Diagnostic value of adenosine deaminase activity in pericardial fluids.

BACKGROUND: The activity of adenosine deaminase (ADA) was determined in serum and pericardial fluid of 70 patients (ages 21 to 71 years) with pericardial effusions of various etiologies and in 15 control subjects. METHODS: The patients were subdivided into five groups on the basis of definite diagnosis: 1) 24 patients with tuberculosis; 2) 22 with malignancies; 3) 12 with uremic pericarditis; 4) 12 with purulent pericarditis; 5) 15 control individuals without pericardial disease. The activity of ADA was determined at the same time in serum and cell-free pericardial fluid according to the method of Karker with minor modification. RESULTS: Mean (+/-SD) ADA activity in pericardial fluid was 66.92+/-4.12 IU/L in group 1; 27.50+/-6.02 in group 2; 28.65+/-4.73 in group 3; 53.05+/-11.14 in group 4; and 5.67+/-1.99 in group 5. Comparing the level achieved in group 1 with all others, the difference is significant at the p<0.001 level. When the cut-off value of 50 IU/L is used the sensitivity of the test for diagnosis of tuberculous effusion is 1, and the specificity is 0.83. Statistical analysis showed that there was no correlation between serum ADA activity and ADA activity in pericardial fluid. CONCLUSIONS: We recommend that determinations of ADA activity in pathologic pericardial fluids seem to be of great value in the early diagnosis of tuberculous pericardial effusions. Levels above 50 IU/L in effusions indicate probable tuberculosis.

Surgical management of congenital lobar emphysema.

Here in nine patients with congenital lobar emphysema who had been treated surgically in the previous 10 years are reported. The ages of the patients at diagnosis ranged from 26 days to 11 months. The six patients whose symptoms started in the neonatal period had more severe dyspnea, cyanosis and respiratory distress. Tube thoracostomy was performed in two of three patients who had been misdiagnosed initially. The affected side was the left upper lobe in five patients, the right upper lobe in three, and the right middle and upper lobes in one patient. Lobectomy was performed in all cases. Dysplasia of the bronchial cartilage was found in six patients and bronchial atresia of the left upper lobe was found in another infant as the etiologic cause of the condition. Although the possibility of conservative management in congenital lobar emphysema has been reported recently, we believe that surgery is the treatment of choice in patients who have persistent or progressive, severe respiratory distress in spite of medical treatment.

Atrial fibrillation after coronary artery bypass surgery: predictors and the role of MgSO4 replacement.

BACKGROUND: Supraventricular arrhythmias continue to complicate the postoperative course of patients undergoing myocardial revascularization. The aim of the study was to identify factors associated with atrial fibrillation (AF) and to determine the efficacy of postoperative magnesium sulphate (MgSO4) replacement on the incidence of AF after coronary artery bypass grafting (CABG) operation. METHODS: Fifty patients undergoing CABG were studied prospectively. Consenting patients with good left ventricular function and without any documented arrhythmias were randomly divided into two groups of 25 patients each in a double-blind fashion. The clinical characteristics of both groups were similar. In the study group, 200 mEq MgSO4 was given for the first 5 postoperative days, in the control group, placebo was given instead of MgSO4. RESULTS: Five (20%) patients in the control group and one (4%) patient in the MgSO4 group experienced AF. There was no significant relationship between the development of AF and the following variables: age; sex; diabetes mellitus; hypertension; previous myocardial infarction; smoking; extension of coronary artery disease; aortic cross-clamp time; number of grafts; cardiopulmonary bypass time; postoperative pericarditis; and anemia. CONCLUSION: The use of MgSO4 in early postoperative period is effective in reducing the incidence of AF after CABG in patients with good ventricular function.

Coarctation of the abdominal aorta with left renal artery and splenic artery aneurysms.

