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Successful myocardial volume reduction in a 9-month-old infant
Ann Thorac Surg 2000;69:1253–5
On postoperative day 6, he was returned to the operating room for repair of his aortic transection. Utilizing left atrial to femoral artery partial bypass, the aortic transection was repaired with a 26-mm Dacron (C. R. Bard, Haverhill, PA) graft. Aortic cross-clamp time was 26 minutes. The patient awakened neurologically intact and was extubated on postoperative day 1. He was transferred out of intensive care and discharged to rehabilitation on postoperative day 10. He remains well 6 months later.
Comment Blunt disruption of the descending thoracic aorta is not uncommon in high-speed deceleration accidents [1]. The mortality associated with this lesion remains high, with 80% of patients succumbing to injury in the field and another 15% expiring in the hospital. Traumatic disruption of the aortic valve is much less common. Initially described in 1830 [2], aortic valve injury occurs as severe increases in intrathoracic pressure are transmitted across the closed valve during early diastole. Before the creation of reliable aortic valve prostheses, aortic valve repair was the technique of choice for traumatic aortic insufficiency [3]. However, long-term results with primary repair have been disappointing [4]. A reliable result has been obtained with prosthetic aortic valve replacement, and this method is currently the procedure of choice[5, 6]. Simultaneous injury to the aortic valve and descending thoracic aorta has been reported once previously [7]. The critical issue is the appropriate timing of surgical intervention for concurrent injuries. Intraabdominal injuries with ongoing hemorrhage require immediate attention. During laparotomy, patients with new murmurs or with radiography suggestive of aortic injury may benefit from evaluation with TEE [8]. The effectiveness of TEE in assessing aortic valve and descending aortic pathology is superb. Greater experience with TEE in this patient population may eventually obviate the need for invasive diagnostic procedures. Patients, who are hemodynamically stable despite acute aortic insufficiency, should have their transection corrected first. The use of left-heart bypass during this repair assists in maintaining hemodynamic stability by unloading the heart during a period of aortic cross-clamping. In the setting of florid heart failure, urgent aortic valve replacement may take precedence over repair of the aortic transection. Medical management of traumatic aortic transection is required in the patient with multiple, life-threatening injuries [9]. Aggressive -blockade and afterload reduction can minimize the risk of complete aortic disruption, while severe intraabdominal or intracranial trauma is attended to. The appropriate sequence of surgical repair should be dictated by the patients’ clinical condition.
References 1. Sturm JT, McGee MB, Luxenberg MG. An analysis of risk factors for death at the scene following traumatic aortic rupture. J Trauma 1988;28:1578– 80. 2. Penderleath D. Case of death from rupture of one of semilunar valves of the aorta. London Medical Gazette 1830;7:109. © 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CASE REPORT VRICELLA ET AL MYOCARDIAL VOLUME REDUCTION IN INFANT
1253
3. Beall AC, Shirkey AL. Successful surgical correction of traumatic aortic valve regurgitation. JAMA 1964;187:507–10. 4. Pretre R, Faidutti B. Surgical management of aortic valve injury after nonpenetrating trauma. Ann Thorac Surg 1993;56: 1426–31. 5. Devineni R, McKenzie FN. Avulsion of a normal aortic valve cusp due to blunt chest injury. J Trauma 1984;24:910–2. 6. Munshi IA, Barie PS, Hawes AS, et al. Diagnosis and management of acute aortic valvular disruption secondary to rapid-deceleration trauma. J Trauma 1996;41:1047–50. 7. Paone RF, Kidd JN, Dobrin DJ, et al. Traumatic aortic incompetence associated with transection of the thoracic aorta. Chest 1996;109:1118 –9. 8. Shapiro MJ, Yanofsky SD, Trapp J, et al. Cardiovascular evaluation of blunt thoracic trauma using transesophageal echocardiography. J Trauma 1991;31:835– 40. 9. Pate JW, Gavant ML, Weiman DS, Fabian TC. Traumatic rupture of the aortic isthmus. World J Surg 1999;23:59– 63.
