Muscle-sparing thoracotomy: Anatomy and technique.

The thoracotomy incision is essential for many thoracic surgery procedures. A number of different variations exist, and different techniques can be used, depending both on the patient and on the technical factors. The muscle-sparing technique was first described by Noirclerc et al. in 1973. [1] Initially, it was thought that preservation of the muscular structures compared with the results of a traditional posterolateral thoracotomy, in which the latissimus dorsi and sometimes the serratus anterior are often divided, would benefit long-term outcomes.  However, subsequent study results  have not demonstrated any difference in postoperative outcomes. The unequivocal benefit of a muscle-sparing approach is to preserve the latissimus dorsi for any future intervention, such as a procedure involving the chest wall and the intrathoracic flaps. In this video tutorial, we describe our approach to this commonly used incision, including the anatomy and the technical aspects used to provide optimal operative exposure and minimal postoperative complications while preserving the underlying musculature.

A novel approach in managing right-sided haemothorax in neurofibromatosis type 1.

Spontaneous haemothorax due to vasculopathy in patients with neurofibromatosis type 1 is rare but life-threatening. A 56-year-old lady with neurofibromatosis type 1 presented with right-sided chest pain, dyspnoea, and collapse. Computed tomography showed a right-sided hemothorax. Urgent angiography showed contrast leakage from a right subclavian artery pseudoaneurysm. A Gore Viabahn endovascular stent graft was deployed. Completion angiography revealed satisfactory haemostasis. She underwent video-assisted thoracoscopic evacuation of the hemothorax, with good results. This case highlights a novel approach to managing a rare emergency, using combined procedures.

Recurrent chest wall abscesses overlying a pneumonectomy scar: an unusual presentation of a cholecystocutaneous fistula.

We report a case of recurrent chest wall abscesses overlying a right thoracotomy scar four years after a pneumonectomy for a right middle lobe bronchus squamous cell carcinoma. Exploration of the abscess cavities revealed no intra-thoracic or intra-abdominal communication. The patient developed sinuses in his thoracotomy scar and two years later, two gallstones were expelled from these sinuses. A cholecystocutaneous fistula was confirmed on a fistulogram.

Kytococcus schroeteri prosthetic valve endocarditis.

We report the case of a 64-year-old male patient with a prosthetic aortic valve who presented with clinical features of endocarditis confirmed by transoesophageal echocardiography. His blood cultures were positive for a very rare and newly described organism-Kytococcus schroeteri. The patient underwent aortic valve replacement and a 6-week course of intravenous antibiotics. This is the fifth reported case of endocarditis associated with this organism.

Intrapericardial paraganglioma directly irrigated by the right coronary artery.

We present a case of a nonfunctioning intrapericardial paraganglioma that presented as a typical chest pain in a 51-year-old woman. The tumor was initially diagnosed on coronary angiography where it had direct irrigation from the right coronary artery. Further computed tomography and magnetic resonance imaging scans showed significant compression of the superior vena cava by the tumor. This was excised through median sternotomy and extracorporeal circulation. Histopathological examination of the mass was characteristic of a paraganglioma.

Visceral leishmaniasis complicated by fungal pulmonary valve endocarditis.

We present a rare neglected case of fungal pulmonary valve endocarditis which presented with typical extra cardiac manifestations after repeated injections for treatment of visceral leishmaniasis. Surgical intervention to replace the pulmonary valve was the only option to manage the patient in spite of extensive medical treatment.

Multiple left ventricular myxomas arising from the interventricular septum and ventricular trabeculae: a case report.

Myxoma is the most common tumor of the heart, with an estimated incidence of 0.5 to 1 per million per year. The majority of these tumors arise from the left atrium, and 20% arise from the right atrium with the remaining 5% arising in either the right or left ventricle. We present a rare case of multiple myxomas of the left ventricle arising from the interventricular septum and nearby ventricular trabeculae that clinically presented with an occlusion of the left axillary artery. The patient was successfully treated using cardiopulmonary bypass, during which the tumor was completely removed using a transventricular approach.

Aorto-right atrial fistula: a complication of prosthetic aortic valve endocarditis. A case report.

The case presented is of prosthetic aortic valve endocarditis in a 23-year-old male patient, complicated by an inflammatory periprosthetic valvular leak, and fistula formation between the aorta and the right atrium. The fistulous tract was diagnosed intraoperatively. Closure of the fistula was performed successfully in concordance with re-replacement of the aortic valve.

Myocardial revascularization in patients with low ejection fraction < or =35%: effect of pump technique on early morbidity and mortality.

BACKGROUND AND AIM: Left ventricular dysfunction is an important predictor of in-hospital mortality. Surgical risk among these patients remains high. The present study is conducted to evaluate the difference in early morbidity and mortality among patients with compromised left ventricular function (LVF) after myocardial revascularization using either off-pump or on-pump coronary artery bypass graft. METHODS: Between April 2000 and April 2004, 150 patients with ejection fraction (EF) < or =35% underwent isolated coronary artery bypass grafting. Eighty-four patients underwent conventional bypass (mean EF 30.1%+/- 4.2) and 66 patients had off-pump coronary artery bypass (mean EF 27.5%+/- 5.5). Different variables (preoperative, intraoperative, and postoperative) were evaluated and compared. Determination of operation risk was done using EuroSCORE. Patients who underwent OPCAB were more risky due to a high percentage of associated comorbidities, mean EuroSCORE was 12.96 +/- 13.21 in comparison to 8.47 +/- 10.22 in CCAB. RESULTS: The mean operative mortality was 8.7%. Patients who underwent OPCAB had a lower operative mortality than CCAB (6.1% vs. 10.7%) inspite of a higher preoperative predicted risk score. Completeness of revascularization was higher among the CCAB group (85.7% vs. 69.7%; p = 0.01). Subsequently, the mean number of grafts was significantly higher among this group (3.4+/-0.7 vs. 2.0 +/-0.9; p < 0.001). On the other hand, morbidity was significantly higher in CCAB (35.7% vs. 19.7%; p = 0.03). However, the incidence of both myocardial infarction and atrial fibrillation was more among OPCAB. CONCLUSIONS: Patients with left ventricular dysfunction are high-risk group. These patients can benefit from myocardial revascularization using either off-pump or conventional CABG, but both are associated with a higher mortality and morbidity than those with normal ventricle. The use of off-pump CABG resulted in better clinical outcome and mortality, but less number of grafts performed than those with conventional CABG especially in patients with lowest EF.

Congenital circumflex coronary arteriovenous fistula with aneurysmal termination in the pulmonary artery.

Coronary arteriovenous fistula is a rare congenital anomaly that is seen in 0.1 % to 0.2% of coronary angiograms. Aneurysmal formation in the fistula is even rarer. We report a case of congenital circumflex arteriovenous fistula with aneurysmal formation just near its termination in the pulmonary artery, associated with atherosclerotic left anterior descending coronary artery. The anomaly was successfully repaired.