Vacuum-assisted closure in the treatment of a 9-year-old child with severe and multiple dog bite injuries of the thorax.

The vacuum-assisted closure (VAC; KCI International, San Antonio, TX) device is a negative pressure dressing, which we have used in the treatment of wounds with devitalized or infected tissues. Although introduced in plastic and reconstructive surgery, its use has extended to orthopedic and cardiothoracic surgical practice in the treatment of infected joint replacement and sternal wound infections, respectively. Although the VAC is becoming more widely used in surgical practice, only a small number of case reports exist in addition to the original case series by Argenta and Morykwas in 1997. Previously, the device was described in treating single wounds in adult patients. We report a case where it was successfully used to treat multiple dog bite injuries in a 9-year-old child.

Perforation of the right ventricle by a suction drain.

Suction drains can be used as alternatives to conventional underwater seal drains following cardiac surgery, and may be advantageous under some circumstances. The authors present a case where a suction drain eroded into the right ventricle causing near-fatal haemorrhage following coronary artery surgery. Caution should be exercised in taking the decision to use suction drains, the material from which they are manufactured should be chosen carefully, and close attention paid to their positioning within the mediastinum.

Pericardial substitution after cardiopulmonary bypass surgery: a trial of an absorbable patch.

Primary closure of the pericardium affords some protection against adhesion formation and the consequent hazards of resternotomy. However, its completion may be impractical and hazardous, and therefore the pursuit of an ideal pericardial substitute has prompted much research. Twenty calves were divided into 3 groups for the study. All animals underwent right posterolateral thoracotomy. The test group (group X), consisting of 6 animals, received a poly-beta-hydroxybutyrate patch (PHB) to close the pericardium following cardiopulmonary bypass (CPB). In group Y (9 animals) the pericardium was left open following CPB. Group Z (5 animals) also had their pericardium left open but did not undergo CPB (non-CPB). The plasminogen activating activity (PAA) of homogenates of pericardial tissue samples were measured in 5 animals in group X, and 5 in group Z. Samples were taken at three time points from the time of pericardiotomy, and at reoperation 4 weeks later. In group X (CPB) there was a significant reduction in the PAA during the operation with some recovery at reoperation. The reduction in the pericardial PAA of group Z (non-CPB) animals did not reach significance. For both group X and group Z the progress of mesothelial damage, compared with that at zero time, showed a significant increase. In addition, their pericardial inflammatory features became more apparent in the later samples but more significantly in group Z. This study demonstrated no significant short-term differences in adhesion formation or postoperative coronary anatomy visibility between any of the groups. At reoperation the patch material contained pronounced macrophage activity but no regenerative mesothelium. There were no infective episodes in any of the animals studied. Furthermore, this study suggests that CPB in comparison to non-CPB has a significant affect on pericardial PAA.

Aortic valve replacement with the Jyros bileaflet prosthetic valve; early echocardiographic and radiological evaluation.

The Jyros bileaflet prosthetic heart valve has a unique hinge mechanism permitting rotation of the leaflets within the valve ring. Thirty patients undergoing aortic valve replacement with a Jyros valve were assessed clinically, echocardiographically and radiologically. Rotation of the valve in vivo was assessed, as well as the hemodynamic characteristics of the valve at rest and after exercise, and functional capacity of the valve recipients. Measured transvalvar gradients were comparable with other bileaflet valves at rest and after exercise, as were calculated effective orifice areas. Initially only four prostheses (13%) showed any evidence of rotating, but this improved to 14 of 23 investigated (60.9%) after exercise; rotation appears to be more common in smaller valves. There were no operative or early deaths, but one patient died at 11 months from a type A ascending aortic dissection. During a total of 28.5 patient-years of follow up (range 2-24 months) valve related complication has not been reported. All survivors are in good clinical condition. Preliminary results with the Jyros valve compare well with other bileaflet devices for aortic valve replacement; the hemodynamic performance of the valve does not appear to be affected by rotation or non-rotation.

Unidentified retained left atrial myxoma: intra-operative detection by trans-oesophageal echocardiography.

A 73-year-old woman underwent surgery for removal of a large left atrial myxoma diagnosed by transthoracic echocardiogram. At operation a large tumour was removed, and the left atrium and atrial septum closed. Trans-oesophageal echocardiography prior to weaning from cardiopulmonary bypass revealed that a smaller tumour, which had not been detected by visual inspection or palpation, remained within the left atrium. This was removed through the atrial septum, and the operation completed uneventfully. The patient made a full recovery.

Gastropleural fistula following pulmonary resection.

A 77 year old man with an eight month history of polymyalgia rheumatica treated by steroids underwent left lower lobectomy for a non-small cell carcinoma. Following discharge he developed a pneumothorax, empyema, septicaemia, and acute renal failure. Reinvestigation and reoperation showed this to be caused by a non-malignant non-traumatic direct gastropleural fistula.