Successful Myocardial Volume Reduction in a 9-Month-Old Infant Luca A. Vricella, MD, Steven R. Gundry, MD, Ranae L. Larsen, MD, and Leonard L. Bailey, MD Division of Cardiothoracic Surgery, Loma Linda University Medical Center and Children’s Hospital, Loma Linda, California
Left ventricular reduction has shown promise as a treatment for end-stage dilated cardiomyopathy, with restoration of the physiologic ratio between myocardial mass and left ventricular diameter. We present a case of successful partial left ventriculectomy utilizing both lateral and septal wall excision as treatment of dilated cardiomyopathy in a 9-month-old patient. (Ann Thorac Surg 2000;69:1253–5) © 2000 by The Society of Thoracic Surgeons
L
eft ventricular reduction has shown promise as a treatment for end-stage dilated cardiomyopathy, with restoration of the physiologic ratio between myocardial mass and left ventricular diameter. We present a case of successful partial left ventriculectomy utilizing both lateral and septal wall excision as treatment of dilated cardiomyopathy in an infant. A 9-month-old, 7.6-kg female developed progressive dilated cardiomyopathy diagnosed at 6 months of age, requiring hospitalization for congestive heart failure and transcatheter coil embolization of patent ductus arteriosus. Etiologic workup of cardiomyopathy was unremarkable. Physical examination was significant for a 2/6 systolic murmur over the cardiac apex and marked hepatomegaly. Chest roentgenograms demonstrated cardiomegaly and mild pulmonary edema; electrocardiogram was significant for biventricular hypertrophy. Endomycardial biopsy did not show histologic evidence of myocarditis.
Accepted for publication Aug 12, 1999. Address reprint requests to Dr Gundry, Division of Cardiothoracic Surgery, Loma Linda University Medical Center, 11234 Anderson Ave, Loma Linda, CA 92354.
0003-4975/00/$20.00 PII S0003-4975(00)01157-7
1254
CASE REPORT VRICELLA ET AL MYOCARDIAL VOLUME REDUCTION IN INFANT
Ann Thorac Surg 2000;69:1253–5
Fig 1. Intraoperative photograph. The lateral wall of the left ventricle has been excised as well as the apical septum. Mild subendocardial fibroelastosis of the left ventricle is evident. (AC ⫽ aortic cannula; IVS ⫽ interventricular septum; LV ⫽ left ventricular free wall; RV ⫽ right ventricular free wall; VC ⫽ venous cannula.)
The therapeutic regimen included digitalis, furosemide, and captopril. Preoperative transthoracic echocardiogram (without any inotropic support) showed ejection fraction of 25%, fractional shortening of 9%, and left ventricular systolic and diastolic diameter of 4.3 and 3.7 cm, respectively. Moderate mitral valve regurgitation was noted. Because of progressive clinical deterioration, surgical options were reviewed, and the patient’s family declined cardiac transplantation. On December 2, 1996, the patient underwent partial ventriculectomy with DeVega mitral annuloplasty and Alfieri mitral valvuloplasty. The left ventriculectomy was performed in the posterolateral wall of the left ventricle, between the anterior and posterior papillary muscles; this was carried to the mitral valve annulus, and extended to the apex and well into the interventricular septum (Fig 1). Twelve grams of myocardium (4.5 ⫻ 4.0 cm) were excised, and closure of the ventriculectomy and the apical septum were both accomplished primarily with a continuous 3-0 vicryl suture. Pericardial pledgets were used in the closure of the posterolateral wall of the left ventricle. The patient was easily weaned from cardiopulmonary bypass on low-dose dopamine and isoproterenol. The postoperative course was complicated by an apical ventricular septal defect secondary to dehiscence of the septal suture line, requiring reoperation with primary closure on postoperative day 15. Shortly after the procedure, the patient manifested mental obtundation. The patient had developed marked systolic hypertension, which necessitated aggressive antihypertensive therapy and was ultimately controlled with calcium antagonists. Computerized tomogram of the head revealed no evidence of focal lesions. With control of the high-output state, mental obtundation slowly resolved. The patient was eventually discharged on postoperative day 47, with no evidence of neurologic sequelae at 1-month followup. Predismissal echocardiography showed an ejection
Fig 2. Two-dimentional echocardiogram showing (A) preoperative and (B) postoperative left ventricular diameter at the time of mitral valve closure. (Ao ⫽ aorta; IVS ⫽ interventricular septum; LA ⫽ left atrium; LV ⫽ left ventricle; MV ⫽ mitral valve; PLVW ⫽ posterior left ventricular wall.)
