[Operative outcome in children with total anomalous pulmonary venous connection]

The authors present their experience in surgical treatment of children with total anomalous pulmonary venous connection. A retrospective analysis was carried out in 42 patients operated on in the years 1979-1999. The group included 30 boys aged 7 days to 7 years (mean 170 +/- 480 days) and 12 girls aged 14 days to 7 months (mean 86 +/- 80 days). Diagnostic studies allowed to determine that 24 patients (57%) had supracardiac type (type I), nine (21%)--cardiac (type II), five (12%)--infracardiac (type III) and four (10%)--mixed (type IV). The diagnosis was based on clinical examinations and echocardiography, supplemented in 17 patients (40%) by hemodynamic studies and angiocardiography. Preoperative pulmonary hypertension was noted in 34 children (81%), including 15 patients (36%) diagnosed by hemodynamic studies and 19 children (45%) by echocardiography. All children were operated on in deep hypothermia with circulatory arrest. In the early postoperative period (30 days), seven children (17%) died, while four more (9.5%) died in the latter period. The former were characterized by significantly lower birth weight values (p = 0.023). The total mortality rate was higher in children with type II and III anomalies. No statistically significant association was found between preoperative pulmonary hypertension and early mortality. Thirty-one children (74%) remain in late follow-up. All of them are in NYHA (New York Heart Association) class I and develop normally. Total anomalous pulmonary venous connection is a rare congenital anomaly that can be fully repaired with improving early and late results.

[Results of surgical treatment of congenital heart defects in infants below 2500 grams]

We present a review of our recent experience of operating on infants below 2500 g suffering from congenital heart disease. A retrospective review was performed in 73 children who had undergone cardiac operations at our institution from 1990 to 1999. There were 43 (59%) females and 30 (41%) males; the mean age at operation was 28 days (range 4 to 92). The mean gestational age was 34.7 weeks (range 24 to 41), mean birth weight--1899 g (range 700 to 2450) and mean weight at operation--2013 g (range 640 to 2500). Cardiac diagnoses included patent ductus arteriosus (PDA) (N = 21, 28.7%), ventricular septal defect (VSD) (N = 9, 12.3%), transposition of great arteries (TGA) (N = 10, 13.7%), tetralogy of Fallot (TOF) (N = 7, 9.6%), double-outlet right ventricle (DORV) (N = 4, 5.5%), truncus arteriosus communis (TAC) (N = 4, 5.5%), hypoplastic left heart syndrome (HLHS) (N = 4, 5.5%), coarctation of aorta (CoAo) (N = 6, 8.2%), total anomalous pulmonary venous return (TAPVR) (N = 2, 2.7%), aortic stenosis (AoVS) (N = 3, 4.1%), interrupted aortic arch (IAA) (N = 1, 1.4%), pulmonary atresia (PA) (N = 1, 1.4%) and common atrioventricular canal (CAVC) (N = 1, 1.4%). Hospital mortality was 16.4%. There were 6 early deaths (8.2%) and 6 late deaths (8.2%). A higher mortality rate was noted in premature children and in children who had undergone palliative procedures. At a 1-116-month follow-up (mean 39 months), of 57 (93.4%) patients, 46 (80.7%) were in NYHA class I and 11 (19.3%) in NYHA class II. In conclusion the authors believe that early intervention can be performed in infants below 2500 g, and the associated mortality and morbidity rates are low.

Primary reconstruction of interrupted aortic arch--surgical management and results

Type B interrupted aortic arch associated with other extracardiac and intracardiac congenital lesions is a lethal defect. Surgical management with a one- or two-stage approach is complex, difficult and associated with high morbidity and mortality. Between January 1996 and December 1999, 5 consecutive patients with type B interrupted aortic arch were operated on. The group included 3 girls and 2 boys weighing from 2.4 kg to 3.5 kg (mean 2.84 kg) and aged from 4 to 35 days (mean 15 days). All patients underwent a primary reconstruction of the aortic arch and one-stage repair of the associated heart defects. Two patients developed symptoms of mild aortic arch narrowing 7-12 months postoperatively. Balloon angioplasty of the obstructed site was successfully carried out in one of the patients. In the second child, angioplasty was not successful and surgery was used. All the patients survived and are being followed-up. This experience supports a strategy of primary one-stage repair of IAA type B, including direct anastomosis for aortic arch reconstruction, and all associated heart anomalies in the neonatal period.

