A challenging case of emergency redo surgery for acute type A aortic dissecting aneurysm of ascending and aortic arch with frozen elephant trunk following aortic root replacement.

Redo ascending and aortic arch surgeries following previous cardiac or aortic surgery are associated with high risk of morbidity and mortality due to multiple factors included sternal re-entry injury, extensive aortic arch surgery, emergency aortic surgery, prolonged cardiopulmonary bypass duration, poor heart function, and patients with older age. Therefore, appropriate surgical strategies are important. We report a case of a 72-year-old gentleman with previous surgery of aortic root replacement who presented with acute Type A aortic dissecting aneurysm of ascending and aortic arch complicated with left hemothorax, which was successfully treated by emergency redo aortic surgery with frozen elephant trunk (FET) technique.

Transapical valve-in-ring mitral valve implantation through the anterior mitral valve leaflet.

Transcatheter mitral valve implantation (TMVI) is a relatively novel intervention used to replace the mitral valve of individuals deemed too high risk or unsuitable for surgery. It is associated with a number of specific risks, including left ventricular outflow tract obstruction (LVOTO).  In this video tutorial we present the case of a 75-year-old man who was unable to undergo redo surgical repair and had a number of risk factors for LVOTO. To minimize these risks, we deployed the TMVI within the anterior mitral valve leaflet. The postoperative result was mild mitral valve regurgitation and no LVOTO.  The long-term outcome of this approach is yet to be determined but we believe this technique offers a novel method to manage a select group of patients suffering with mitral valve disease and at risk of LVOTO.

Staged carotid endarterectomy under local anaesthetic in patients requiring cardiac surgery.

INTRODUCTION: There is no clear guidance as to the management of carotid stenotic disease prior to cardiac surgery. We aimed to review the results of a single centre performing carotid endarterectomy (CEA) under local anaesthesia prior to cardiac surgery. PATIENTS AND METHODS: All patients referred for cardiac surgery in our tertiary referral unit between January 1998 and August 2008 were identified and data relating to those 100 undergoing CEA prior to cardiac surgery were reviewed. Eighty had coronary artery bypass grafting (CABG) alone, 15 combined valve surgery and CABG and three underwent isolated valve surgery. Two patients died prior to cardiac surgery. RESULTS: One hundred patients were prospectively identified after screening by clinical features and carotid duplex scanning to require CEA from a total of 11,394. The stroke rate was 1% between CEA and cardiac surgery, 2% following cardiac surgery and 3% in total. Ninety-eight patients proceeded to cardiac surgery (two deaths post-CEA). The cumulative event rate (stroke, myocardial infarct [included in view of the nature of the patients in our cohort] and/or death) was 10.2% following all cardiac surgery (CABG and valve). In 80 patients undergoing CABG only, the cumulative event rate was 7.5% after CABG. Including the two deaths pre-cardiac surgery, the rates were 12% and 8%. The risk of peri-operative stroke and 30-day mortality were reduced to that of patients undergoing cardiac surgery without significant carotid arterial disease, 3% versus 3.3% and 5.1% versus 6.5%, respectively. CONCLUSIONS: This study demonstrates that a policy of selective screening for significant carotid artery disease in cardiac surgical patients combined with a strategy of CEA under local anaesthesia prior to unselected cardiac surgery (CABG with or without valve surgery) leads to rates of peri-operative CVA, myocardial infarction and death comparable to rates published for CEA prior to isolated CABG surgery. Furthermore, it reduces the risk of peri-operative stroke and 30-day mortality to that observed in patients undergoing cardiac surgery without significant carotid arterial disease.

Ambulatory intercostal drainage for the management of malignant pleural effusion: a single center experience.

BACKGROUND: Malignant pleural effusions are common and can be difficult to manage. We have reviewed our use of ambulatory drains (Pleurex drains) in this regard with particular reference to hospital stay, duration of drainage, and incidence of complications. MATERIALS AND METHODS: Of 125 patients with malignant pleural effusion with trapped lung or failed previous pleurodesis who underwent insertion of ambulatory pleural drain, 41 patients were under local anesthesia and 84 patients were under general anesthesia. Mean age was 66.5 years with male:female = 80:45. Data were collected retrospectively from the clinical notes, and the family doctors' clinics were contacted to enquire about the patients' survival. RESULTS: When data collection concluded, 48 patients (38.4%) had died, giving mean survival following drain insertion of 84.1 days. There were no in-hospital deaths related to the procedure. One procedure was converted to a mini-thoracotomy to control bleeding from a lung tear. Mean duration of catheter placement was 87.01 days (5-434). Video-assisted thoracoscopic surgery was used in 77 patients (61.6%), and Seldinger's technique was used in 48 patients (38.4%). Mesothelioma was the most common malignant cause. Minor complications were encountered in 15 patients (12%), and they were managed as outpatients. CONCLUSION: The use of ambulatory pleural catheters for managing malignant pleural effusion is a safe and effective strategy. It has only minor complications that are related to prolonged drainage. We feel that this strategy should be considered the first choice option for these patients.

Stented esophageal transfixion injury.

Esophageal perforation is a rare, but life-threatening condition with a mortality rate ranging between 10% and 40%. It can happen at the level of the cervical, intrathoracic, or intra-abdominal segment. It usually occurs as a result of iatrogenic injury after endoscopic procedures or as a spontaneous rupture. It is seen less frequently in trauma after gunshot or stab wounds. Stenting of the esophagus after iatrogenic perforation is well documented in the literature, but yet it is to be published for management of penetrating injury. We report a case of esophageal perforation with a wooden fence post treated successfully with a covered esophageal stent.

Recuento histórico de los programas de especialización médica en Colombia / Reminiscences of graduate medical training in Colombia

Se hace un relato histórico de cómo fue el desarrollo en los sistemas de formación del médico para alcanzar la meta de ser un especialista en el campo de su elección, en las décadas de 1940 hasta 1992, año en el cual se organiza por el Gobierno Nacional el servicio público de la Educación Superior, Ley 30 de 28 de diciembre de 1992.

Historical portrayal of how the formation of higher medical education, post-graduated specialties, developed in Colombia, dating from 1940 until 1992. In 1992 the Colombian government organizes Higher Medical Education by Law N° 30 passed on the 28 of December of 1992. In the article the author expresses how more organized this education may have become it may have lost some of its mystic and ethical vitality.

Prevalencia de limitaciones físicas en la población de Cali / Prevalence of physical limitations in the population of Cali

Con base en una muestra probabilística en Cali de 2 248 viviendas (2 473 familias, 12 532 personas), se encontró una tasa general de limitados de 43 por mil, 48 para hombres y 39 para mujeres. La limitación se da en todas las edades y la tasa aumenta a medida que se incrementa la edad. Con referencia al nivel socioeconómico se encontró una tasa de 30 por mil en el nivel alto, 37 en el medio y 51 en el bajo. El total de limitados en la muestra fue 537, con una mortalidad distribuida así: visión, 21.3%; audición, 11.3%; problemas de lenguaje y de aprendizaje, 10.3%; retardo, mongolismo y parálisis cerebral, 8.4%; problemas ortopédicos, 7.3%; amputados, 6%; alcoholismo y drogadicción, 5%; otros problemas del sistema nervioso central, 4%; enfermedades reumáticas, 4%; y enfermedades cardiopulmonares, 2.7%. Dijeron recibir algún tipo de atención médica 34% de los limitados y las causas alegadas para no recibirla fueron: factores económicos, 49%; falta de interés, motivación o descuido, 29%; porque "no había nada que hacer", 6.4%