fraction of 50%, fractional shortening of 21%, and left ventricular diastolic and systolic diameter of 3.3 and 2.7 cm, respectively, without mitral valve regurgitation (Figs 2 and 3). Slow deterioration in left ventricular function secondary to endocardial fibroelastosis and development of nonfixed pulmonary hypertension led to orthotopic cardiac transplantation 12 months later. The child is alive and well 2 years after transplantation.
Comment Idiopathic dilative cardiomyopathy (IDC) is one of the most frequent indications for cardiac transplantation in the pediatric age group [1, 2]. According to the registry of the International Society for Heart and Lung Transplantation, IDC was the indication for cardiac transplantation in 40.9% of patients between the ages of 0 and 15 years [3]. The natural history of this disease is often character-
Ann Thorac Surg 2000;69:1255–7
CASE REPORT AL-SOFYANI ET AL CERVICAL MEDIASTINOSCOPY METASTASIS
1255
improve with time. Accurate patient selection will be of utmost importance, perhaps reserving this treatment modality for those patients who have the least likelihood of improvement over time, or in whom cardiac transplantation may be contraindicated.
References
Fig 3. (A) Preoperative and (B) postoperative M-mode echocardiographic tracings. (IVS ⫽ interventricular septum; LV ⫽ left ventricular wall; PLVW ⫽ posterior left ventricular wall.)
ized by progressive deterioration, in particular for children beyond 2 years of age [4, 5]. Diminished myocardial contractility in the setting of IDC is perhaps the one variable most frequently associated with poor outcome [2, 6], and should prompt evaluation for early transplantation or other interventions. Cardiac transplantation, eventually “bridged” by a ventricular assist device or extracorporeal membrane oxygenation, is currently the only viable long-term therapeutic option for IDC once medical therapy has failed. The scarce availability of organ donors makes the search for alternative sources imperative. Partial left ventriculectomy, as recently reported by Batista and associates, aims at restoring the physiologic ratio between myocardial mass and left ventricular diameter, leading to improvement in cardiac performance [7]. This report represents a unique case of cardiac volume reduction performed in an infant. The patient’s hemodynamic improvement, as noted by comparison of pre- and postoperative M-mode and D-mode echocardiograms, is shown in Figures 2 and 3. Decrease in systolic and diastolic left ventricular diameter, as well as improved contractility, are evident. In the case reported, we observed a very pronounced hyperdynamic state in the early postoperative period, characterized by marked systolic hypertension and mental obtundation deteriorating into a true comatose state, eventually resolving. This response appears strikingly similar to that not infrequently observed after transplantation of oversized donor hearts, the so-called “big-heart syndrome” [8]. This pathophysiologic similarity points to calcium antagonist or beta-blockade therapy as potentially beneficial in these patients, to avoid neurological sequelae. In conclusion, partial left ventriculectomy may be a bridging technique or, perhaps, even a definitive treatment in those patients with stable but symptomatic cardiomyopathy or those with deteriorating disease who, heretofore, depend on organ transplant as their only hope for survival. Myocardial reduction may also benefit those patients with etiologically proved dilated cardiomyopathy (myocarditis, metabolic, toxic, etc) who fail to © 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
1. Dec GW, Fuster V. Idiopathic dilated cardiomyopathy. N Engl J Med 1994;331:1564–75. 2. Chan DP, Allen HD. Dilated congestive cardiomyopathy. In: Moss AJ, Adams FH, eds. Heart disease in infants, children and adolescents, 5th ed, vol 2. Baltimore: Williams & Wilkins, 1995:1365– 81. 3. Hosenpund JD, Novick RJ, Bennett LE, Keck BM, Fiol B, Daily OP. The registry of the International Society for Heart and Lung Transplantation: thirteenth official report—1996. J Heart Lung Transplant 1996;15:655–74. 4. Griffin ML, Hernandez A, Martin TC, Goldring D, Bolman RM, Spray TL et al. Dilated cardiomyopathy in infants and children. J Am Coll Cardiol 1988;11:139– 44. 5. Burch M, Siddiqui SA, Celermajer DS, Scott C, Bull C, Deanfield JE. Dilated cardiomyopathy in children. Determinants of outcome. Br Heart J 1994;72:246 –50. 6. Lewis AB, Chabot M. Outcome of infants and children with dilated cardiomyopathy. Am J Cardiol 1991;68:365–9. 7. Batista RJ, Santos JL, Takeshita N, Bocchino L, Lima PN, Cuhna MA. Partial left ventriculectomy to improve left ventricular function in end stage heart disease. J Cardiol Surg 1996;11:96–7. 8. Reichart B. Size matching in heart transplantation. J Heart Lung Transplant 1992;11(4 Pt 2):S199 –202.
