Postinfarction ventricular septal defect is a serious complication of acute myocardial infarction. Early surgical repair is the treatment of choice. Closure of the septal rupture is a demanding technical problem. We describe our experience with a modified technique to close the defect using a dacron patch, fibrin sealing, and a continuous suture in the undamaged septum. Of 7 patients, five survived. One patient had a small residual VSD. These initial results are encouraging.
Dehiscence of a median sternotomy wound results in significant morbidity and mortality. These wounds are classified into 3 types according to the time of presentation from the original cardiac procedure and the appearance of the wound. The classification gives an indication of the degree of debridement necessary and whether flap reconstruction is required. We describe a series of 54 flaps in 41 patients. These included 27 pectoralis major myocutaneous advancement flaps, 12 pectoralis muscle turnover flaps, 6 rectus abdominus muscle flaps and 9 omental flaps. There was partial loss of one flap. The mortality rate of 8.6% compares favourably with the alternative procedures of open debridement and packing, or closed irrigation.
Creation of a pericardial window using video assisted thoracoscopy (VAT) was successful in 7 of 8 adult patients. Advanced VAT techniques offer an alternative approach for surgical treatment of significant pericardial effusion. In appropriately selected patients, it provides an alternative to standard surgical techniques.
Acute renal failure is common after cardiac surgery and is associated with a high mortality. There are many causes, but renal ischaemia associated with low cardiac output and hypotension, nephrotoxins and sepsis are the most common. Most patients who develop renal failure continue to pass an adequate volume of urine, so urine output is a poor indicator of renal function. Prevention should be based on maintaining circulating blood volume, which requires close haemodynamic monitoring and optimisation of renal oxygen delivery by maintaining an adequate arterial oxygen saturation, haemoglobin concentration, cardiac output and perfusion pressure. Nephrotoxic agents such as gentamicin, vancomycin and indomethacin should be avoided, particularly in patients at increased risk of renal failure. Sepsis must be detected early and treated appropriately. Renal failure requires aggressive nutritional support and careful fluid, electrolyte and acid-base management. This is best done with a continuous form of renal replacement therapy such as venovenous haemofiltration.
Quadricuspid aortic valve is a rare congenital anomaly in isolated form, not generally associated with any functional abnormality. A case report is presented of a patient with severe aortic incompetence and a history of rheumatoid arthritis who was found at surgery to have a quadricuspid aortic valve.
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