Surgical Management of Caseous Calcification of the Mitral Annulus.

Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification; it can manifest with conduction abnormalities or systemic embolization. It typically involves the posterior mitral annulus, and surgery is indicated for severe mitral valve dysfunction, for embolic complications or when the diagnosis is not certain. We describe a structured approach to the surgical management of CCMA using bovine pericardium to repair the defect.

Minimally invasive surgery for cardiac myxomas using an upper hemi-sternotomy and biatrial septal approach.

BACKGROUND: Minimally invasive surgery is pervading all fields of surgery with the principal benefits being: reduced pain, smaller incision, faster recovery, shorter hospital stay and reduced cost. Cardiac surgery is no different. Cardiac myxoma morbidity and mortality depends on early diagnosis, adequate exposure, complete resection, minimal manipulation and unifocal presence. We reviewed our cases of cardiac myxoma excised via an upper hemi-sternotomy with a biatrial septal cardiac approach, to demonstrate this technique as a valid alternative to a full-length median sternotomy. METHODS: From April 1997 to March 1999, one surgeon excised two cardiac myxomas via this minimal technique. Upper hemi-sternotomy was midline without transverse sternal transection. Standard aortobicaval cardiopulmonary bypass and myocardial protection were established with complete tumour excision via a biatrial septal approach commenced in the left atrial dome and extended to the right atrial appendage. RESULTS: Inpatient care was prolonged with cardiorespiratory morbidity a consequence of preoperative co-morbidities. Neither patient required return to theatre and hospital mortality was nil. Patients demonstrated reduced sternal wound pain, reduced length of incision, excellent healing and improvement in New York Heart Association functional class with no evidence of recurrence. CONCLUSIONS: Most proposed benefits of minimally invasive surgery were demonstrated in cardiac myxoma application without significant compromise to patient care and recovery using upper hemi-sternotomy and biatrial septal approach. Cardiac myxoma excision via upper hemi-sternotomy and biatrial septal approach can be achieved without compromise to patient care.

Anaphylaxis to trimethoprim: an under-appreciated risk in acute medical care.

Anaphylaxis is a severe, systemic allergic reaction, which is frequently unexpected and carries a high mortality risk as a medical emergency. Anaphylaxis to trimethoprim is not a well recognized event. Since trimethoprim represents the leading antibiotic for the treatment of urinary tract infections, its potential to cause anaphylaxis needs to be recognized, whether alone or as the 'active' ingredient in cotrimoxazole (trimethoprim-sulphamethoxazole combination), by those prescribing it and those providing acute care. A case of probable anaphylaxis following trimethoprim ingestion is presented with discussion supporting its potency including evidence at an immunological level highlighting its under-appreciated risk in acute medical care.