Bronchiolitis obliterans syndrome after heart-lung transplantation: a case report and review of literature.

Bronchiolitis obliterans syndrome (BOS) is regarded as a manifestation of chronic rejection after lung transplantation and remains the major cause of late morbidity and mortality after lung and heart-lung transplantation. The authors, herein, reported the first documented case of a patient who receiving heart-lung transplantation at our institute and developed BOS as a late complication. The patient presented 5 years after received heart-lung transplantation with progressive shortness of breath due to obstructive lung disease. He was diagnosed with BOS by typical clinical presentation, pulmonary function test and radiographic findings and there were no other identified etiologies of airway obstruction. The authors also reviewed the recent update on the diagnosis and management of BO after lung transplantation.

Intraaortic balloon entrapment--a rare complication of intraaortic balloon pump.

Intraaortic balloon entrapment syndrome is a rare complication of intraaortic balloon catheter. The leakage of blood into the balloon produces clots if the catheter is not immediately removed. Later removal is usually not possible and can be complicated by laceration of the aorta or its branches. The authors report a seventy year old woman who had an intraaortic balloon inserted via her right femoral artery because of heart failure secondary to severe coronary artery stenosis. Blood appeared in the balloon before emergency coronary artery bypass grafting, but the catheter was left to be removed after surgery. After successful triple coronary bypass grafting, pulling the catheter resulted in hypovolemic shock secondary to avulsion of the right common iliac artery. Immediate laparotomy and replaement of the torn artery with prosthetic vascular graft was successfully performed. This rare and life threatening complication of intraaortic balloon catheter can be prevented by immediate removal of the catheter when blood appears in the balloon.

Extended replacement of aorta in chronic type A aortic dissection.

BACKGROUND: Chronic type A dissection is itself an indication for urgent surgery. Usually, replacement of the ascending aorta alone is adequate. Arch and descending aortas are replaced only in rare occasions-impending rupture, dilatation with diameter >5 cm. Extended replacement of the proximal aorta is associated with high morbidity and mortality. Staged repair is usually recommended by many centers. The disadvantages are the requirement for two stage operations, rupture of descending aorta in the interim period and patient denial to have the second stage. The authors use one stage operation in such patients. PATIENT AND METHOD: A retrospective study of three patients who presented with chronic type A aortic dissection. Two patients were male and one was female, aged 65, 67 and 70 years old. All of them had a history of hypertension. One patient also had severe left main coronary stenosis and total occlusion of theright coronary artery. Clamshell incision was used for two patients and median sternotomy for one. Profound systemic hypothermia and circulatory arrest was used for replacement of the aortic arch first. Reperfusion of the brain was performed via a side graft to the main graft. And then proximal ascending aortic-graft anastomosis was performed, followed by descending aortic anastomosis. Distal coronary anastomoses were performed during the rewarming period followed by proximal anastomoses to the aortic grafts. RESULTS: The circulatory arrest time was 38, 18 and 25 minutes. There was no reoperation for excessive post-operative hemorrhage. There was no lung contusion or injuries to left phrenic and left recurrent laryngeal nerve. All patients were alert and the time of endotracheal extubation was 16, 18 and 88 hours. One patient developed right pneumothorax after removal of the chest drain. Otherwise, all three patients survived without any complications. CONCLUSION: In some patients who need extended replacement of proximal aorta, replacement of aortic arch first under circulatory arrest is a safe technique. Clamshell incision offers better exposure than median sternotomy. Because of the brief period of circulatory arrest, neurologic complications are rare.

Surgical management for type A aortic dissection: 38 cases experience in King Chulalongkorn Memorial Hospital: early result and longterm follow-up.

OBJECTIVE: The objective of the present study was to evaluate the outcome of operative treatment for type A aortic dissection during the past 8 year period. PATIENTS AND METHOD: From January 1992 to March 2000, 38 patients (24 men and 14 women) underwent operations for acute (n = 26) and chronic (n = 12) type A aortic dissection. Patient's age ranged from 24 to 82 years (mean age 56 years). Surgical procedures included supracoronary ascending aortic graft for normal sinuses and valve (n = 34) with valve resuspension for commissural detatchment (n = 2), composite valve and ascending aortic graft for abnormal sinuses and valve (n = 1), and valve replacement and supracoronary ascending aortic graft for normal sinuses and abnormal valve (n = 1). Resection was extended into the arch and descending aorta in chronic dissection if there was excessive dilatation of the arch and descending aorta (n = 3). In 28 patients, aortic graft replacement was accomplished by proximal and distal anastomoses during aortic cross-clamping just proximal to the innominate artery. In 10 patients, deep hypothermia and circulatory arrest was used for open distal anastomosis or for arch replacement. Simultaneous coronary artery bypass grafting was performed in 4 patients. Pre-operative risk factors and the condition of the patients were defined and post-operative morbidity and mortality were followed in the early and long term period. RESULTS: There were 2 post-operative deaths (5.2%); one patient died of acute renal failure, the other patient had intra-operative rupture of the heart chamber; both were operated on in the acute phase of dissection. Complications included sternal wound infection in one case, neurological complication in two cases, respiratory problems in three cases, pericardial effusion in one case and post-operative bleeding that required re-operation in five cases. There was no hospital mortality in the group that were operated on in the chronic phase of dissection. Patient follow-up ranged 2 months to 8 years, there were two late mortalities, both, from acute myocardial infarction (at 33 days and 2 years after surgery). Survival rate was 92 per cent and 86 per cent at 30 days and 2 years, respectively. CONCLUSION: The result of repair of type A dissection in both phases was good in our center. The operative mortality was 5.2 per cent. Predictive factors of mortality were pre-operative shock (p=0.021), tamponade (p=0.021) and operation in the acute phase of dissection (p=0.042). In chronic type A dissection, the operative mortality was zero. Coronary artery disease was the most common cause of late deaths. Intermediate term survival in the present series was satisfactory.