Both coarctation of the abdominal aorta, and splenic artery aneurysm reside in the hilus, a rare but extremely important pathological condition. Herein a 36-year-old woman hospitalized for uncontrolled hypertension is presented. Aortography demonstrated segmental abdominal aortic coarctation with left renal artery and splenic artery aneurysms. Medical control of hypertension was not possible and thoracoabdominal bypass with a prosthetic graft was undertaken. Left renal artery aneurysm was resected and aorto-renal saphenous vein bypass was performed. But splenic artery aneurysm was left in situ because it was asymptomatic and less than 2 cm in diameter. Postoperatively the patient was normotensive. Although the pathogenesis of such lesions remain unknown, it may be to congenital or related medial degeneration as demonstrated histologically.

Coarctation of the aorta in infants and neonates: results and assessment of prognostic variables.

From 1984 until 1994, 75 consecutive patients younger than 12 months of age were operated on for coarctation of the aorta. We retrospectively analyzed predictive factors for morbidity and mortality, and also interaction between surgical procedures and recoarctation. Surgical procedures were as follows: resection with a traditional end-to-end (E-E) anastomosis in 55 patients (73.3%), prosthetic patch aortoplasty (PPA) in 12 patients (16%) and subclavian flap aortoplasty (SFA) in 8 patients (10.7%). Early mortality was 9.33% (7 patients). Logistic regression analysis proved that age at operation, associated anomalies of heart, type of coarctation, aortic arch hypoplasia and pulmonary banding were independent predictors of hospital death. Late mortality occurred in 7 patients (10.3%). Associated anomalies of heart were an independent prognostic factor for late mortality. Actuarial freedom from recoarctation at 1 year was 91% [confidence limits (CL): 82% to 97%] and 5 years were 74% (CL: 67% to 86%). Immediate postrepair gradient was equal after E-E anastomosis and other procedures. We conclude that the treatment of first choice in the management of coarctation of the aorta in infants is E-E anastomosis.

Left ventricular size following shunt operation in tetralogy of Fallot.

This study was performed in 24 patients with tetralogy of Fallot in whom shunt operation was performed instead of total correction because of small left ventricular end-diastolic dimension. Left ventricular end-diastolic dimension was measured using M-mode and two-dimensional echocardiography pre- and at least one year postoperatively. There was no change in the postoperative left ventricular size in two patients. However, in the other 22 patients, the left ventricular dimension was increased to 70 to 103 percent of normal left ventricular size. According to the findings of this study, we can conclude that the patients in whom shunt operation was performed would most likely have an increased left ventricular size over time.

Long-term experience with pericardiectomy: analysis of 105 consecutive patients.

A retrospective analysis of the records of 105 patients who underwent pericardiectomy from 1983 to 1993 was performed. Primarily, 40 patients (38%) had tuberculosis, 16 patients (15%) a malignancy, 12 patients (11.4%) uremia, and 11 patients (10.5%) had rheumatic disorders. Pericardiectomy was performed through midline sternotomy in all cases, 9 of them required cardiopulmonary bypass. On operation, the anterior pericardium was excised parallel to the phrenic nerves on both side. The early mortality rate was 10.5% (11 patients). Mean follow-up time was 5.8 +/- 2.1 years, ranging from 1 year to 11 years. Actuarial survival of the patients at 1 year and 5 years were 81.1% +/- 6.8% and 63.5% +/- 8.2%, respectively. We conclude that pericardiectomy using midline sternotomy with or without cardiopulmonary bypass can be performed safely and can lead to good functional results and long-term survival.

The influence of pulmonary insufficiency on ventricular function following total correction of Fallot's tetralogy: evaluation using radionuclide ventriculography and clinical findings.

Long-standing pulmonary insufficiency after repair of tetralogy of Fallot may adversely affect ventricular function. We evaluated 20 patients postoperatively by radionuclide ventriculography and clinical findings after total correction of tetralogy of Fallot. Patients were divided into two groups as follows: Group I patients (10) had no pulmonary insufficiency; Group II patients (10) had moderate or severe pulmonary insufficiency. Preoperatively, there was no difference between groups in terms of age, functional capacity according to the New York Heart Association criteria, hemoglobin and hematocrit level, cardiothoracic ratio, McGoon ratio, left and right ventricular ejection fraction, cardiac output or cardiac index. Postoperatively, right ventricular ejection fraction was 40.10 +/- 2.28 in Group I and 29.5 +/- 2.86 in Group II, p < 0.01. Left ventricular ejection fraction was 59.3 +/- 2.90 in Group I and 50.9 +/- 4.19 in Group II, p < 0.01. Radionuclide ventriculography is a useful means of identifying right ventricular dysfunction following repair of tetralogy of Fallot. The dysfunction appears significantly worse in patients with pulmonary insufficiency.