Cervical Mediastinoscopy Incisional Metastasis Medhat Al-Sofyani, MD, Donna E. Maziak, MDCM, and Farid M. Shamji, MD Division of Thoracic Surgery, University of Ottawa, Ottawa Hospital, Ottawa, Ontario, Canada
Tumor deposit in the cervical mediastinoscopy incision is a rare complication of this operation when it is done to stage lung cancer. The etiology of this complication remains unclear. We present the case of a patient with this condition, discuss the cause and management, and review the literature. (Ann Thorac Surg 2000;69:1255–7) © 2000 by The Society of Thoracic Surgeons
C
ervical mediastinoscopy has become a routine staging operation for the assessment of mediastinal nodes in lung cancer. One of the rare complications of mediastinoscopy is tumor metastasis in the neck incision. We report such a case and review the literature. A 51-year-old man was seen with cough, hemoptysis, and fatigue. Chest roentgenographic examination revealed a right lower lobe mass. A computed tomographic scan of Accepted for publication Sep 30, 1999. Address reprint requests to Dr Maziak, Ottawa Hospital—Civic Campus, 1053 Carling Ave, CPC Room 162, Ottawa, ON, Canada K1Y 4E9.
0003-4975/00/$20.00 PII S0003-4975(00)01461-7
On postoperative day 6, he was returned to the operating room for repair of his aortic transection. Utilizing left atrial to femoral artery partial bypass, the aortic transection was repaired with a 26-mm Dacron (C. R. Bard, Haverhill, PA) graft. Aortic cross-clamp time was 26 minutes. The patient awakened neurologically intact and was extubated on postoperative day 1. He was transferred out of intensive care and discharged to rehabilitation on postoperative day 10. He remains well 6 months later.
Comment Blunt disruption of the descending thoracic aorta is not uncommon in high-speed deceleration accidents [1]. The mortality associated with this lesion remains high, with 80% of patients succumbing to injury in the field and another 15% expiring in the hospital. Traumatic disruption of the aortic valve is much less common. Initially described in 1830 [2], aortic valve injury occurs as severe increases in intrathoracic pressure are transmitted across the closed valve during early diastole. Before the creation of reliable aortic valve prostheses, aortic valve repair was the technique of choice for traumatic aortic insufficiency [3]. However, long-term results with primary repair have been disappointing [4]. A reliable result has been obtained with prosthetic aortic valve replacement, and this method is currently the procedure of choice[5, 6]. Simultaneous injury to the aortic valve and descending thoracic aorta has been reported once previously [7]. The critical issue is the appropriate timing of surgical intervention for concurrent injuries. Intraabdominal injuries with ongoing hemorrhage require immediate attention. During laparotomy, patients with new murmurs or with radiography suggestive of aortic injury may benefit from evaluation with TEE [8]. The effectiveness of TEE in assessing aortic valve and descending aortic pathology is superb. Greater experience with TEE in this patient population may eventually obviate the need for invasive diagnostic procedures. Patients, who are hemodynamically stable despite acute aortic insufficiency, should have their transection corrected first. The use of left-heart bypass during this repair assists in maintaining hemodynamic stability by unloading the heart during a period of aortic cross-clamping. In the setting of florid heart failure, urgent aortic valve replacement may take precedence over repair of the aortic transection. Medical management of traumatic aortic transection is required in the patient with multiple, life-threatening injuries [9]. Aggressive -blockade and afterload reduction can minimize the risk of complete aortic disruption, while severe intraabdominal or intracranial trauma is attended to. The appropriate sequence of surgical repair should be dictated by the patients’ clinical condition.
