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Modified Blalock-Taussig shunt (MBTS) is a palliative operation for cyanotic congenital heart disease (CCHD) in patients for whom total correction is not appropriate. Many synthetic or biologic grafts have been proposed as alternative shunt materials. The use of a bovine mesenteric venous graft (BMVG) as a systemic-to-pulmonary artery shunt conduit without the administration of antiaggregant and anticoagulant has been proposed as a treatment for neonates with CCHD, but few reports address the importance of thrombophilic risk factors in MBTS and bovine venous graft as a shunt material. We used BMVG as a shunt material without any antiaggregant or antiplatelet regimen in 13 patients with CCHD, all of whom were candidates for MBTS and had thrombophilic risk factors assessed in our initial study. Early shunt failure occurred in the first 3 patients and was attributed to less surgical experience with this graft. No complications were attributable to graft material or surgery itself. In all cases functioning MBTSs were observed on follow-up. Our study results show that thrombophilic factors should be evaluated before the MBTS procedure. BMVG could be the choice of graft for use without the administration of antiaggregant and anticoagulants in patients with thrombophilic risk factors.

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A pseudoaneurysm is defined as an aneurysmatic sac surrounded byfibrous tissue instead of other vascular layers such as the muscular one. It is a rare incident in infants especially in the brachial artery. Blunt trauma and vascular access attempts are the most common etiologic factors. We present two infants with brachial artery pseudoaneurysm in the antecubital region following accidental arterial puncture.

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A unique case of superoinferior ventricles, left atrial isomerism, concordant atrioventricular connection, and discordant ventriculoarterial connection is described. The associated anomalies were azygous vein continuation, large subpulmonary and apical ventricular septal defects, and left ventricular outflow tract obstruction (pulmonary stenosis). The diagnosis was mostly made by fetal echocardiography and the superoinferior location of the ventricles was confirmed by postnatal echocardiography. Fetal and postnatal echocardiography facilitated the precise morphologic diagnosis and segmental analysis of this defect.

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A late complication of the CardioSEAL atrial septal defect (ASD) occluder is reported. Although left atrial umbrella was completely epithelialized and occluded ASD without residual defect, the right atrial umbrella protruded toward the center of right atrium after 18 months. We believe this may be associated with the structural abnormality of the device.

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The effect of aprotinin, a protease inhibitor, on myocardial interleukin-8 (IL-8) production after ischemia-reperfusion injury was investigated. Twenty patients who had elective coronary artery bypass grafting were included in this study. Patients were randomly divided into two groups (n = 10 in each). Group A patients received high dose aprotinin (20,000 IU/kg as pretreatment followed by 7500 IU/kg for 6 h) and Group B patients received normal saline as a control. Serum IL-8 levels after the termination of cardiopulmonary bypass (CPB) showed a significant improvement in aprotinin treated group compared to control group (70 +/- 42.6 vs 360.71 +/- 87.9 ng/ml) (P < 0.005). Levels were also significantly higher at post-operative 24th hour in patients who did not received aprotinin (340.16 +/- 92.10 vs 96.13 +/- 34.33 ng/ml). However at post-operative 48th hour levels were again higher in control (untreated) group, but the difference was not statistically significant (78.8 +/- 34.4 vs 42.8 +/- 9.29 ng/ml). Aprotinin prevented the IL-8 release from myocytes in ischemia-reperfusion injury. The mechanism is highly dependent on anti-protease activity of aprotinin.

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Extension of Wilms' tumor through inferior vena cava into the heart two years after the completion of therapy, is a very rare clinical aspect. We successfully operated on a 7 year old girl who had a huge right atrial mass which filled the right ventricle and right ventricular out flow tract, on an emergency basis using cardiopulmonary bypass.

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A case of ossifying fasciitis occurring in the left femoral region of a 57-year-old male is reported. The patient complained of pain in his left lower extremity which was the site of previous catheterization. During a left femoropopliteal by-pass, a firm and cylindric mass measuring 5 x 3 x 2.5 cm in size was found and extracted from the left groin. Histologically, a reactional lymph node and an irregularly shaped lesion extended into the perinodal fat tissue which is composed of proliferating fibroblasts with occasional mitotic activity. Within this fibroblastic proliferation, immature woven bone composed of osteoid with calcification and chondroid differentiation were seen. Metaplastic bone is an uncommon finding in cases of nodular fasciitis, parosteal fasciitis, cranial fasciitis and florid reactive periostitis. Ossifying fasciitis is known as an uncommon variant of nodular fasciitis. It is an uncommon post-traumatic benign lesion of subcutaneous tissue with an unclear etiology of ossification which is neither related with a bony structure nor contains any muscle tissue. This lesion has been reported only once previously, in the femoral region after a trauma history of catheterization.

