Cardiac surgery simulation: a low-cost feasible option in an Australasian setting.

BACKGROUND: Simulation training is a useful adjunct to surgical training and education (SET) in Cardiothoracic Surgery yet training opportunities outside the Royal Australasian College of Surgery or industry-sponsored workshops are rare due to high cost and limited training faculty, time, assessment tools or structured curricula. We describe our experience in establishing a low-cost cardiac simulation programme. METHODS: We created low-cost models using hospital facilities, hardware stores, abattoirs and donations from industry. Three workshops were conducted on coronary anastomoses, aortic and mitral valve replacement. RESULTS: Whole porcine hearts were sourced from local farms. Industry donations of obsolete stock were used for suture and valve material-stations constructed using ironing-board, 2-L buckets and kebab-skewers. Suture ring holders were fashioned from recycled cardboard or donated. All participants were asked to complete pre and post simulation self-assessment forms. Across three workshops, 45 participants (57.8% female) with a median age 27 (interquartile range 24-31) attended. Training level consisted of nurses (8, 17.8%), medical students (17, 37.8%), residents/house officers (6, 13.3%) and registrars (14, 31.1%). There were improvements in knowledge of anatomy (mean difference 18%; 95% confidence interval 12%-24%), imaging (16%; 10%-22%) and procedural components (34%; 28%-42%); and practical ability to describe steps (30%; 24%-38%), partially (32%; 26%-38%) or fully complete (32%; 28%-38%) the procedure. CONCLUSIONS: Simulation-based training in cardiac surgery is feasible in a hospital setting with low overhead costs. It can benefit participants at all training levels and has the potential to be implemented in training hospitals as an adjunct to the SET programme.

A rare case of cholesterol granuloma in the anterior mediastinum.

Cholesterol granulomas are reactant lesions that develop in response to cholesterol crystals and foreign body giant cells. They are a commonly described benign condition affecting the middle ear and paranasal sinuses, however have been reported in various sites within the body. We describe a rare case of an incidental cholesterol granuloma in the anterior mediastinum of a cardiac surgical patient.

Tricuspid valve repair for torrential tricuspid regurgitation after permanent pacemaker lead extraction.

Tricuspid regurgitation secondary to percutaneous lead extraction is uncommon, and it rarely requires surgical intervention. Most tricuspid regurgitation occurs during the implantation of tined leads, which can be entrapped in the tricuspid valve apparatus and may require immediate withdrawal. Severe tricuspid regurgitation as a sequela of extracting chronically implanted leads has rarely been reported. Herein, we report a case of torrential tricuspid regurgitation in a 67-year-old woman after the extraction of a permanent pacemaker lead. The regurgitation was confirmed on transesophageal echocardiography during lead extraction, and the tricuspid valve was successfully repaired with suture bicuspidization of the valve and the support of ring annuloplasty. A short review of the relevant literature follows the case report.

Urgent and emergency coronary artery bypass grafting for acute coronary syndromes.

BACKGROUND: Urgent and emergency coronary artery bypass grafting may be associated with significant mortality and morbidity. We report our recent experience with this group of patients. METHODS: A retrospective analysis of 441 patients undergoing urgent and emergency surgery over a 3-year period was carried out. Multivariate analysis was used to identify subgroups of patients who were most at risk of death. RESULTS: The 30-day mortality was 3.3 and 16.3% in the urgent and emergency groups, respectively. Urgent surgery was associated with significantly shorter duration of ventilation (16 h vs 69 h) and stay at the intensive care unit (31 h vs 102 h). The incidence of pneumonia, pulmonary embolism, renal failure and neurological events were also less in the urgent group. The preoperative use of the intra-aortic balloon pump was low (0.8% in the urgent group and 4.8% in the emergency group). Multivariate analysis showed that patients over 70 years of age (odds ratio 3.2, 95% confidence interval 1.1-9.5) with left main stenosis (odds ratio 4.4, 95% confidence interval 1.5-12.4) complicated by cardiogenic shock (odds ratio 17.8, 95% confidence interval 5.2-61.1) were at highest risk of death. Patients transferred directly to theatre from cardiac catheter laboratory following failed percutaneous interventions were found to be most at risk. Mortality in this group was 29%, with 50% patients being in shock and 36% having left main stenosis. CONCLUSION: Satisfactory results have been obtained in urgent coronary artery bypass grafting, but acute coronary syndromes complicated by cardiogenic shock remain a high-risk group. Further studies are needed to define the optimal operative management in this group of patients.

Experience with unipolar radiofrequency ablation for atrial fibrillation.

