A novel and simple technique for correction of posterior leaflet prolapse due to chordal elongation or rupture.

OBJECTIVE: The study objective was to evaluate the midterm results of a technique for correction of posterior leaflet prolapse without resection or use of artificial chordae. METHODS: From May 2009 to October 2013, 96 patients with isolated posterior leaflet prolapse (n=36) or bileaflet prolapse (n=60) with or without chordal rupture underwent posterior leaflet repair at the Prince Sultan Cardiac Center. The novel Uniscallop ("U") technique was used in 46 patients (group U), based only on scallop suture without resection or artificial chordae application. A conventional approach (quadrangular or triangular resection, focal sliding, artificial chordae) was adopted in the remaining 50 patients (group C). In both groups, the annulus was reshaped using a 40- or 50-mm-long band. Postoperative echocardiography was performed in all patients after a mean follow-up of 18±13 months in group U and 20±9 months in group C. RESULTS: There were no early or late deaths. No patients in either group showed systolic anterior motion. Both surgical strategies were successful in obtaining a significant reduction in mitral regurgitation grade. Left ventricular function was maintained, and tricuspid regurgitation grade was reduced overall. Moderate mitral regurgitation during follow-up developed in only 1 patient in group C, as the result of dehiscence of a plication stitch. CONCLUSIONS: Although the rationale for the use of the U technique is different from what is generally accepted, the midterm results of this approach are comparable to those obtained with more conventional techniques, remaining stable after a mean follow-up of 18 months.

Chondrosarcoma of the chest wall: single-center experience.

BACKGROUND: chondrosarcoma is the most common primary tumor of the chest wall. We analyzed cases of chest wall chondrosarcoma to establish the presentation, diagnostic tools, surgical treatment, and outcome. METHODS: this was a retrospective observational analysis of 45 patients who underwent surgery for chondrosarcoma. RESULTS: the mean age was 42.3 ± 8.5 years, and 57.8% patients were male. Symptoms were a painful chest wall mass in 91.1% of patients. Chest radiography and computed tomography, and biopsy were the diagnostic tools. The tumor was right-sided in 57.8% of patients. It was located in the lateral (71.1%), anterior (26.7%), or posterior (2.2%) chest wall. The mean tumor diameter was 7.6 ± 3.3 cm. Radical en-bloc excision was performed in all patients. Chest wall reconstruction was carried out using methylmethacrylate and Prolene mesh (42.2%), Prolene mesh alone (37.8%), and direct closure (20%). A muscle flap was used for soft tissue reconstruction in 11.1%. Complications were encountered in 6.7%. There was no operative mortality. Follow-up was complete in 66.7% of patients. The mean follow-up period was 3.7 ± 2.1 years. Local recurrences and late mortality occurred in 4.4%. CONCLUSION: surgery for chondrosarcoma can be performed with acceptable morbidity and mortality. Proper selection of patients and radical en-block excision of the tumor are the keys for successful treatment and better outcomes.

Chordal cutting in ischemic mitral regurgitation: a propensity-matched study.

OBJECTIVE: The optimal surgical treatment of ischemic mitral regurgitation (MR) has not been well defined. Second-order chordal cutting (CC), in selected patients, can improve surgical outcomes. METHODS: From 2007 to 2011, 31 patients underwent CC for ischemic MR. The indication was the presence of increased tethering of the anterior leaflet, with a bending angle (BA) <145°. Patients with same echocardiographic characteristics were identified and propensity matched for age, ejection fraction (EF), MR grade, diameters, and BA. Only patients with preoperative and follow-up echocardiograms were included and divided into 2 groups of 26 patients each, CC and no-CC. RESULTS: Preoperatively, in the CC and no-CC groups, the age was 61 ± 9 and 62 ± 10 years, EF was 31% ± 5% and 29% ± 8%, MR grade (0-4) was 3.6 ± 0.6 and 3.3 ± 0.8, and diastolic and systolic dimension was 56 ± 7 and 43 ± 8 mm and 57 ± 11 and 44 ± 11 mm, respectively. The New York Heart Association class and BA was 2.7 ± 0.6 and 2.6 ± 0.7 and 137° ± 4° and 137° ± 6°, respectively. All patients underwent overreductive annuloplasty. In the CC group, second-order chords were cut using aortotomy. After a mean of 33 ± 15 months, the MR grade was 0.6 ± 0.6 and 1.1 ± 0.8 (P = .014) and the EF was 40% ± 5% and 35% ± 7% (P = .005) in the CC and no-CC groups, respectively. The corresponding diastolic and systolic diameters were 52 ± 5 and 38 ± 8 mm and 53 ± 11 and 41 ± 12 mm (P = NS). The modifications were significant only in the CC group (P = .022 and P = .029 for the diastolic and systolic dimensions, respectively). The corresponding New York Heart Association class decreased to 1.1 ± 0.3 and 1.5 ± 0.6 (P = .004). The BA increased to 182° ± 4° in the CC (P < .001) and remained unchanged (137° ± 6°) in the no-CC group. CONCLUSIONS: In selected patients with a BA <145° and coaptation depth ≤10 mm, CC is related to less MR return or persistence, improved EF, and lower New York Heart Association class.