Operative treatment of truncus arteriosus communis coexisting with tricuspid atresia

The coexistence of tricuspid atresia and common arterial trunk is extremely rare. We present a successful three-stage surgical treatment of this defect. The first stage included disconnection of the pulmonary arteries from the common trunk, atrial septectomy and systemic-to-pulmonary shunt; the second stage, a hemi-Fontan procedure; and the third stage, a fenestrated Fontan completion. The child is now 8 years old and is developing well.

Isolation And Structure Elucidation Of 5,7-disubstituted Simple Coumarins In The Fruits Of Heracleum Mantegazzianum

In addition to bergapten ( 1 ), xanthotoxin ( 2 ), isopimpinellin ( 3 ), imperatorin ( 4 ), and pimpinellin ( 5 ), for the first time 5,7-disubstituted simple coumarins, limettin (5,7-dimethoxycoumarin) ( 6 ) and a new compound 5-methoxy-7-(3,3-dimethylalliloxy)-coumarin ( 7 ), have been isolated from the fruits of Heracleum mantegazzianum Somm. et Lev. The new compound 7 is a derivative of anisocoumarin B. The structures of 6 and 7 were determined on the basis of 1D and 2D NMR spectra.

Results of surgical treatment of congenital heart defects in children with Down's syndrome

We analyzed early and late results of surgical treatment of 100 consecutive children with Down's syndrome (DS) and congenital heart defect (CHD) who were operated on between 1990 and 1997. Fifty had common atrioventricular canal (CAVC), 24 ventricular septal defect, 8 the ostium primum atrial septal defect, 8 tetralogy of Fallot (TOF), 3 patent ductus arteriosus, 3 the ostium secundum atrial septal defect, and 4 CAVC coexisting with TOF. In 93 patients total correction was performed. The total death rate was 6%. Death in the CAVC group was 8%, but it decreased to 2.7% during the past 3 years. The children who were followed up (from 7 months to 6 years; mean, 39 months) are in NYHA class I or II. There were no reoperations. The postoperative course was complicated by pulmonary infections in 38% of patients, which converted to generalized infection in 10% and was the cause of death in 8% of patients. These results indicate that CHD in DS children can be repaired with a low death rate and low incidence of severe mitral atrioventricular valve regurgitation in the CAVC group. A high incidence of severe infections can influence the final results. Repair of CHD in infancy helps to eliminate problems connected with congestive heart failure and pulmonary hypertension.

Seasonal changes in the concentrations of four taxoids in Taxus baccata L. during the autumn-spring period

The concentrations of four common taxoids: baccatin III, paclitaxel, cephalomannine and 10-deacetylbaccatin III (10-DAB III) were measured in fresh needles and stems of Taxus baccata L. during the late autumn-spring period (November'96-April'97) which has not been investigated to date in this species. Baccatin III, paclitaxel and 10-DAB III were present on the surface of the twigs in concentrations of 8-26 micrograms/1000 g (fresh weight). Changes in the levels of baccatin III and paclitaxel inside the needles and stems showed similar trends over the investigated period. From November to March the total level of taxoids differed between the needles and stems, and were the same only in April. Total levels in fresh needles were stable from December to March. The highest concentrations of 10-DAB III in the whole analysed period in fresh stems were measured, as well as in the fresh needles except for samples collected in November and December when the levels of cephalomannine were higher. The concentrations of paclitaxel were usually the lowest. These results confirm that epigenetic factors--date of collection (and thus phyllogenesis) and kind of plant tissue--determine taxoid levels during the late autumn-spring period in T. baccata. The opposite patterns of changes for 10-DAB III and cephalomannine, especially in the fresh needles, suggest a possible role for 10-DAB III in the biosynthetic pathway to cephalomannine, a less polar taxoid with a side-chain at position C-13. As well, owing to the thermolability of taxoids, the influence of low temperatures in December and January could explain the highest observed concentrations of 10-DAB III in the fresh stems and needles, respectively.