Resection of left ventricular tumor using videocardioscopy and echocardiography.

Assessment of large cardiac tumors requires careful definition of the extent, cell type, and degree of invasiveness to determine the best operative management. Preoperative magnetic resonance imaging and echocardiography were helpful, but limited in the assessment and management in the case of a 19-year-old pregnant woman with a large (9 x 5.5-cm) left ventricular mass. Intraoperative echocardiography and videocardioscopy facilitated precise operative decisions and management. Successful resection was achieved without the need for cardiac transplantation. This case demonstrates the complexity of the diagnosis and management of large cardiac tumors.

Can a dilated coronary sinus produce left ventricular inflow obstruction? An unrecognized entity.

Drainage of a persistent left superior vena cava to the coronary sinus is a common congenital lesion associated with dilatation of the coronary sinus. We report on 4 cases in which marked enlargement of the coronary sinus was present, immediately superior to and partially occluding the mitral valve, with consequent obstruction to left ventricular inflow. In 1 patient, presenting with cardiac failure in early infancy, this abnormality was the major defect, mimicking the features of cor triatriatum, and surgical correction led to significant symptomatic improvement. In 3 other patients this abnormality was associated with other congenital lesions, and it is postulated that in these cases impairment of flow into the left ventricle in the presence of an atrial septal defect elevated the left atrial pressure and increased the shunt across the atrial septum, thereby increasing the symptoms and clinical findings. Surgical reduction of the enlarged coronary sinus was performed in each case through the interatrial septum, and the technique is described.

The management of aneurysms and arterio-venous fistulae of the popliteal artery arising from war trauma. Emphasis on sigmoid operative approach.

Between 1986-1988, 600 vascular cases arising from the Iran-Iraq conflict were dealt with within an 18 month period and 60 cases of popliteal artery and/or venous disruption were encountered presenting at variable times after injury. A policy of management between the forward and base hospital surgical teams was introduced, observing the following broad categorizations: (a) assessment/referral, (b) assessment/fasciotomy/referral, (c) immediate operation/referral for further operation/review/management. Two types of incision were used to enter the popliteal fossa: (a) a medial incision and (b) a sigmoid posterior incision (which we now favor). The results of this strategy of management and operative technique (when compared with our previous experience within the same time frame) suggested an improved outcome. Fifty-four out of 60 cases had a satisfactory operative result with below-knee amputation being required in only four cases and higher amputations in two others. No operative or postoperative deaths occurred. The implementation of this "vetting policy" at the front line appeared to reduce the number of amputations and assisted the clarification of management criteria in assessing limb viability at the forward hospital when a large number of casualties were being received. Operative access using the sigmoid posterior incision was not associated with any complications, offered better exposure than the medial incision and was technically easier for the surgeon to perform.

Plasma histamine profiles in paediatric cardiopulmonary bypass.

We have previously reported our findings of very high plasma histamine levels in the extracorporeal blood primes of infants undergoing cardiopulmonary bypass (CPB) for correction of congenital cardiac defects and have now extended this enquiry to examine the whole peri-operative period. In this preliminary study, samples of blood for plasma histamine were drawn from a mixed group of congenital cardiac patients featuring varying degrees of cyanosis, differing hypothermic operative conditions and utilising two oxygenator systems. Despite the diversity of this group a common pattern of histamine release emerged with a clear origin at the commencement of bypass, and continuing during the operative period. Our results suggest that priming procedures using stored donor blood provide a major contributing source of histamine release with inevitable deleterious consequences to the post-operative outcome.

The clinical significance of elevated CSF and plasma histamine in cerebral aneurysm surgery utilizing cardiopulmonary bypass with total circulatory arrest.

Recently there has been a renewed interest in the neurosurgical treatment of large cerebral aneurysms and AV malformations utilising cardiopulmonary bypass (CPB) and total circulatory arrest (TCA). However, the differing tolerance limits of coagulation and bleeding, pH control and fluid constraint are difficult to reconcile. Although clinical assessment, electro encephalogram (EEG) and intracranial pressure-monitoring assist in identification of cerebral damage, CPB and TCA inflict their own penalties with resultant uncertainty in post-operative neurological evaluation, and producing difficulties in interpretation and management. Additionally, an unanswered question is, to what extent the known cardiac and cerebral effects of circulating histamine might influence the post-circulatory arrest recovery in these patients, and whether this would further compromise the neurological result. We report our experience of 9 such cases who underwent this procedure, and were able to achieve a satisfactory neurological result in 7 patients with differing lesions. During the operation both CSF (from the open cranium) and blood (from the right internal jugular vein) were sampled at intervals for subsequent plasma histamine estimation. Despite markedly elevated histamine levels during CPB and TCA, this was not associated with an unfavourable neurological outcome. These early findings have given us encouragement to the useful role of CPB and TCA in these complex neurosurgical presentations, and raise interesting questions about the clinical importance of histamine-evoked cerebral ischaemia that has been demonstrated in experimental models.

Some studies on the isolation and properties of pulmonary mast cells from the pig.

Mast cells were isolated by the enzymic dissociation of lung tissue from the pig. The responses of these cells to a variety of histamine liberators and anti-allergic drugs were examined. On the basis of these findings, the possible use of porcine pulmonary mast cells in the study of immediate hypersensitivity reactions is discussed.

Histamine release in paediatric cardiopulmonary bypass--a possible role in the capillary leak syndrome.

Recent studies have reported pathologically elevated plasma histamine levels in adult patients during and after open heart surgery. In paediatric practice, the increased use of donor-blood primes might be expected to produce even greater rises in the histamine levels, by creating histamine release in the prime before initial perfusion commences. The present study covered 40 arbitrarily chosen paediatric cases. Pathologically elevated plasma histamine levels (greater than 1 ng/ml) were found in the prime of 26 out of 37 cases (73%). Histamine levels were substantially higher than levels encountered in previously reported studies, and massively elevated prime histamine levels (greater than 80 ng/ml) were encountered in 9 out of the 40 cases (22%). These results suggest that in conventional paediatric cardiac surgical practice, the prime content of histamine is markedly elevated in the majority of patients. The inevitable delivery of this prime histamine load at the onset of perfusion might be expected to produce systemic pathological effects.

Management of difficult intracranial aneurysms by deep hypothermia and elective cardiac arrest using cardiopulmonary bypass.

Giant anterior circulation aneurysms and some basilar aneurysms can cause problems due to their size, the presence of clot in the aneurysm and the difficulty of applying a clip without kinking the perforating vessels. By utilising cardiopulmonary bypass via the femoro-femoral perforating vessels. By utilising cardiopulmonary bypass via the femoro-femoral route the patient can be cooled to below 20 degrees C allowing the circulation to be stopped for up to 3/4 hour. This will enable the neurosurgeon to unhurriedly dissect out the aneurysm without fear of rupture and where necessary open the aneurysm to remove clot and clip the aneurysm. By draining the circulating volume into the venous reservoir of the pump, a large aneurysm may collapse thus enabling it to be clipped more easily. It is, therefore, a useful technique for difficult aneurysms. We present here a series of 11 patients who underwent this procedure with excellent results in 7. All patients had aneurysms which would otherwise have been either inoperable or very risky to tackle.