Successful management of multiple permanent pacemaker complications--infection, 13 year old silent lead perforation and exteriorisation following failed percutaneous extraction, superior vena cava obstruction, tricuspid valve endocarditis, pulmonary embolism and prosthetic tricuspid valve thrombosis.

A 59 year old man underwent mechanical tricuspid valve replacement and removal of pacemaker generator along with 4 pacemaker leads for pacemaker endocarditis and superior vena cava obstruction after an earlier percutaneous extraction had to be abandoned, 13 years ago, due to cardiac arrest, accompanied by silent, unsuspected right atrial perforation and exteriorisation of lead. Postoperative course was complicated by tricuspid valve thrombosis and secondary pulmonary embolism requiring TPA thrombolysis which was instantly successful. A review of literature of pacemaker endocarditis and tricuspid thrombosis along with the relevant management strategies is presented. We believe this case report is unusual on account of non operative management of right atrial lead perforation following an unsuccessful attempt at percutaneous removal of right sided infected pacemaker leads and the incidental discovery of the perforated lead 13 years later at sternotomy, presentation of pacemaker endocarditis with a massive load of vegetations along the entire pacemaker lead tract in superior vena cava, right atrial endocardium, tricuspid valve and right ventricular endocardium, leading to a functional and structural SVC obstruction, requirement of an unusually large dose of warfarin postoperatively occasioned, in all probability, by antibiotic drug interactions, presentation of tricuspid prosthetic valve thrombosis uniquely as vasovagal syncope and isolated hypoxia and near instantaneous resolution of tricuspid prosthetic valve thrombosis with Alteplase thrombolysis.

Changes in potassium concentration and haematocrit associated with cardiopulmonary bypass in paediatric cardiac surgery.

INTRODUCTION: A blood prime is frequently required for paediatric bypass surgery to maintain adequate haematocrit (Hct). However, stored blood can have high extracellular potassium levels and this study aims to investigate the effect of stored blood on the potassium concentration, both in the prime and subsequently in the patient after cardiopulmonary bypass (CPB) has been established. In neonatal surgery, the stored blood may be irradiated if there is a question of impaired immunity. Irradiation may cause a further increase in potassium levels. METHODS: Blood-primed circuits prepared for 320 consecutive paediatric bypass cases were analysed for electrolyte levels, Hct and acid-base status before and immediately after establishment of CPB. Patients were divided into three groups according to body weight (<5kg, 5-10kg and > 10 kg) and both stored blood and irradiated blood primes were compared. RESULTS: The potassium concentration was above the physiological range in all bypass primes pre-CPB and was significantly higher when using irradiated blood (8.12 +/- 2.54 mmol/L versus 4.94 +/- 3.35 mmol/L, p < 0.0001). Despite this, on commencing CPB, the potassium level remained within the physiological range in the majority of patients (4.16 +/- 2.72mmol/L for stored blood prime and 4.55 +/- 1.01mmol/L for irradiated blood, p = 0.02). However, in smaller patients (<5 kg) who had irradiated blood prime potassium level > 7.0 mmol/L, there was resultant hyperkalaemia (5.60 +/-0.90 mmol/L) on commencing CPB, that returned to normal later. No adverse clinical events were associated with the hyperkalaemia. Hct was well maintained on CPB (22-25%) in all groups and was not related to patient weight. CONCLUSION: Blood primes result in high potassium concentrations in the prime fluid that is more severe if irradiated blood is used. The concentration is not sufficient to cause hyperkalaemia in the patients on commencing CPB except when irradiated blood prime is used in infants < 5 kg. Hct is well maintained in all patient groups with the use of blood prime.

D-transposition of the great arteries with an aortopulmonary window: a new corrective technique.

D-transposition of the great arteries with an aortopulmonary window is rare. Five cases have been previously reported. Arterial switch is the procedure of choice. We describe a new method of transferring coronaries making use of the aortopulmonary window and a pericardial patch to form a pouch.

Use the bulla for pneumostasis.

Prolonged air leak following bullectomy is a common problem and increases the morbidity of the procedure and hence the hospital stay for patients. Different surgical methods have been used to decrease the duration of the air leak. One of the common methods is the use of sealant material, synthetic or biological, over which either a stapler or suture closure is made. We report the use of the wall of the resected bulla as a sealant material to achieve pneumostasis with stapler/suture reinforcement, with good results.

Mitral annuloplasty with autologous pericardium and saphenous vein.

Two techniques for constructing annuloplasty rings at the time of surgery are described, using great saphenous vein and autologous pericardium. These rings are easy to make and offer a no-cost alternative to commercially available rings. The long-term performance of such rings has not been determined.