Bypass of the superior vena autologous spiral saphenous cava vein using graft

Bypassing an obstructed superior vena cava represents a challenge to the surgeon due to absence of a suitable graft with a good long term patency. This study was conducted to assess the technique used to fashion the spiral saphenous vein graft, clinical improvement of the patients and postoperative patency of the fashioned graft with mid term follow up. This study was prospectively carried out in the sections of cardiotboracic surgery and chest internal medicine of Kasr El Aini Faculty of Medicine as well as private practice between 1999 and 2006. Eight patients suffering from SVC obstruction due to a nonmalignant cause were submitted to this study. A benign aetiology was proved in all 8 cases [100%]. Thoracic CT scanning showed idiopathic fibro sing mediastinitis in a five patients [62.5%] and dense mediastinal scarring with enlargement of different mediastinal lymph node groups for chronic non-specific mediastinal granuloma in a single patient [12.5%] whereas 2 patients had Behcet Syndrome [25%]. Preoperative tissue diagnosis confirming benignity and excluding malignancy by lymph node sampling of one or two different groups in the thorax: the left supraclavicular group in 4 cases [50%]; axillary group 1 case [12.5%]; or the in ternal mammary group in 3 cases [37.5%]. Preoperatively, these patients were following different regimens of medical treatment that included diuretics. bronchodilatois, as well us corticosteroids. The Saphenous Vein Graft [SVG], harvested from the medial aspect of the thigh, was fashioned spirally and sutured using 7/0 prolene to form a tube graft that was anastomosed proximally to the patent left innominate vein and distally to the right atrial appendage. None of our patients died. All 8 patients had prompt relief of their symptoms [upper limbs, head and neck congestion, and the severe dyspnea and orthopnoea] immediately after surgery together with disappearance of dilated superficial veins, and the negative need for medical treatment, In a mean post operative follow- up period of 3 years and 3 months, 7 patients [87.5%] remained symptom-free with a patent graft visualized by venography. Only one patient [12.5%], who had hypercoagulability due to Behcet syndrome, needed revision of the graft after he stopped Warfarin anticoagulation. In our experience, fashioning the SVG in a spiral manner represented an appealing option as a bypass conduit. Using it to bypass the obstructed SVC in non-malignant cases of SVC occlusion, showed sound safety, alleviated symptomatology, and provided a good postoperative patency rate

Total anomalous pulmonary venous connection: outcome of surgical correction and long term follow up

We report a prospective analysis of the demographic and clinical profiles of patients in order to assess the results of operative repair for total anomalous pulmonary venous connection [TAPVC] and the long term follow up. Methods: In the period between January 1998 and September 2006, 28 patients [16 boys, 12 girls] underwent repair for total anomalous pulmonary venous connection. Their ages ranged from 2 weeks to 1.2 years [mean 4 months]. The patients weight ranged from 3 to 7.5 kg [mean 5 kg]. About 80% of patients [n=22] were less than the 50th percentile of predicted weight for age and sex. The anomalous connection was supracardiac in 23 [82%], cardiac in 3 [11%], infracardiac in 1[3.6%] and mixed in 1[3.6%] patient. Six [21%] patients had obstructed drainage and 9 patients [32%] had moderate or severe pulmonary arterial hypertension. Five patients [18%] had to be operated upon on an emergency basis. For supracardiac and infracardiac connections, a posterior approach was used for anastomosis. In cardiac type, coronary sinus was unroofed and the resultant defect along with atrial septal defect was closed with a single patch. All the patients were operated upon using moderately hypothermic cardiopulmonary bypass. There were 2 [7.1%] in-hospital deaths. Two patient died of pulmonary arterial hypertensive crisis. One of them had preoperative pulmonary venous obstruction. Follow-up ranged from 7 to 97 months [mean 57 months]. There were no late deaths, but 2 patients developed venous obstruction and required balloon dilatation. Mortality continues to be relatively high in infants with total anomalous pulmonary venous connection. Severe pulmonary arterial hypertension appears to be the most important predictor of operative mortality. Severe malnutrition, delayed diagnosis and late referrals possibly contribute to the high mortality

Follow-up of small muscular ventricular septal defects after surgical closure of large ventricular septal defect

Background: closure of ventricular septal defects [VSDs] in infancy due to pulmonary hypertension has greatly replaced pulrnonary artery banding. This approach has been extended to infants with multiple VSDs, closing large VSD and in many cases leaving small muscular VSDs behind. The hemodynamic relevance and rate of closure of these VSDs are unknown. The purpose of this study was to assess the outcome of infants with multiple VSDs after surgical closure of a large VSD leaving another small muscular VSD [s] behind

