Open heart surgery during pregnancy

Open heart surgery is now more frequently utilized to treat severely disabled pregnant patients with surgically correctable cardiac lesions. Review of the literature and personal communications reveals only 11 pregnant patients undergoing successful surgery involving cardiopulmonary bypass with subsequent delivery of normal infants. Two additional cases are reported from the Yale-New Haven Medical Center. The potential and actual fetal hazards appear multiple, but as yet their precise mechanisms of action remain undetermined.     

Ovarian cancer in the elderly: feasibility of surgery and chemotherapy in 89 geriatric patients

Gynecological oncologists are faced with an increasing proportion of geriatric ovarian cancer patients. Comorbidities are frequently a matter of concern in this age group, and what is adequate treatment for such patients is still debated. The aims of this study were to analyze the feasibility of standard surgery and chemotherapy in a series of elderly ovarian cancer patients (>/=70 years) and to investigate the influence of age (70-75 vs >75 years) on survival. We retrospectively evaluated 89 elderly patients treated at our department between 1985 and 2005. Comorbidities, type of surgical procedure, complications, drugs and schedules of chemotherapy, number of cycles, toxicity, and clinical outcome were registered. Comorbidities were present in 71.9%. Only six patients were inoperable. Among the 83 patients who underwent surgery, 76.4% received adequate surgical treatment. Severe postoperative complications occurred in 16.8%, operative mortality was zero. A total of 801 cycles of chemotherapy were administered to 77 patients (median 10; range 1-38). Overall, G3-G4 toxicity was documented in 61.0%. The rates of dose reduction, treatment delay, and discontinuation were 13.0%, 20.7%, and 3.9%, respectively. Patients who received adequate surgery and those with residual disease <1 cm did significantly better than their counterparts (P= 0.04 and P < 0.001, respectively). No difference in survival according to age (70-75 vs >75 years) was found. Standard surgery and chemotherapy were feasible in elderly ovarian cancer patients. The type of surgery and the amount of residual disease, but not the age of the patients, significantly influenced the clinical outcome.     

T lymphocyte changes in open heart surgery.

To investigate the effect of open heart surgery on T lymphocytes and their subpopulations, 20 patients, who had undergone moderate- to high-dose fentanyl anesthesia and a cardiopulmonary bypass (CPB), were studied using flow cytometry techniques and monoclonal antibodies during and after surgery. The ages of these patients ranged from four to 61 years with eight being male and 12 being female. The disease entity consisted of four with coronary, six with congenital and 10 with valvular heart disease. No cyanotic patients were included in this study. Peripheral blood samples were collected before anesthesia, immediately before the surgical incision, on the first postoperative day (POD1) and on the second postoperative day (POD2), respectively. We found no significant changes in the percentage of total T cells (T3), or helper (T4) and suppressor (T8) T cells during anesthesia before the surgical incision. On POD1, all T lymphocyte subset percentages decreased significantly when compared to pre-operative values (total T cells: 58.4 +/- 12.6 vs 24.4 +/- 8.4, helper T cells: 33.3 +/- 10.1 vs 15.4 +/- 6.3, suppressor T cells: 23.0 +/- 6.4 vs 10.0 +/- 4, all p less than 0.001) but returned to preoperative levels on POD2. Throughout the study period, there were no significant changes in the T helper cell to T suppressor cell ratio. In spite of the transient decrease in T lymphocytes and their subpopulations, no clinical evidence of infection was noted in any patient.(ABSTRACT TRUNCATED AT 250 WORDS)     

Open fetal surgery for myelomeningocele

Despite efforts at prevention through the use of preconception folic acid, spina bifida remains one of the most common congenital anomalies of the central nervous system that is compatible with life. It is, however, associated with a significant degree of lifelong morbidity. The development of open fetal surgery for myelomeningocele (MMC) has been a long process but one that serves as a model for how new procedures and technologies need to be properly evaluated before being brought into mainstream medical practice. Even so, risks and benefits need to be evaluated for each patient. The currently available studies have been carried out on a highly selected patient population where the fetal findings provided the maximum opportunity for benefit from prenatal closure of the MMC defect. There is the potential that as the surgery becomes more widely available, pressure will be brought to bear to perform surgery in cases where the likelihood for benefit is decreased and yet the risks are not. The only way to duplicate the results of the current studies is to follow the methodology and criteria that were used in the studies. This will mean that not every fetus with an MMC will be a candidate for in utero surgery. The balance of risk to benefit will continue to evolve as further technological advances are evaluated and more follow-up information is obtained.     