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Osteosarcoma metastasis to the heart caused by tumor thrombosis is very rare. A 7-year-old girl with an osteosarcoma of the right humerus, refused the treatment, at first, then, 1 year later, referred to the hospital with metastasis to the heart. The mass invading the pulmonary arteries was successfully removed with open-heart surgery.

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BACKGROUND: Clinical procedures involving extracorporeal blood circulation are potentially complicated by the interaction of various blood systems with foreign surfaces. In cardiopulmonary bypass, exposure of blood to synthetic surfaces generally leads to activation of cellular and humoral blood systems with activation of complement cascade. This reaction can be associated with a variety of postoperation clinical complications such as increased pulmonary capillary permeability, anaphylactic reactions and various degrees of organ failure which contributes to mortality in routine cardiac operations. Application of biocompatible materials in an extracorporeal circuit modifies the normal pattern of blood activation, and therefore potentially may reduce clinical complications in routine cardiac surgery. METHODS: To evaluate whether the use of heparin coated extracorporeal circuits could reduce this activation process we performed a study on forty coronary artery bypass graft patients perfused randomly with heparin-coated circuits (Duraflo II, n = 20) or with non-coated circuits (De Bakey roller pump, control n = 20). Standardized heparinization was maintained for both groups of patients during cardiopulmonary bypass. RESULTS: The use of heparin-coated circuits resulted in reduction of systemic leukocyte activation of cardiopulmonary bypass reflected by reduced leukocyte and neutrophil counts 24 hours after operation (p < 0.05). Furthermore, blood samples taken from both the right and left atrium after reperfusion revealed that the differences in neutrophil counts between the right and left atrium occur less in the heparin-coated circuit in contrast to the control group (p < 0.05). The pattern of complement activation, probably initiating this inflammatory reaction, was modified by heparin coating in two different aspects. There was a significant reduction of C3 during and after cardiopulmonary bypass in patients perfused with heparin coated circuits as compared with the control group, also there was reduction of C4 after protamine administration in the same groups (p < 0.05). The reductions in blood and complement activation with heparin-coated circuit indicate a substantial improvement in biocompatibility, and consequently reducing clinical complications associated with cardiopulmonary bypass. CONCLUSIONS: In conclusions using the Duraflo II heparin-coated circuit in open heart surgery can reduce the complement activation and inflammatory response to cardiopulmonary bypass.

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BACKGROUND: The activity of adenosine deaminase (ADA) was determined in serum and pericardial fluid of 70 patients (ages 21 to 71 years) with pericardial effusions of various etiologies and in 15 control subjects. METHODS: The patients were subdivided into five groups on the basis of definite diagnosis: 1) 24 patients with tuberculosis; 2) 22 with malignancies; 3) 12 with uremic pericarditis; 4) 12 with purulent pericarditis; 5) 15 control individuals without pericardial disease. The activity of ADA was determined at the same time in serum and cell-free pericardial fluid according to the method of Karker with minor modification. RESULTS: Mean (+/-SD) ADA activity in pericardial fluid was 66.92+/-4.12 IU/L in group 1; 27.50+/-6.02 in group 2; 28.65+/-4.73 in group 3; 53.05+/-11.14 in group 4; and 5.67+/-1.99 in group 5. Comparing the level achieved in group 1 with all others, the difference is significant at the p<0.001 level. When the cut-off value of 50 IU/L is used the sensitivity of the test for diagnosis of tuberculous effusion is 1, and the specificity is 0.83. Statistical analysis showed that there was no correlation between serum ADA activity and ADA activity in pericardial fluid. CONCLUSIONS: We recommend that determinations of ADA activity in pathologic pericardial fluids seem to be of great value in the early diagnosis of tuberculous pericardial effusions. Levels above 50 IU/L in effusions indicate probable tuberculosis.

