Chylothorax after surgery on congenital heart disease in newborns and infants -risk factors and efficacy of MCT-diet

<p>Abstract</p> <p>Objectives</p> <p>To analyze risk factors for chylothorax in infants after congenital heart surgery and the efficacy of median chain triglyceride diet (MCT). To develop our therapeutic pathway for the management of chylothorax.</p> <p>Patients and methods</p> <p>Retrospective review of the institutional surgical database and patient charts including detailed perioperative informations between 1/2000 and 10/2006. Data analyzing with an elimination regression analysis.</p> <p>Results</p> <p>Twenty six out of 282 patients had chylothorax (=9.2%). Secondary chest closure, low body weight, small size, longer cardiopulmonary bypass (242 ± 30 versus 129 ± 5 min) and x-clamp times (111 ± 15 versus 62 ± 3 min) were significantly associated with chylothorax (p < 0.05). One patient was cured with total parenteral nutrition (TPN) and one without any treatment. 24 patients received MCT-diet alone, which was successful in 17 patients within 10 days. After conversion to regular alimentation within one week only one chylothorax relapsed. Out of 7 patients primarily not responsive to MCT-diet, 2 were successfully treated by lysis of a caval vein thrombosis, 2 by TPN + pleurodesis + supradiaphragmatic thoracic duct ligation, one by octreotide treatment, and two patients finally died.</p> <p>Conclusions</p> <p>Chylothorax may appear due to injury of the thoracic duct, due to venous or lymphatic congestion, central vein thrombosis, or diffuse injury of mediastinal lymphatic tissue in association with secondary chest closure. Application of MCT alone was effective in 71%, and more invasive treatments like TPN should not be used in primary routine. After resolution of chylothorax, MCT-diet can be converted to regular milk formula within one week and with very low risk of relapse.</p

Poststenotic aneurysm in a child with native coarctation of the aortic arch

This article contains images taken whilst diagnosing a 12-year old girl who was admitted to hospital because of arterial hypertension, emboli to lower extremities and exertional dyspnea. The patient was operated by using a 18 mm Dacron tube prothesis.peer-reviewe

Implications of fast recovery after left ventricular assist devices implantation

Objectives: The treatment of advanced heart failure patients using continuous-flow left ventricular assist devices (CF-LVAD) has become an established therapy with low mortality and morbidity. However the critically ill patients often require long intensive care and recovery periods. We sought to identify determinants of shorter recovery after LVAD implantation. Methods: 158 patients undergoing primary CF-LVAD implantation were consecutively included in a retrospective analysis regarding time of recovery after implantation. An ICU stay ≤7 days and a total hospitalization ≤30 days were defined as “fast-track” (21 patients) and compared to the remaining patients. Results: The median support duration was 465.1 (± 396.5) days. The patients in the fast-track group were younger (54 vs. 59, p = 0.044), had lower pre-implant creatinine values (1.0 vs. 1.3, p = 0.006) and spent less inpatient days prior to implantation (7 vs. 11, p < 0.001). No difference was observed regarding preoperative liver function (AST: 45 vs. 48, p = 0.715; total bilirubin: 1.1 vs. 1.4, p = 0.217) and weight (195.5 vs. 196.3, P = 0.923). At time of admission end-organ function (creatinine: 1.1 vs. 1.4, p = 0.107; AST: 51 vs. 54, p = 0.948) did not differ. The overall survival of the fast-track patients was favorable compared to the control group (HR: 4.18 (95%CI:1.27 - 4.77). Fig. 1 Conclusion: Heart failure patients with fast-track recovery after CF-LVAD implantation had a favorable long-term outcome. At time of implantation fast-track patients were younger, had lower creatinine levels and a shorter hospitalization prior to implantation. As end-organ functions at time of admission were indifferent an early implant strategy may beneficially affect post LVAD morbidity and mortality

Synthetic material abdominal swabs reduce activation of platelets and leukocytes compared to cotton materials.

During surgical procedures, cotton abdominal swabs with their high absorptive capacity and malleability are used to retain organs and absorb blood or other body fluids. Such properties of the natural material cotton are advantageous for most operations, but in cardiopulmonary bypass (CPB) surgery, a high blood volume can accumulate in the thoracic cavity that is quickly retransfused via the heart–lung machine (HLM). This common practice is supposed to be safe due to the high anticoagulation. However, in vitro analyses showed that blood cells and plasma proteins were activated despite a high anticoagulation, which can propagate especially an inflammatory response in the patient. Thus, we investigated patients’ blood during CPB surgery for inflammatory and coagulation-associated activation after contact to the HLM and either cotton or synthetic abdominal swabs. Contact with cotton significantly increased thrombocyte and neutrophil activation measured as β-thromboglobulin and PMN-elastase secretion, respectively, compared to synthetic abdominal swabs. Both inflammatory cytokines, interleukin (IL) 1β and IL6, were also significantly increased in the cotton over the synthetic patient group, while SDF-1α was significantly lower in the synthetic group. Our data show for the first time that cotton materials can activate platelets and leukocytes despite a high anticoagulation and that this activation is lower with synthetic materials. This additional activation due to the material on top of the activation exerted by the tissue contact that blood is exposed to during CPB surgery can propagate further reactions in patients after surgery, which poses a risk for this already vulnerable patient group

How does the ascending aorta geometry change when it dissects?

OBJECTIVES The purpose of this study is to delineate changes in aortic geometry and diameter due to dissection. BACKGROUND Aortic diameter is the major criterion for elective ascending aortic replacement for dilated ascending aortas to prevent aortic dissection. However, recommendations are made on the basis of clinical experience and observation of diameters of previously dissected aortas. METHODS Six tertiary centers on 2 continents reviewed their acute aortic dissection type A databases, which contained 1,821 patients. Included were all non-Marfan patients with nonbicuspid aortic valves who had undergone computed tomography angiography <2 years before and within 12 h after aortic dissection onset. Aortic geometry before and after dissection onset were compared. RESULTS Altogether, 63 patients were included (27 spontaneous and 36 retrograde dissections, median age 68 [57; 77] years; 54% were men). In all but 1 patient, maximum ascending aortic diameter was <55 mm before aortic dissection onset. The largest increase in diameter and volume induced by the dissection were observed in the ascending aorta (40.1 [36.6; 45.3] mm vs. 52.9 [46.1; 58.6] mm, +12.8 mm; p < 0.001; 124.0 [90.8; 162.5] cm(3) vs. 171.0 [147.0; 197.0] cm(3), +47 cm(3); p < 0.001). Mean aortic arch diameter increased from 39.8 (30.5; 42.6) mm to 46.4 (42.0; 51.6) mm (+6.6 mm; p < 0.001) and descending thoracic aorta diameter from 31.2 (27.0; 33.3) mm to 34.9 (30.9; 39.5) mm (+3.7 mm; p < 0.001). Changes in thoracic aorta geometry were similar for spontaneous and retrograde etiology. CONCLUSIONS Geometry of the thoracic aorta is affected by aortic dissection, leading to an increase in diameter that is most pronounced in the ascending aorta. Both spontaneous and retrograde dissection result in similar aortic geometry changes