References 1. Sturm JT, McGee MB, Luxenberg MG. An analysis of risk factors for death at the scene following traumatic aortic rupture. J Trauma 1988;28:1578– 80. 2. Penderleath D. Case of death from rupture of one of semilunar valves of the aorta. London Medical Gazette 1830;7:109. © 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CASE REPORT VRICELLA ET AL MYOCARDIAL VOLUME REDUCTION IN INFANT
1253
3. Beall AC, Shirkey AL. Successful surgical correction of traumatic aortic valve regurgitation. JAMA 1964;187:507–10. 4. Pretre R, Faidutti B. Surgical management of aortic valve injury after nonpenetrating trauma. Ann Thorac Surg 1993;56: 1426–31. 5. Devineni R, McKenzie FN. Avulsion of a normal aortic valve cusp due to blunt chest injury. J Trauma 1984;24:910–2. 6. Munshi IA, Barie PS, Hawes AS, et al. Diagnosis and management of acute aortic valvular disruption secondary to rapid-deceleration trauma. J Trauma 1996;41:1047–50. 7. Paone RF, Kidd JN, Dobrin DJ, et al. Traumatic aortic incompetence associated with transection of the thoracic aorta. Chest 1996;109:1118 –9. 8. Shapiro MJ, Yanofsky SD, Trapp J, et al. Cardiovascular evaluation of blunt thoracic trauma using transesophageal echocardiography. J Trauma 1991;31:835– 40. 9. Pate JW, Gavant ML, Weiman DS, Fabian TC. Traumatic rupture of the aortic isthmus. World J Surg 1999;23:59– 63.
Successful Myocardial Volume Reduction in a 9-Month-Old Infant Luca A. Vricella, MD, Steven R. Gundry, MD, Ranae L. Larsen, MD, and Leonard L. Bailey, MD Division of Cardiothoracic Surgery, Loma Linda University Medical Center and Children’s Hospital, Loma Linda, California
Left ventricular reduction has shown promise as a treatment for end-stage dilated cardiomyopathy, with restoration of the physiologic ratio between myocardial mass and left ventricular diameter. We present a case of successful partial left ventriculectomy utilizing both lateral and septal wall excision as treatment of dilated cardiomyopathy in a 9-month-old patient. (Ann Thorac Surg 2000;69:1253–5) © 2000 by The Society of Thoracic Surgeons
L
eft ventricular reduction has shown promise as a treatment for end-stage dilated cardiomyopathy, with restoration of the physiologic ratio between myocardial mass and left ventricular diameter. We present a case of successful partial left ventriculectomy utilizing both lateral and septal wall excision as treatment of dilated cardiomyopathy in an infant. A 9-month-old, 7.6-kg female developed progressive dilated cardiomyopathy diagnosed at 6 months of age, requiring hospitalization for congestive heart failure and transcatheter coil embolization of patent ductus arteriosus. Etiologic workup of cardiomyopathy was unremarkable. Physical examination was significant for a 2/6 systolic murmur over the cardiac apex and marked hepatomegaly. Chest roentgenograms demonstrated cardiomegaly and mild pulmonary edema; electrocardiogram was significant for biventricular hypertrophy. Endomycardial biopsy did not show histologic evidence of myocarditis.
Accepted for publication Aug 12, 1999. Address reprint requests to Dr Gundry, Division of Cardiothoracic Surgery, Loma Linda University Medical Center, 11234 Anderson Ave, Loma Linda, CA 92354.
0003-4975/00/$20.00 PII S0003-4975(00)01157-7
1254
CASE REPORT VRICELLA ET AL MYOCARDIAL VOLUME REDUCTION IN INFANT
Ann Thorac Surg 2000;69:1253–5
Fig 1. Intraoperative photograph. The lateral wall of the left ventricle has been excised as well as the apical septum. Mild subendocardial fibroelastosis of the left ventricle is evident. (AC ⫽ aortic cannula; IVS ⫽ interventricular septum; LV ⫽ left ventricular free wall; RV ⫽ right ventricular free wall; VC ⫽ venous cannula.)