Breastfeeding an infant after heart transplant surgery.

The case study describes an infant who was diagnosed 24 hours after birth with hypoplastic left heart syndrome, a cognitive malformation of the heart. He received a heart transplant 30 days later. The infant received breast milk before transplant and successfully breastfed after the transplant until the age of 13 months. For the 5 years since the transplant, he has had no complications associated with hypoplastic left heart syndrome.     

Closed heart surgery for congenital heart disease in infancy

Closed heart surgery in congenital heart disease can be palliative or corrective. Palliative surgery aims at improving the physiologic deficit rather than the anatomic defect of the heart. Palliative procedures aim to increase pulmonary blood flow in cyanotic children with decreased pulmonary blood flow (Blalock-Taussig shunt), decrease pulmonary blood flow when there is unrestricted flow (pulmonary artery banding), or improve venous mixing in cyanotic children that require pulmonary and systemic venous mixing for survival (atrial septectomy). The indications for palliation over corrective surgery have changed over time. Now we reserve palliation for children that require low pulmonary vascular resistance for correction, a conduit that will require replacement as the child grows, or where the risk of the corrective procedure decreases rapidly with age. For palliation with systemic to pulmonary artery shunts, we prefer to perform a Blalock-Taussig subclavian to pulmonary artery shunt using a synthetic (PTFE) tube graft in infants. The operative mortality is higher in infants under 1 month of age but is not affected by weight or diagnosis. Palliative surgery to decrease pulmonary blood flow is restricted primarily to infants with large left-to-right shunts where the risk of correction in infancy is high (multiple VSDs) or not feasible (univentricular heart). The operative risk for pulmonary artery banding is affected mostly by the complexity of the cardiac defect and the clinical state of the infant (severe congestive failure) at the time of surgery. A trial septectomy to improve venous mixing is used mostly in infants with univentricular heart in whom a balloon septostomy was ineffective.(ABSTRACT TRUNCATED AT 250 WORDS)     

Uterine-umbilical velocimetry in open heart surgery

The effect of the nonpulsating cardiac pump in uterine and umbilical circulation has not been studied extensively by measuring the resistance of the uterine and umbilical circulation with velocimetry. During open heart surgery, we were able to demonstrate the effects of the nonpulsatile cardiac pump.     

Tolerance to enteral tube feeding diets in hypoalbuminemic critically ill, geriatric patients.

Tolerance of elemental (for example, Peptamen [PEP]) or free amino acid (for example, Vivonex TEN [VIV]) tube feeding diets is controversial, especially in the critically ill patient who is hypoalbuminemic. A prospective, randomized trial was conducted to compare differences between feeding PEP (n = 8) or VIV (n = 8) in critically ill, elderly (average age of 66 years) patients. Diets were administered through nasogastric or postpyloric feeding tubes. Eleven patients had diseases of the gastrointestinal tract; all underwent surgical treatment. Patients were fed each diet at full strength, beginning with 20 to 30 milliliters per hour and advancing by 10 to 20 milliliters every day until goal rate was reached, usually on day 4. Assessment was made for ability to comply with rate of tube feeding ordered, compliance with caloric goal and tolerance (as evidenced by abdominal discomfort and diarrhea). Diarrhea was qualitatively defined as more than three stools per day and then quantitatively as the mean number of stools daily. There were no significant differences between the two groups in terms of compliance with prescribed tube feeding order or caloric goal or the presence of diarrhea and abdominal discomfort. There was a significant difference between the two groups in terms of the actual number of stools per day (PEP equals 1.38 versus VIV equals 2.25, p less than 0.02). Serum albumin concentrations upon initiation of the diets were 2.3 grams per deciliter in both groups. We conclude that tolerance to the two diets were similar because it was possible to feed enterally either PEP or VIV in critically ill, hypoalbuminemic patients (serum albumin concentrations of less than 2.5 grams per deciliter) successfully, irrespective of diet. Although there were more stools in the VIV group, this did not reduce compliance with the goals.     

Pelvic radiation therapy for gynecologic malignancy in geriatric patients

Thirty-one patients, aged 75 years or older, who received pelvic radiation therapy as part of primary treatment for a gynecologic malignancy, were reviewed. Ten patients (32%) failed to complete their treatment and 4 patients (13%) died of treatment-related complications. The treatment-related complications were independent of increasing age, but did correlate closely with the patients' pretreatment ECOG performance status. Ten patients with performance levels of 2 or higher had a mortality rate of 30%, while 70% failed to complete treatment. Treatment fractions of greater than 220 cGy per day also resulted in unacceptably high complication rates. Alternative treatment formats should be considered in geriatric patients with poor initial performance levels.     

