Muscle and myocutaneous flaps in reconstructive surgery of thoracic defects.

Reconstructive surgery of thoracic defects presents a challenge for the surgeon. With defects of different aetiology and the need for precise localisation of the area to be treated, a broad range of experience is required. We present our interdisciplinary experience in dealing with full thickness thoracic wall defects and intrathoracic cavities. The latissimus dorsi muscle as well as the pectoralis major muscle and their covering skin are the most commonly used flaps in covering an intrathoracic or extrathoracic defect. They have the advantage of being easily and safely dissected. Other flaps such as the greater omentum, serratus anterior, the transverse rectus abodominal muscle (TRAM), and the filet of the arm are less frequently used. Indications and applications of these flaps are reviewed. Our interdisciplinary surgical treatment of thoracic wall defects allows optimal operative excision and reconstruction as well as giving best functional and aesthetic results for the patients.

Repair of a postinfarct ventricular septal defect on the beating heart. Surgical considerations.

Postinfarct ventricular septal defect (VSD) still remains associated with a high mortality and morbidity. Despite the development of modern surgical techniques and medical care it continues to be a difficult therapeutic challenge. This report describes a case of a 70-year-old female patient, who presented with a postinfarct VSD after having anterior wall infarction. She presented with left heart failure, pulmonary hypertension and left to right shunt of 78% (Qp/Qs=4.3). The patient was operated on using cardiopulmonary bypass on the beating heart. The closure was performed with a Dacron-patch and a single bypass to the diagonal branch using the left internal thoracic artery. Postoperatively the patient did well and was discharged in good condition on the 13th postoperative day. We conclude that postinfarction VSD can be repaired on cardiopulmonary bypass avoiding cross-clamping. This method is helpful for the outcome as well as for the early postoperative recovery of elderly patients.

[The extracorporeal circulation in the treatment of pulmonary diseases]. / Die extrakorporale Kreislaufzirkulation bei der Behandlung von Lungenkrankheiten.

The extracorporeal circulation is seldom used in pulmonary surgery. In this paper, we present some clinical cases and discuss the different indications for extracorporeal circulation in pulmonary diseases. Pulmonary embolectomy and lung transplantation are the main indications for the use of heart-lung-machine. Less frequent indications are oxygen support during whole lung lavage in pulmonary alveolar proteinosis. Lung cancer surgery and other indications for extracorporeal circulation are also discussed.

The impact of hypertension on the operative and early postoperative outcome of aortic valve surgery.

Hypertension is a known risk factor in heart disease. It can lead to pressure overload and hypertrophy of the left ventricle. The aim of this study is to examine the effect of hypertension on the operative and early postoperative outcome after aortic valve surgery using the retrograde cardioplegia. All the data of all the patients who had aortic valve surgery in our department were retrospectively examined during the period from January 1994 until April 1996 and received retrograde blood cardioplegia. 397 patients were included in this study. 213 of them had arterial hypertension, as preoperatively diagnosed by the referring cardiologist. There were 163 females and 234 males. 142 were above 70 yr of age. 22 patients had an ejection fraction (EF) < or =0.4 and in 168 patients the LVEDP was >15 mmHg. Hypertension alone proved to be no risk factor. Decreased EF in hypertensive patients leads to an increase in the occurrence of prolonged ICU-stay, low cardiac output and neurological complications. Hypertension alone does not increase the risk of operative and early postoperative aortic valve surgery.

The impact of normothermia on the outcome of aortic valve surgery.

The purpose of this study was to examine the effects of systemic perfusion temperature on the clinical outcome after aortic valve surgery. In this study, we examined 323 patients who underwent aortic valve surgery between January 1994 and April 1996. Forty-six patients were perfused in moderate hypothermia (28 degrees C) and 277 patients in normothermia. Age and sex distribution of the patients were similar. There were no statistically significant differences between the groups regarding neurological, renal or cardiac complications. Patients in hypothermia required less catecholamine at the end of the operation (p = 0.00001), but there was no significant difference in the length of the stay in the intensive care unit between the groups. Cardiopulmonary bypass temperature did not influence early outcome after aortic valve surgery.

Primary myxoid sarcoma of the pleura: 5 years follow-up.

Primary sarcomas of the pleura are rare intrathoracic tumours. We describe a case of a recurring myxoid pleural sarcoma in a 51-year-old male patient with coronary heart disease, who initially was admitted for coronary revascularization surgery. Tumour diagnosis was based on pathological examination of a biopsy after radiological detection of a nodule in the right upper lobe. The nodule was excised. The first recurrence was diagnosed after 15 months. Pleuropneumonectomy was done. Four years after the first excision further tumour masses appeared above the diaphragm and were surgically removed and adjuvant irradiation carried out. A year later the patient is doing well.

Combination of extracorporeal membrane oxygenation (ECMO) and pulmonary lavage in a patient with pulmonary alveolar proteinosis.

We describe a rare case of pulmonary alveolar proteinosis in a young woman with dyspnea and progressive hypoxaemia due to the alveolar deposition of insoluble, surfactant-like material. Routine treatment includes whole-lung-lavage (WLL) using double-lumen-tubes for selective lavaging of each lung. We performed three whole-lung-lavages and used veno-venous extracorporeal membrane oxygenation (v-vECMO) to support oxygenation during these procedures.

Relationship between position of the coronary sinus catheter and distribution of cardioplegia.

BACKGROUND AND AIMS OF THE STUDY: The use of retrograde cardioplegia is controversial, mainly due to differences in theoretic and methodologic aspects. The aim of this study was to identify an optimal position for the cardioplegia catheter within the coronary sinus. METHODS: Thirteen cadaver hearts was used, and three different catheter positions in the coronary sinus were compared, using a radio-opaque dye which had a viscosity similar to that of blood. The distribution of dye at different segments of the heart was examined. RESULTS: Dye distribution, indicative of cardiac perfusion, was found to be related to the position of the catheter in the coronary sinus and the quantity of dye injected. CONCLUSIONS: This study demonstrated the efficiency of retrograde cardioplegia, and also that optimal positioning of the catheter and the use of high-volume cardioplegia are required concomitantly for successful perfusion.

[Reconstructive plastic surgery of thoracic wall defects]. / Plastische Rekonstruktion von Thoraxwanddefekten.

Full-thickness defects of the thoracic wall following tumor resection, irradiation damage or secondary wound healing in thoracic surgery require early interdisciplinary cooperation to achieve patient-specific treatment modalities. Plastic surgical differential therapy allowing for sufficient soft tissue coverage, stabilisation of the thoracic wall and space filling in intrathoracic cavities, is presented and critically discussed.

Combined congenital pericardial and diaphragmatic defects: a case report.

This report describes the case of a 62-year-old woman who had a preoperative diagnosis of mitral valve insufficiency. At operation her heart was covered by fat which was identified as omental tissue. The pathogenesis, clinical presentation and management of this disorder are presented.