Patients and Methods: this prospective study was done between January 2004 and December 2005, in the department of Cardio-thoracic Surgery, Abu El-Rish Children Hospital Aff./ Kasr El-Ainy Hospital, Faculty of Medicine, Cairo University. The study sample consisted of 20 infants who were operated for closure of multiple VSDs, closing only the large haemodynamically significant VSD and leaving other small muscular VSD[s]. Tran thoracic echocardiography [TTE], preoperative and postoperative, in the intensive care unit, at hospital discharge, and during follow-up, were performed for all patients. Intra-operative transesophageal echocardiography [TEE] was performed for last 9 patients. Mean follow-up time was 1.5 years [range 0.25- 3.0 years]. Residual defects were graded as absent, < 2 m or between 2 and 4 mm

Results:- due to a pulmonary hypertensive crisis, one patient [5%], died in the 1.C.U comprising our single early postoperative hospital mortality. Morbidity occurred in only one patient [5%] in the form of conduction disturbances which needs implanting a permanent DDD-pacemaker. Follow-up was complete in 17 patients [85%] as only 3 patients [15%] were lots of follow-up. During follow-up no reoperations were necessary for closing a residual VSD. After discharge, all residual defects less than 2 mm closed. Of residual defects greater than 2 mm. only one closed after a man follow-up of 2.4 years. All patients with residual shunts, were hemodynamically stable, requiring no or minimal medication and in none of them endocarditis was noted

Conclusion: our results showed that in infants, postsurgical residual muscular VSDs less than 2mm closed spontaneously in the majority within 1.5 years. Defects greater than 2mm are less likely to close spontaneously. At early follow-up. Residual shunts remained hemodynamically and clinically irrelevant

Modified bronchoalveolar lavage for pulmonary alveolar proteinosis in pediatrics and adults

Pulmonary Alveolar Proteinosis [PAP] is a rare disease of uncertain etiology and variable natural course. This study aimed to evaluate the clinical features and natural history following our management protocol for PAP which consisted of multiple sessions of modified bronchoalveolar lavage under general anaesthesia. This prospective study was carried in Kasr El Aini's University Hospital and new Kasr El Aini hospital From October 2003 till May 2006. Nine patients received 24 sessions of whole bronchoalveolar lavage for management of pulmonary alveolar proteinosis [PAP]. Patients age ranged from 7 and 42 years [mean of 23 years] and were categorized into two groups: [A] the pediatric group [included 3 patients aged 7,8 and 11 years] and [B] the adult group which included 6 patients. Whole lung lavage [one lung at a time] was carried out under general anesthesia with selective one lung ventilation using a double-lumen endotracheal tube in adult patients. In the pediatric group as a double-lumen endotracheal tubes suitable for their size were not available, a small-for-weight endotracheal tube was introduced through the vocal cords to ventilate one lung while a rigid bronchoscope was passed beside it to lavage the other lung. In each adult patient around 20 liters of warm normal saline [to which 1 ampoule of heparin was added to each 500 mls] were instilled in increments of 5 ml/kg inside the main bronchus of a single lung followed by a few minutes of postural changes while multiple gentle chest percussions were applied. The process was stopped when the lavage fluid suctioned from the endo-bronchial tree became clear. None of our patients died in the follow up period. No morbidity occurred in our patients apart from an episode of mild retention of saline inside the alveolar tree which was manifested by marked increase in the CVP, low arterial oxygen saturation and low [PaO[2]] in the ABG which was managed promptly using combination of Oxygen inhalation by mask, bronchodilators and intravenous diuretics. All patients stated a remarkable improvement in their tolerance to physical exertion. All 9 patients [100%] expressed total disappearance of SOB during the follow-up period. One patient [11.1%] complained of intermittent cough for 4 days before being ameliorated. A single patient [11.1%] complained of transient low-grade fever. Few scattered rales were present in 6 patients [66.6%] due to residual retention of the lavage fluid inside the alveoli from which they were treated by diuretics until it totally disappeared within the first 24 hours. Plain chest radiographs and CT chest showed fainting and near-total disappearance of the ground glass and the reticulation patterns. Spirometry and lung volumes [percentage predicted] revealed a marked improvement with FVC and mean total lung capacity values. The mean value of Forced Expiratory Volume [FEV1] during the first second became 94.9 +/- 13.6, the total lung capacity [TLC] became 83.1 +/- 15.7 and the ratio of FEV1 to the Forced vital capacity became 101 +/- 8.4. Arterial blood gases measurements, showed that the mean arterial oxygen tension [PaO[2]] was 79.5 +/- 6.2 mmHg, while the mean PCO[2] tension was 36.3 +/- 3.5 mmHg. The mean pH value of the blood was 7.43 +/- 0.02. The mean arterial oxygen saturation became 84 +/- 8.8%, [mean of 79-96%]. In our experience whole lung PAL was simple, safe and could be applied in patients with pulmonary alveolar proteinosis with a sound degree of safety with no grave complications. Careful attention to all preoperative and intraoperative patient parameters is mandatory in order to perform whole-lung lavage under general anesthesia in adults or pediatrics