Open fetal surgery for life-threatening fetal malformations

After more than two decades of experimental and clinical work, fetal surgery has become an accepted treatment modality for selected fetuses with life-threatening anomalies. Color Doppler ultrasound and ultrafast fetal magnetic resonance imaging have enhanced the accuracy of prenatal evaluation traditionally made by ultrasound alone. Fetal lung masses associated with hydrops are nearly 100% fatal. These lesions can be resected in utero if they are predominantly solid or multicystic. Thoracoamniotic shunting may be effective in the setting of a single large predominant cyst. Fetuses diagnosed with left congenital diaphragmatic hernia before 26 weeks' gestation with liver herniation and a sonographic right lung to head circumference ratio (LHR) of less than one may benefit from fetal tracheal occlusion. Fetal sacrococcygeal teratoma complicated with placentomegaly, hydrops, or progressive high output heart failure may benefit from in utero resection of the tumor. Although preterm labor still remains the Achilles heel of open fetal surgery, effective tocolysis may, in the future, expand the scope of fetal surgery.     

Mitral valve surgery and maternal and fetal outcome in valvular heart disease.

OBJECTIVES: To compare maternal and fetal outcomes in patients with non-operated valvular heart disease and patients who had surgery before or during pregnancy. METHODS: The 308 women with valvular heart disease who delivered in this hospital in the last 8 years were divided into three groups. The 218 (70.7%) women in group 1 had no surgical intervention; the 42 (13.6%) women in group 2 underwent balloon mitral valvotomy during pregnancy; and the 48 (15.5%) women in group 3 had surgical intervention before pregnancy (35 had balloon mitral valvotomy, eight had mitral valve replacement, and five had mitral valve repair). Maternal and fetal outcomes were compared for these three groups. RESULTS: The antenatal events differed significantly: 175 (80.3%), 40 (94.2%), and 46 (95.8%) patients in groups 1, 2 and 3, respectively, had uneventful pregnancies. In group 1, 14 (6.4%) patients had congestive heart failure (P>0.05) and 24 (11%) patients had cardiac arrhythmias, which was statistically significant. The rate of preterm deliveries did not differ significantly among the three groups. The groups did not differ in mean birth weight, mode of delivery, low birth weight, Apgar scores less than 8, stillbirths, neonatal death, or congenital anomalies. CONCLUSIONS: Mitral valve surgery before or during pregnancy did not significantly improve maternal and fetal outcomes but decreased adverse events such as congestive heart failure and cardiac arrhythmias. It should be therefore performed only in selected cases.     

妊娠合并心脏病外科处理策略及微创心脏手术的优势

妊娠期合并风湿性心脏病和先天性心脏病的处理,长期以来一直是妇产科和心脏外科医生所感到棘手的问题[1]。有不少患者结婚前无明显症状而未能查出心脏病,婚后妊娠,因循环负担加重而逐渐出现心慌、气急等症状才得到确诊。随着体外循环技术和微创心脏手术的发展[2,3],目前心脏病变属于手术范围者均能得到可靠的外科治疗。1育龄妇女妊娠期合并心脏病的外科处理策略我国妊娠期合并的心脏病在20世纪80年代以前最多见的是风湿性心脏病[4],最近20余年来随着医疗卫生条件的改善,先天性心脏病所占的比例逐渐增加。对婚前即出现症状的心脏病患者,妊娠…     

Appendectomy in patients undergoing laparoscopic surgery for pelvic pain.

STUDY OBJECTIVE: To evaluate pathologic findings in appendixes of women undergoing laparoscopic surgery for pelvic pain. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: Private practice specializing in gynecologic endoscopic surgery. PATIENTS: One hundred ninety women. INTERVENTION: Prophylactic appendectomy. MEASUREMENTS AND MAIN RESULTS: On pathologic evaluation, 154 appendixes were diagnosed as having one or more abnormal findings, such as endometriosis, carcinoid, chronic appendicitis, periappendicitis, fibrous obliteration, and lymphoid hyperplasia. CONCLUSION: Women undergoing laparoscopic surgery for pelvic pain should be counseled on the high frequency of abnormal findings in the appendix, including endometriosis. Prophylactic appendectomy appears to be a worthwhile consideration in these patients.