The therapeutic regimen included digitalis, furosemide, and captopril. Preoperative transthoracic echocardiogram (without any inotropic support) showed ejection fraction of 25%, fractional shortening of 9%, and left ventricular systolic and diastolic diameter of 4.3 and 3.7 cm, respectively. Moderate mitral valve regurgitation was noted. Because of progressive clinical deterioration, surgical options were reviewed, and the patient’s family declined cardiac transplantation. On December 2, 1996, the patient underwent partial ventriculectomy with DeVega mitral annuloplasty and Alfieri mitral valvuloplasty. The left ventriculectomy was performed in the posterolateral wall of the left ventricle, between the anterior and posterior papillary muscles; this was carried to the mitral valve annulus, and extended to the apex and well into the interventricular septum (Fig 1). Twelve grams of myocardium (4.5 ⫻ 4.0 cm) were excised, and closure of the ventriculectomy and the apical septum were both accomplished primarily with a continuous 3-0 vicryl suture. Pericardial pledgets were used in the closure of the posterolateral wall of the left ventricle. The patient was easily weaned from cardiopulmonary bypass on low-dose dopamine and isoproterenol. The postoperative course was complicated by an apical ventricular septal defect secondary to dehiscence of the septal suture line, requiring reoperation with primary closure on postoperative day 15. Shortly after the procedure, the patient manifested mental obtundation. The patient had developed marked systolic hypertension, which necessitated aggressive antihypertensive therapy and was ultimately controlled with calcium antagonists. Computerized tomogram of the head revealed no evidence of focal lesions. With control of the high-output state, mental obtundation slowly resolved. The patient was eventually discharged on postoperative day 47, with no evidence of neurologic sequelae at 1-month followup. Predismissal echocardiography showed an ejection
Fig 2. Two-dimentional echocardiogram showing (A) preoperative and (B) postoperative left ventricular diameter at the time of mitral valve closure. (Ao ⫽ aorta; IVS ⫽ interventricular septum; LA ⫽ left atrium; LV ⫽ left ventricle; MV ⫽ mitral valve; PLVW ⫽ posterior left ventricular wall.)
fraction of 50%, fractional shortening of 21%, and left ventricular diastolic and systolic diameter of 3.3 and 2.7 cm, respectively, without mitral valve regurgitation (Figs 2 and 3). Slow deterioration in left ventricular function secondary to endocardial fibroelastosis and development of nonfixed pulmonary hypertension led to orthotopic cardiac transplantation 12 months later. The child is alive and well 2 years after transplantation.
Comment Idiopathic dilative cardiomyopathy (IDC) is one of the most frequent indications for cardiac transplantation in the pediatric age group [1, 2]. According to the registry of the International Society for Heart and Lung Transplantation, IDC was the indication for cardiac transplantation in 40.9% of patients between the ages of 0 and 15 years [3]. The natural history of this disease is often character-
Ann Thorac Surg 2000;69:1255–7
CASE REPORT AL-SOFYANI ET AL CERVICAL MEDIASTINOSCOPY METASTASIS
1255
improve with time. Accurate patient selection will be of utmost importance, perhaps reserving this treatment modality for those patients who have the least likelihood of improvement over time, or in whom cardiac transplantation may be contraindicated.
References
Fig 3. (A) Preoperative and (B) postoperative M-mode echocardiographic tracings. (IVS ⫽ interventricular septum; LV ⫽ left ventricular wall; PLVW ⫽ posterior left ventricular wall.)