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Vascular hamartoma of the mediastinum is a rare benign vascular tumor. A 13-year-old girl presented with back pain, persistent coughing, palpitation, and angina pectoris. Preoperative investigations demonstrated an enlarging mass involving the superior mediastinum extending posteriorly (T6-T8). An encapsulated, 6x5x3 cm dark purplish mass adherent to the aortic wall was found. The main mediastinal mass was totally excised but limited resection was carried out in the paravertebral region. Microscopic examination revealed a vascular hamartoma.

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Aortic root abscess, aneurysm of sinus Valsalva, severe aortic valve insufficiency, and a fragile aortic wall caused by infective endocarditis were found in a 10-year-old child. Aortic valve replacement was intended as a preoperative strategy, but one of modifications of Cabrol had to be used urgently because of aortic root rupture between right atrial and aortic connection just after pericardiotomy.

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The study was designed to clarify whether captopril, an angiotensin-coverting enzyme inhibitor, will reduce the injury of global ischaemia and reperfusion after cardioplegic arrest in isolated guinea pig hearts, in a modified Langendorff model. The hearts were randomly allocated into four groups (n = 10 in each) and subjected to 90 min of normothermic global ischemia, followed by 30 min of reperfusion; in all groups, cardioplegic arrest was achieved by administering St. Thomas's Hospital cardioplegic solution (STHCS). The first group was utilized as the control group. In the second group, captopril (200 mumol/L) was added to STHCS. In the third group, oral pretreatment was carried out (0.3 mg/kg captopril was given twice a day for 10 days). In the fourth group, oral pretreatment was achieved and captopril-enriched solution was applied in the first 5 min of reperfusion. Although the study groups showed better recovery of contractility than the control group, in the fourth group the hearts had the best left ventricular contractile function, where contractile force (g contractility/g heart weight) was 55.4% +/- 3.8% of the preischameic values. Groups I, II, and III achieved 31.0% +/- 3.2%, 41.6% +/- 3.8%, and 48.3% +/- 3.9% of their preischaemic contractile force values. Creatine kinase leakage was significantly lower and postischaemic coronary flows, too, were significantly higher in the fourth group. Coronary flow after reperfusion increased from 48.5 +/- 6.7 to 65.2 +/- 7.1 ml/min g heart in group 4 (p < 0.05). Myocardial lipid peroxides and glutathione contents showed that there was a correlation between the depletion of myocardial glutathione content and increased lipid peroxidation. These preliminary results showed that: the addition of captopril to reperfusion solution and oral preconditioning improved post-ischameic myocardial function and decreased myocardial injury.

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Here in nine patients with congenital lobar emphysema who had been treated surgically in the previous 10 years are reported. The ages of the patients at diagnosis ranged from 26 days to 11 months. The six patients whose symptoms started in the neonatal period had more severe dyspnea, cyanosis and respiratory distress. Tube thoracostomy was performed in two of three patients who had been misdiagnosed initially. The affected side was the left upper lobe in five patients, the right upper lobe in three, and the right middle and upper lobes in one patient. Lobectomy was performed in all cases. Dysplasia of the bronchial cartilage was found in six patients and bronchial atresia of the left upper lobe was found in another infant as the etiologic cause of the condition. Although the possibility of conservative management in congenital lobar emphysema has been reported recently, we believe that surgery is the treatment of choice in patients who have persistent or progressive, severe respiratory distress in spite of medical treatment.

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Multiple chondromatous hamartomas are extremely rare and we have not found any bilateral presentation in the literature. We report the case of a 47-year-old woman presenting with a cough, chest pain and dyspnea. Chest x-ray and computed tomography revealed multiple and bilateral pulmonary nodules. A metastatic carcinoma was considered, but the open lung biopsy revealed a chondromatous hamartoma of the lung. The pathogenesis of hamartomas is discussed and the recent literature is reviewed.

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A case of chylopericardium associated with lymphangiomatous malformation of the thymus is presented. The specific diagnosis of chylopericardium was made by pericardiocentesis and analysis of the fluid. Despite the pericardiocentesis and pericardial tube drainage, pericardial effusion recurred and the patient underwent pericardiectomy. At operation the thymus, which contained a tumor and showed diffuse hyperplasia, was excised and pericardiectomy was performed. The 2-year-old patient recovered uneventfully without reaccumulation of the chyle. The pathologic diagnosis of the mass was intrathymic ectatic lymphangiomatous malformation.

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