Repair or prosthesis insertion in ischemic mitral regurgitation: Two faces of the same medal.

OBJECTIVE: The proper treatment of chronic ischemic mitral regurgitation (CIMR) is still under evaluation. The different role of mitral valve repair (MVr) or mitral valve prosthesis insertion (MVPI) is still not defined. METHODS: From May 2009 to December 2011 167 patients with ejection fraction (EF) ≤ 40% had MV surgery for CIMR, MVr in 135 (80.8%) and MVPI in 32 (19.2%). Indication to MVPI was a MV coaptation depth > 10 mm. EF was lower (26 ± 7 vs 32 ± 6, p = 0.0000) in MVPI, whereas MR grade (3.6 ± 0.8 vs 2.7 ± 0.9, p = 0.0000), left ventricle dimensions (end diastolic, LVEDD, 62 ± 7 vs 57 ± 6 mm, p = 0.0001; end systolic, LVESD, 49 ± 8 vs 44 ± 8 mm, p = 0.0018), systolic pulmonary artery pressure (51 ± 22 vs 41 ± 16 mm Hg, p = 0.0037) and NYHA Class (3.6 ± 0.5 vs 2.8 ± 0.6, p = 0.0000) were higher. RESULTS: In-hospital mortality was similar (3.1 vs 3.7%) as well as 3-year survival (86 ± 6 vs 88 ± 4) and survival in NYHA Class I/II (80 ± 5 vs 83 ± 4). One hundred thirty nine patients had an echocardiographic evaluation after a minimum of 4 months (13 ± 8). EF rose significantly in both groups (from 26 ± 7% to 30 ± 4%, p = 0.0122, and from 32 ± 6% to 35 ± 8%, p = 0.0018). LVESD reduced significantly in both groups (from 49 ± 8 to 43 ± 9 mm, p = 0.0109, and from 44 ± 8 to 41 ± 7 mm, p = 0.0033). MR grade was significantly lower in patients who had MVPI (0.1 ± 0.2 vs 0.3 ± 0.3, p = 0.0011). CONCLUSIONS: With appropriate indications, MVPI is a safe procedure which provides similar results to MVr with lower MR return, even if addressed to patients with worse preoperative parameters.

Surgical treatment of bronchiectasis: a retrospective observational study of 138 patients.

BACKGROUND: We analyzed cases of bronchiectasis; its presentation, etiology, diagnosis, indications for surgery, surgical approach, and the outcome. METHODS: A retrospective analysis of 138 patients who underwent surgery for bronchiectasis. RESULTS: The mean age was 30.2±15.7 years. 55.8% patients were males. Symptoms were recurrent infection with cough in all patients, fetid sputum (79.7%), and hemoptysis (22.5%). The etiology was recurrent childhood infection (38.4%), pneumonia (29%), TB (9.4%), sequestration (4.3%), foreign body obstruction (4.3%), and unknown etiology (14.5%). CXR, CT scan, and bronchoscope were done for all patients. Bronchiectasis was left-sided in (55.1%) of patients. It was mainly confined to the lower lobes either alone (50.7%) or in conjunction with middle lobe or lingual (7.2%). Indications for resection were failure of conservative therapy (71.7%), hemoptysis (15.9%), destroyed lung (8%), and sequestration (4.3%). Surgery was lobectomy (81.2%), bilobectomy (8.7%), and pneumonectomy (8%). Complications occurred in 13% with no operative mortality. 84% of patients had relief of their preoperative symptoms. CONCLUSIONS: Surgery for bronchiectasis can be performed with acceptable morbidity and mortality at any age for localized disease. Proper selection and preparation of the patients and complete resection of the involved sites are required for the optimum control of symptoms and better outcomes.

Traumatismos torácicos en niños: experiencia de un centro / Chest Trauma in Children, Single Center Experience

Los traumatismos son la primera causa de mortalidad en los niños de más de un año de edad en los países industrializados. En este estudio retrospectivo hemos revisado todos los traumatismos torácicos en pacientes pediátricos ingresados en el centro de urgencias del Mansoura University Emergency Hospital entre enero de 1997 y enero de 2007. Nuestro hospital recibió a 472 pacientes de menos de 18 años de edad. Hubo 374 pacientes varones, con una media de edad de 9,2±4,9 años. Las causas fueron traumatismos penetrantes (2,1%) y traumatismos cerrados (97,9%). Consistieron en traumatismos sufridos por peatones (38,3%), accidentes de vehículos a motor (28,1%), choques de motocicletas (19,9%), caídas desde una altura (6,7%), traumatismos causados por animales (2,9%) y lesiones deportivas (1,2%). Los tipos de lesión fueron contusiones (27,1%) y laceraciones pulmonares (6,9%), fracturas costales (23,9%) y volet costal (2,5%), hemotórax (18%), hemoneumotórax (11,8%), neumotórax (23,7%), enfisema quirúrgico (6,1%), lesiones traumáticas traqueobronquiales (5,3%) y lesión traumática del diafragma (2,1%). Las lesiones asociadas consistieron en traumatismos craneales (38,9%), fracturas óseas (33,5%) y traumatismos abdominales (16,7%). El tratamiento consistió en un enfoque conservador (29,9%), un tubo de toracostomía (58,1%) o una toracotomía (12,1%). La tasa de mortalidad fue del 7,2%, y los politraumatismos fueron la principal causa de muerte (82,3%) (p<0,001). Nuestra conclusión es que los traumatismos cerrados son la causa más frecuente de traumatismo torácico en los niños y que a menudo se producen en atropellos de peatones. Las fracturas costales y las contusiones pulmonares son los tipos de traumatismos más frecuentes. El retraso en el diagnóstico y los politraumatismos se asocian a una incidencia elevada de mortalidad(AU)