ized by progressive deterioration, in particular for children beyond 2 years of age [4, 5]. Diminished myocardial contractility in the setting of IDC is perhaps the one variable most frequently associated with poor outcome [2, 6], and should prompt evaluation for early transplantation or other interventions. Cardiac transplantation, eventually “bridged” by a ventricular assist device or extracorporeal membrane oxygenation, is currently the only viable long-term therapeutic option for IDC once medical therapy has failed. The scarce availability of organ donors makes the search for alternative sources imperative. Partial left ventriculectomy, as recently reported by Batista and associates, aims at restoring the physiologic ratio between myocardial mass and left ventricular diameter, leading to improvement in cardiac performance [7]. This report represents a unique case of cardiac volume reduction performed in an infant. The patient’s hemodynamic improvement, as noted by comparison of pre- and postoperative M-mode and D-mode echocardiograms, is shown in Figures 2 and 3. Decrease in systolic and diastolic left ventricular diameter, as well as improved contractility, are evident. In the case reported, we observed a very pronounced hyperdynamic state in the early postoperative period, characterized by marked systolic hypertension and mental obtundation deteriorating into a true comatose state, eventually resolving. This response appears strikingly similar to that not infrequently observed after transplantation of oversized donor hearts, the so-called “big-heart syndrome” [8]. This pathophysiologic similarity points to calcium antagonist or beta-blockade therapy as potentially beneficial in these patients, to avoid neurological sequelae. In conclusion, partial left ventriculectomy may be a bridging technique or, perhaps, even a definitive treatment in those patients with stable but symptomatic cardiomyopathy or those with deteriorating disease who, heretofore, depend on organ transplant as their only hope for survival. Myocardial reduction may also benefit those patients with etiologically proved dilated cardiomyopathy (myocarditis, metabolic, toxic, etc) who fail to © 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
1. Dec GW, Fuster V. Idiopathic dilated cardiomyopathy. N Engl J Med 1994;331:1564–75. 2. Chan DP, Allen HD. Dilated congestive cardiomyopathy. In: Moss AJ, Adams FH, eds. Heart disease in infants, children and adolescents, 5th ed, vol 2. Baltimore: Williams & Wilkins, 1995:1365– 81. 3. Hosenpund JD, Novick RJ, Bennett LE, Keck BM, Fiol B, Daily OP. The registry of the International Society for Heart and Lung Transplantation: thirteenth official report—1996. J Heart Lung Transplant 1996;15:655–74. 4. Griffin ML, Hernandez A, Martin TC, Goldring D, Bolman RM, Spray TL et al. Dilated cardiomyopathy in infants and children. J Am Coll Cardiol 1988;11:139– 44. 5. Burch M, Siddiqui SA, Celermajer DS, Scott C, Bull C, Deanfield JE. Dilated cardiomyopathy in children. Determinants of outcome. Br Heart J 1994;72:246 –50. 6. Lewis AB, Chabot M. Outcome of infants and children with dilated cardiomyopathy. Am J Cardiol 1991;68:365–9. 7. Batista RJ, Santos JL, Takeshita N, Bocchino L, Lima PN, Cuhna MA. Partial left ventriculectomy to improve left ventricular function in end stage heart disease. J Cardiol Surg 1996;11:96–7. 8. Reichart B. Size matching in heart transplantation. J Heart Lung Transplant 1992;11(4 Pt 2):S199 –202.
Cervical Mediastinoscopy Incisional Metastasis Medhat Al-Sofyani, MD, Donna E. Maziak, MDCM, and Farid M. Shamji, MD Division of Thoracic Surgery, University of Ottawa, Ottawa Hospital, Ottawa, Ontario, Canada
Tumor deposit in the cervical mediastinoscopy incision is a rare complication of this operation when it is done to stage lung cancer. The etiology of this complication remains unclear. We present the case of a patient with this condition, discuss the cause and management, and review the literature. (Ann Thorac Surg 2000;69:1255–7) © 2000 by The Society of Thoracic Surgeons
C
ervical mediastinoscopy has become a routine staging operation for the assessment of mediastinal nodes in lung cancer. One of the rare complications of mediastinoscopy is tumor metastasis in the neck incision. We report such a case and review the literature. A 51-year-old man was seen with cough, hemoptysis, and fatigue. Chest roentgenographic examination revealed a right lower lobe mass. A computed tomographic scan of Accepted for publication Sep 30, 1999. Address reprint requests to Dr Maziak, Ottawa Hospital—Civic Campus, 1053 Carling Ave, CPC Room 162, Ottawa, ON, Canada K1Y 4E9.
0003-4975/00/$20.00 PII S0003-4975(00)01461-7