BACKGROUND: The cut and sew Cox maze procedure for atrial fibrillation (AF), although effective, is not widely used because of technical complexity, prolonged duration and significant risk of postoperative bleeding. This study reviews our experience with the unipolar radiofrequency ablation (RFA) procedure, which was used to create a modified maze to treat AF. METHODS: A retrospective review of 31 patients undergoing consecutive cardiac surgery who had concomitant RFA for AF over a 16-month period was carried out. A Cobra unipolar RFA probe (EPT; Boston Scientific, San Jose, CA, USA) was used to create a standard set of lesions. RESULTS: There were 20 men and 11 women (mean age, 66 +/- 9 years; range, 48-87 years). AF was continuous in 21 patients and intermittent in 10. The median duration of AF leading up to surgery was 48 months (range, 6 months-20 years). Left atrium was enlarged in 81% of the patients. Operations included mitral valve repair (7 patients), replacement (5), coronary artery bypass (10), aortic valve replacement (1) and combined procedures (8). There were no complications directly attributable to RFA. There were three early deaths. One patient required a permanent pacemaker. Median follow up was 22 months (range, 12-30 months). One patient died 2 years after the operation from a stroke. Cardioversion was attempted in five patients within 3 months of operation and was successful in four. At 2 years following the procedure, the probability of the patient remaining in sinus rhythm was 0.71 +/- 0.15. CONCLUSION: Surgical RFA can be carried out as a useful adjunct to conventional cardiac surgery. Although the results were satisfactory in this series, further studies are needed to refine the indication of the procedure and to assess its longer-term efficacy.

Use of a single silastic chest drain following thoracotomy: initial evaluation.

BACKGROUND: It is standard practice to use multiple large bore semi-rigid chest tubes to drain the pleural cavity following thoracic procedures. These can cause pain and discomfort at the insertion site. METHODS: We describe our experience with the use of a single small silastic drain following thoracotomy. From November 2001 to November 2003, size 19-F silastic chest tubes (Blake drains) were used for drainage of the pleural cavity in 37 patients at our institution. The patients ranged in age from 18 to 81 years (mean 65). The operations included 22 lobectomies, two bilobectomies, 10 wedge resections, and three other procedures. RESULTS: Total drainage in each patient ranged from 420 to 5440 mL (mean 1387 mL). Tubes were left in place for an average of 4.3 days (range 1-12). The average postoperative length of stay was 7.6 days (range 3-44, median 5). Three patients required insertion of an additional tube for dislodgement, persistent air leak, and bronchopleural fistula, respectively. These complications occurred among the first 15 patients in the present series. None of the patients had persistent pleural effusion. Subjectively, these tubes were more comfortable for the patients and were easier to remove. SUMMARY: The use of a single, small silastic chest drains following thoracotomy may be safe and effective in draining both fluid and air, though an additional tube may be necessary for persistent leaks.

Follow-up of Australian aboriginal patients following open-heart surgery in Western Australia.

BACKGROUND: To date there has been only one published report pertaining to the outcomes following open-heart surgery in Australian aboriginal patients. METHODS: The records of 57 consecutive aboriginal patients who underwent open-heart surgery at our institution over a 6-year period were retrospectively reviewed. Attempts were made to contact the patient by telephone, by letter, through their listed next of kin, general practitioners, community nurse or through the aboriginal liaison officer. RESULTS: There were 38 males and 19 females. Forty-five patients had coronary artery bypass grafting, 10 had isolated valve procedures while 2 had a combined operation. Mechanical prostheses were used for all valve replacements. There was a high incidence of diabetes, hypertension, hypercholesterolemia and smoking. There was one hospital death. Follow-up ranged from 6 months to 6 years with a mean of 3.09 years. Forty-four of the 56 (78.6%) hospital survivors were contactable while 21.4% were not contactable. There were two late deaths. Of the coronary patients who could be contacted, only 79% were taking Aspirin and a similar number Statin. 23% patients had recurrence of angina. There were five episodes of anticoagulation related complications in three patients. Only 44% of the patients were conversant with anticoagulation. CONCLUSIONS: The follow-up of the aboriginal patients was disappointing. The compliance with the medications was sub-optimal. There was a high incidence of recurrence of angina and anticoagulation related complications. The results raise concern about the use of mechanical prosthesis in these patients.

Retroaortic course of the anomalous left main coronary artery: is it a benign anomaly? A case report and review of literature.

BACKGROUND: Left coronary artery sharing a common origin with the right coronary artery and taking a retroaortic course is a rare coronary anomaly. It has been considered a benign entity. CASE REPORT: We report a 19-year-old man who presented with chest pain. Cardiac enzymes were elevated suggesting myocardial ischaemia. Coronary angiography revealed single origin of the coronary artery in the right coronary sinus. The left main coronary artery followed a retroaortic course before bifurcating. The anomalous left coronary artery was dissected and reimplanted in the left coronary sinus. The patient made an uneventful recovery. One year later, he is well with no recurrence of symptoms. CONCLUSIONS: Surgery to restore the normal anatomic position of the left coronary ostium is advisable whenever this anomaly is discovered.

Atrial myxoma with coexistent coronary artery disease: a report of two cases.

The age at presentation and the symptoms of atrial myxomas and coronary artery disease can be similar. At times, the two lesions coexist. Operative strategy needs to be carefully planned when combined surgical treatment is contemplated. In the present paper, two cases of concomitant atrial myxoma and atherosclerotic coronary artery disease are reported. The first patient had a left atrial myxoma with triple-vessel coronary artery disease. The other had a right atrial myxoma and needed two bypass grafts. Both patients had a satisfactory outcome.

Functional tricuspid regurgitation secondary to aortic annular abscess: An unusual presentation of infective endocarditis.

An unusual case of aortic annular abscess is presented, in which the patient presented with features of gross tricuspid regurgitation. There was no direct involvement of the tricuspid valve. Tricuspid regurgitation disappeared following surgical repair of the annular abscess. The present case also illustrates the utility of trans-oesophageal echocardiography in establishing the diagnosis and planning surgical intervention.