Surgical treatment in tetralogy of Fallot diagnosed by echocardiography.

The purpose of this paper is to present the authors' 3-yr experience of echocardiographic examination of patients with the clinical diagnosis of tetralogy of Fallot, and their evaluation for surgical treatment without prior cardiac catheterization. Among the patients with the clinical diagnosis of tetralogy of Fallot 227 had a definite diagnosis made by M-mode, two-dimensional, Doppler and contrast echocardiography. For the diagnosis of tetralogy of Fallot, ventricular septal defect, pulmonary stenosis, and overriding of the aorta were considered to be fundamental. Ventricular septal defect could be seen easily in the subaortic region by two-dimensional echocardiography. However, in some patients whose ventricular septal defect was not seen clearly, peripheral vein contrast echocardiography was performed. The diameters of pulmonary artery, and main branches at a few millimeters distal to their origin were measured. These parameters were correlated with the aortic diameter for evaluation as to whether they were able to accept the total cardiac output. In patients whose left ventricular end-diastolic dimension was small, shunt operation was preferred. In 115 patients the pediatric cardiologist performing the echocardiography thought that cardiac catheterization was necessary. In these cases the reliability of echocardiography in detecting important cardiac abnormalities was evaluated. Detection of ventricular septal defect, presence of pulmonary valve, detection of stenosis on the pulmonary bifurcation and/or main branches revealed a high sensitivity. Two-hundred-and-one patients diagnosed by echocardiography underwent total correction. In all cases except one the preoperative diagnosis was confirmed by surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Mitral valve surgery in the presence of pulmonary hypertension.

Mitral valve surgery was performed in 59 patients with severe pulmonary hypertension (average systolic pulmonary artery pressure 77.1 +/- 18.6 mmHg; range 50-115 mmHg) between 1983 and 1990. Thirty-eight patients had been subjected to mitral valve replacement, 16 patients both mitral and aortic valve replacement, and 5 patients had open mitral commissurotomy, with an operative (30 day) mortality of 5.0%. These 3 deaths happened during the early postoperative period. Survivors were followed up for a period ranging from 6 months to 7 years with a mean of 36 months. Four late deaths (7.1%) occurred in patients with valve replacement. Actuarial survival was 93 +/- 3% at 5 years, and 90.7 +/- 4.4% at 7 years. Right ventricular catheterization was performed on 14 patients a mean of 38 months following operation. Systolic pulmonary artery pressure had decreased from a mean of 77.1 +/- 18.6 to 39.7 +/- 14.0 mmHg (p less than 0.001) and 90% of the survivors were in New York Heart Association Class 1 or II compared to 23.7% preoperatively. The clinical and hemodynamic findings in this series suggest that severe pulmonary hypertension is not a contraindication, and pulmonary hypertension decreases significantly after mitral valve surgery.

Right ventricular hydatid cyst causing recurrent pulmonary emboli.

A hydatid cyst of the heart is rare. Surgical treatment is the preferable method in the treatment of cardiac echinococcosis. A 27-year-old patient with right ventricular hydatid cyst causing recurrent pulmonary emboli and diagnosed by 2-dimensional echocardiography and treated surgically is presented.

Blood cyst originating from tricuspid septal leaflet.

Successful removal of a blood cyst of the tricuspid valve in a 34 years old man is reported. The rarity of this cyst in an adult and diagnostic clues are discussed.

The effect of aprotinin (trasylol) on postoperative bleeding in cyanotic congenital heart disease.