Trauma is the leading cause of mortality in children over one year of age in industrialized countries. In this retrospective study we reviewed all chest trauma in pediatric patients admitted to Mansoura University Emergency Hospital from January 1997 to January 2007. Our hospital received 472 patients under the age of 18. Male patients were 374 with a mean age of 9.2±4.9 years. Causes were penetrating (2.1%) and blunt trauma (97.9%). The trauma was pedestrian injuries (38.3%), motor vehicle (28.1%), motorcycle crash (19.9%), falling from height (6.7%), animal trauma (2.9%), and sports injury (1.2%). Type of injury was pulmonary contusions (27.1%) and lacerations (6.9%), rib fractures (23.9%) and flail chest (2.5%), hemothorax (18%), hemopneumothorax (11.8%), pneumothorax (23.7%), surgical emphysema (6.1%), tracheobronchial injury (5.3%), and diaphragm injury (2.1%). Associated lesions were head injuries (38.9%), bone fractures (33.5%), and abdominal injuries (16.7%). Management was conservative (29.9%), tube thoracostomy (58.1%), and thoracotomy (12.1%). Mortality rate was (7.2%) and multiple trauma was the main cause of death (82.3%) (P<.001). We concluded that blunt trauma is the most common cause of pediatric chest trauma and often due to pedestrian injuries. Rib fractures and pulmonary contusions are the most frequent injuries. Delay in diagnosis and multiple trauma are associated with high incidence of mortality(AU)

Chest trauma in children, single center experience.

Trauma is the leading cause of mortality in children over one year of age in industrialized countries. In this retrospective study we reviewed all chest trauma in pediatric patients admitted to Mansoura University Emergency Hospital from January 1997 to January 2007. Our hospital received 472 patients under the age of 18. Male patients were 374 with a mean age of 9.2±4.9 years. Causes were penetrating trauma (2.1%) and blunt trauma (97.9%). The trauma was pedestrian injuries (38.3%), motor vehicle (28.1%), motorcycle crash (19.9%), falling from height (6.7%), animal trauma (2.9%), and sports injury (1.2%). Type of injury was pulmonary contusions (27.1%) and lacerations (6.9%), rib fractures (23.9%), flail chest (2.5%), hemothorax (18%), hemopneumothorax (11.8%), pneumothorax (23.7%), surgical emphysema (6.1%), tracheobronchial injury (5.3%), and diaphragm injury (2.1%). Associated lesions were head injuries (38.9%), bone fractures (33.5%), and abdominal injuries (16.7%). Management was conservative (29.9%), tube thoracostomy (58.1%), and thoracotomy (12.1%). Mortality rate was 7.2% and multiple trauma was the main cause of death (82.3%) (P<.001). We concluded that blunt trauma is the most common cause of pediatric chest trauma and often due to pedestrian injuries. Rib fractures and pulmonary contusions are the most frequent injuries. Delay in diagnosis and multiple trauma are associated with high incidence of mortality.

Blunt traumatic diaphragmatic rupture: a retrospective observational study of 46 patients.

A retrospective study aimed to analyze our experience in 46 patients with blunt traumatic diaphragmatic rupture (BTDR) admitted to our tertiary hospital from 1995 to 2007. Charts, chest roentgenograms (CXR), and computed tomography (CT) scans were carefully reviewed. The mean age was 36.5+/-10.1 years, 36 (78.3%) were males. The etiology was a traffic accident in 36 (78.3%) patients. BTDR was left-sided in 34 (73.9%) and right-sided in 12 (26.1%) patients. CXR was diagnostic in 26 (56.5%) and CT in 12 (26.1%) patients. Associated injuries included lung 12 (26.1%), liver 10 (21.7%), spleen 24 (52.2%) and bowel 2 (4.2%) patients. BTDR was approached through thoracotomy 26 (56.5%), laparotomy 16 (34.8%), and combined approach 4 (8.7%) patients. The repair was primarily with interrupted non-absorbable sutures in 42 (91.3%) and by prosthetic mesh in four patients. Complications developed in 20 patients. Mortality was observed in 2 (4.3%) patients. We concluded that BTDR is a common lesion in young adult males on the left side caused by a traffic accident. A high index of suspicion combined with repeated and selective radiologic evaluation is necessary for early diagnosis. Associated injuries represent the main prognostic factor affecting morbidity and mortality. Thoracotomy and primary repair is adequate surgical treatment.