Comparative study of subxiphoid versus video-thoracoscopic pericardial "window".

BACKGROUND: It remains undefined whether surgical subxiphoid drainage or thoracoscopic pericardial "window" is the optimal operative approach to pericardial effusion. We hypothesized that the true window into the pleural space created by the latter might improve the duration of freedom from recurrent effusion. METHODS: We conducted a retrospective chart review of indications, preoperative and intraoperative variables, morbidity, recurrence, and survival. RESULTS: Fifty-six patients underwent the subxiphoid procedure and 15 underwent the thoracoscopic procedure. Echocardiographic evidence of tamponade was present before 8 of 10 thoracoscopic procedures (80%) and 43 of 56 subxiphoid procedures (81%) for which descriptions of hemodynamics were available. In addition, non-pericardial procedures were performed in 10 (67%) and 18 (32%) patients, respectively (p = 0.020). Anesthesia time was longer at thoracoscopy (117.1 +/- 32.4 vs 81.1 +/- 25.5 minutes; p < 0.001). Procedural morbidity was higher after thoracoscopy (4 [27%] vs 1 [2%]; p = 0.006), but was generally minor. Hospital mortality tended to be higher after the subxiphoid procedure (7 [13%] vs 0 [0%]; p = 0.332), but none of the deaths was procedure-related. Follow-up was complete for 65 patients (92%). Recurrence occurred in 1 thoracoscopy patient (8%) and 5 subxiphoid patients (10%) (p = 1.000). Mean time to recurrence by Kaplan-Meier analysis trends were longer after thoracoscopy (36.1 vs 11.4 months; p = 0.16), and multivariate analysis identified the thoracoscopic approach as an independent predictor of freedom from recurrence (relative risk, 0.41; p = 0.014). CONCLUSIONS: Operative time and minor procedural morbidity are higher with thoracoscopic pericardial window, but long-term control of effusion seemed to be better than after subxiphoid surgical drainage.

Differential expression of neuronal fos protein after cold water drowning and controlled rewarming.

BACKGROUND: Cardiopulmonary bypass has often been applied to revive victims of cold water drowning. The success of resuscitative efforts in patients who have sustained severe hypothermia is largely determined by neurologic outcomes. Measurement of Fos, the protein product of the immediate-early gene c-fos, is a marker of cerebral injury. STUDY DESIGN: Twenty-eight infant lambs were sedated and ventilated. Group 1 lambs were immersed in a cold water bath for 2 hours (17.3 +/- 2.7 degrees C). Group 2 lambs were placed on normothermic cardiopulmonary bypass for 2 hours (37.7 degrees +/- 0.7 degrees C). Group 3 lambs were immersed in a cold water bath for 2 hours (17.6 degrees +/- 2.4 degrees C), and then rewarmed for a period of 2 hours on cardiopulmonary bypass (37.0 degrees +/- 0.6 degrees C). The lambs were euthanized and immunohistochemical analysis for neuronal Fos was performed. RESULTS: There was significant induction of Fos-labeled nuclear profiles (cells/1130 microm(2)) in group 3 in the hippocampal regions and dentate gyrus compared with groups 1 and 2 (p < 0.001). CONCLUSION: Isolated exposure to either hypothermia or cardiopulmonary bypass results in minimal expression of neuronal Fos; the significant induction of Fos in the group 3 animals may represent an ischemic-reperfusion phenomenon. Modifications of rewarming techniques that minimize Fos expression may improve neurologic outcomes in victims of cold water drowning.

Expanding the indications for pulmonary valve replacement after repair of tetralogy of fallot.

BACKGROUND: Insertion of a competent pulmonary valve has been advocated to reduce right ventricular volume overload associated with pulmonary regurgitation (PR) after repair of tetralogy of Fallot. However the indications, proper timing, and long-term benefits of restoring pulmonary valve function remain controversial. METHODS: Thirty-six patients (aged 15.2 +/- 9.2 years) underwent pulmonary valve implantation (31 homografts, 5 heterografts) 12.2 +/- 6.9 years after tetralogy repair. Additional surgical procedures included pulmonary artery augmentation (n = 14), closure of septal defects (n = 10), and cryoablation and endocardial resection of ventricular tachycardia (n = 2). RESULTS: All patients have had clinical improvement in their exercise capacity. Preoperative and postoperative bicycle ergometry tests in 6 patients demonstrated significant improvement in the percent of predicted peak workload (68.5% +/- 19.8% to 80.7% +/- 17.4%, p < 0.015). One midterm death occurred in a 38-year-old patient with a history of ventricular tachycardia who died suddenly 2 years after pulmonary valve insertion. Postoperative echocardiographic measurements were available in 34 patients at a mean follow-up of 5 years. There was a 30% reduction in right ventricular end-diastolic diameter indexed to body surface area after surgery (30.1 +/- 10.2 to 18.6 +/- 6.0 mm/m(2), p < 0.0001). Two patients required conduit replacements at 1 and 9 years postoperatively. CONCLUSIONS: Timely insertion of a competent pulmonary valve in children, adolescents, and young adults with significant PR after tetralogy of Fallot repair results in subjective and objective improvement in exercise capacity and is associated with reduction in right ventricle size.