Despite the widespread clinical success in open-heart surgery, bleeding after cardiopulmonary by-pass (CPB) has been a common problem especially in cyanotic congenital heart disease. Recently, there have been reports demonstrating that treatment with high doses of aprotinin reduces postoperative bleeding. We studied the effect of aprotinin on postoperative bleeding in patients with tetralogy of Fallot who had undergone total correction in the Department of Thoracic and Cardiovascular Surgery of the Hacettepe University Faculty of Medicine, and compared our results with those in the literature. Ten patients out of 20 in the study were given high doses of aprotinin and were compared with the remaining 10 patients who had not received the drug. Standard anesthesia, perfusion and surgical techniques were used in all operations. The total amount of bleeding in the aprotinin-treated group was found to be 1530 ml, while in the other group it was 4185 ml (p < 0.05). The total quantity of blood transfused in the aprotinin-treated patients was 3250 ml while it was 5865 ml in the control group (p < 0.05). No significant effect of aprotinin was found on Hb, Hct, PT, aPTT and thrombocyte counts (p > 0.05). However, the effect of the drug on bleeding and coagulation time was found to be statistically significant (p < 0.05).

Bronchoscopic removal of foreign bodies in children: retrospective analysis of 822 cases.

At the Department of Thoracic and Cardiovascular Surgery of Hacettepe University, a total number of 822 pediatric bronchoscopies were performed from 1984 through 1990 for suspected foreign body aspiration. Of the children 65.3% were boys and 34.7% were girls ranging in age from one month to 14 years. Definitive statement of foreign-body aspiration was obtained from 394 patients. Unilateral hyperaeration, atelectasis, and unilateral parenchymal infiltration were the most common radiological findings. In all endoscopic procedures, a pediatric rigid bronchoscope was used under general anesthesia and controlled ventilation. Foreign bodies were found in 77.7% of the 822 patients. In the rest of the children inflammatory disorders were confirmed. The foreign bodies most commonly found in 639 patients were sun-flower seeds (21.1%), beans (10.4%), water-melon seeds (10%), and hazelnuts (9.8%). In our presented series, the incidence of non-fatal complication was 1.8%, apart from these patients 5 of them (0.6%) died after the bronchoscopic procedures.

Right atrial myxoma in an infant.

Cardiac myxomas are extremely rare in infancy. We report a case of right atrial myxoma in a 35-day-old male infant (with cyanosis and convulsions). Echocardiography was carried out and a diagnosis of right atrial myxoma was made. Open heart surgery was performed using cardiopulmonary bypass and a 2.5 X 3.0 cm mass was removed. The patient's postoperative course was uneventful. To our knowledge there is no previously reported case of right atrial myxoma in such a young infant which was operated on successfully.

Surgical treatment of renovascular hypertension in children.

Hypertension of renovascular origin in pediatric patients is frequently encountered. Herein, we review our experience, as well as that of others, with this type of patient, and discuss the characteristic features of renovascular hypertension and the favourable response to reconstructive vascular surgery.

De Vega's tricuspid annuloplasty: analysis of 195 patients.

In the years 1984-1989, 195 De Vega tricuspid annuloplasties were performed in association with mitral or mitral-aortic valve procedures. Preoperatively, 9 patients (4.6%) were in New York Heart Association functional class II, 124 (63.6%) were in class III, and the remaining 62 (31.8%) were in class IV. Tricuspid insufficiency was recognized by routine digital palpation of the tricuspid valve during the operation in 42 (21.5%) of the patients. Hospital mortality rate was 7.6% (15 patients). Late deaths occurred in 6 (3.0%) cases during a follow-up period of 3 to 72 months (mean 42 months). 8 patients (4.1%) required reoperation. Tricuspid annuloplasty failure was observed in 4 patients (2%). These valves were replaced with biological valves in three patients and with a mechanical valve in one patient. 112 of the survivors (64.3%) were evaluated by echocardiography and/or right ventriculography. Analysis of postoperative data showed that in 84 of the 112 patients (75%) tricuspid regurgitation disappeared completely after annuloplasty, 88% of surviving patients were in functional class I or II. For the series presented actuarial survival rate at 6 years was 79.1% +/- 14.4%. In the light of this study we recommend De Vega's annuloplasty as the method of choice for moderate to severe functional tricuspid insufficiency.