Surgical management of congenital heart disease: correlation between hospital costs and the Aristotle complexity score

BACKGROUND

Hospital costs are expected to correlate with clinical complexity. Do costs for congenital heart surgery correlate with Aristotle complexity scores?

METHODS

442 inpatient stays in 2008 were evaluated. Aristotle scores and levels were determined. Costs were estimated according to the German Institute for Hospital Reimbursement system. Pearson and Spearman R correlation coefficients and corresponding goodness-of-fit regression coefficients R2 were calculated.

RESULTS

Mean basic and comprehensive Aristotle scores were 7.60 +/- 2.74 and 9.23 +/- 2.94 points, respectively. Mean expenses per hospital stay amounted to 29,369 +/- 30,823 Euros. Aristotle basic and comprehensive scores and levels were positively correlated with hospital costs. With a Spearman R of 1 and related R2 of 0.9436, scores of the 6 Aristotle comprehensive levels correlated best. Mean hospital reimbursement was 26,412 +/- 17,962 Euros. Compensation was higher than expenses for patients in comprehensive levels 1 to 3, but much lower for those in levels 4 to 6.

CONCLUSIONS

Aristotle comprehensive complexity scores were highly correlated with hospital costs. The Aristotle score could be used as a scale to establish the correct reimbursement after congenital heart surgery.

Function of Contegra valved grafts after unifocalization

BACKGROUND

Can Contegra grafts withstand high pressure?

METHODS

The function of Contegra grafts implanted after unifocalization of major aortopulmonary collateral arteries (MAPCAs) in 10 patients was evaluated. Median age at repair was 194 days and two conduit sizes were used: 12 mm (n = 8) and 14 mm (n = 2). Echocardiography and heart catheterization findings were reviewed.

RESULTS

Two patients died: one early after repair, one late. Death was not graft related. The median duration of observation for survivors was 31 (range 4 - 42) months. The postoperative right ventricular/left ventricular pressure ratio was greater than 75 % in 9 patients. High pressures persisted in 6 survivors. Seven patients underwent interventional dilatation/stenting of pulmonary arteries on 19 occasions. No obstruction was detected in the conduit. Graft valve regurgitation increased in 5 patients, but never exceeded grade 2 (n = 4). Freedom from reoperation for conduit dysfunction/failure was 100 % at month 42.

CONCLUSION

At mid-term follow-up, the Contegra grafts withstood high pressure without significant dysfunction or aneurysmal dilatation requiring surgery. Contegra appears to be an acceptable alternative to the aortic homograft for use after unifocalization of MAPCAs in infancy.

The fate of small-diameter homografts in the pulmonary position

BACKGROUND

Limited durability is expected for small homograft valves that are used to correct congenital cardiac disease.

METHODS

All 76 homograft valves with an internal annulus diameter ranging from 8 to 13 mm that were implanted from 1987 through 2000 in the pulmonary position were retrospectively analyzed. In each case, homograft size was normalized to the patient's body surface area: z-value. For 93% (14 of 15) of the 8 to 9 mm grafts, z was less than 2. For 56% (5 of 9) of the 10 mm grafts and 98% (51 of 52) of the 11 to 13 mm allografts, z was greater than 2. Survival and freedom from complications were estimated by the Kaplan-Meier method. Homograft failure was defined as homograft replacement or late death; significant dysfunction, as homograft obstruction with an echo-Doppler gradient greater than 50 mm Hg or grade III or IV valvular insufficiency. The log-rank test was used to compare outcomes.

RESULTS

Seven patients died early after operation; three, late. Survival was 86.5% +/- 3.8% at 1 year and remained stable during the succeeding years. Freedom from failure for all homografts was 90.6% +/- 3.7%, 71.8% +/- 6.9%, and 61.8% +/- 9.0% at 1, 5, and 10 years, respectively. Corresponding freedom from significant dysfunction was 87.6% +/- 4.1%, 51.2% +/- 7.4%, and 10.1% +/- 8.3%. The smaller homografts (z less than 2) failed and deteriorated faster (p < 0.0001): only 32.1% +/- 13.0% were still functioning at 24 months. The larger grafts (z at least 2) retained function for the first 4 years, and 73.7% +/- 10.4% had not yet failed at 10 years.

CONCLUSIONS

Smaller (z less than 2) homografts (the great majority of 8 to 9 mm grafts) have to be replaced early, usually within 2 years of implantation. Larger (z at least 2) grafts (nearly all 11 to 13 mm grafts) show remarkable durability and are suitable valved conduits for establishing right ventricle to pulmonary artery continuity in neonates and young infants.

Transposition of the great arteries associated with ventricular septal defect: surgical results and long-term outcome

OBJECTIVES

To identify potential risk factors influencing early and late outcome following the arterial switch operation (ASO) for transposition of the great arteries associated with ventricular septal defect including double-outlet right or left ventricle.

METHODS

All patients who underwent ASO in our department until August 2000 (n=105) were included in this study. There were 77 transpositions of the great arteries with ventricular septal defect, 22 Taussig-Bing hearts and six patients with double-outlet morphology. The median age at operation was 24 days. Aortic arch obstruction was present in 25 patients; in 13 of these patients, a repair with aortic arch reconstruction was done before ASO. The usual coronary artery pattern was present in 59% of the patients. In six patients, we found an intramural course of at least one coronary artery. The ventricular septal defect was closed with a patch through the right atrium (n=35), the aorta (n=25), the pulmonary artery (n=25) or the right ventricle (n=3); in 17 patients a combined approach was necessary.

RESULTS

There were five hospital deaths (4.7%, 95% confidence limit 2-11%). The median duration of follow-up was 72 months. Fourteen patients underwent 15 reoperations 33 months after repair (median), eight for right ventricular outflow tract obstruction or neopulmonary stenosis. Four late deaths occurred, two due to complications related to coronary artery anomalies. Statistical analysis revealed no significant risk factor whatsoever correlating with death or need for reoperation. Survival after 12 years was 91.6%, and freedom from reoperation was 82.6%. Latest follow-up data showed that 13% of patients were in NYHA class II and/or required medical treatment; 87% were in NYHA class I.

CONCLUSIONS

ASO associated with patch closure of ventricular septal defect can be performed early in life with a low risk of mortality (<5%), low incidence of reintervention (<15%) and promising long-term outcome.

[Heart surgery under cardiopulmonary bypass during the neonatal period remains a high-risk procedure]

Congenital Heart disease with a poor prognosis has to be operated early but with an acceptable surgical risk and a good chance of survival. The aim of this study was to analyse the indications, the operative mortality and medium-term survival of neonates undergoing cardiac surgery under cardiopulmonary bypass from 1991 to 1998. Three hundred and twenty nine operations were programmed in 326 neonates, 18% (329/1805) of all open heart surgical procedures. Anatomical detransposition of the great arteries was the commonest operation (N = 226). Correction was complete (biventricular) in 97% of cases (317/326). Twenty-eight neonates died. The operative mortality was 8.5%, much higher than that of children of 3 months or over (1.5%; p < 0.0001). There were 8 late deaths, all in the first postoperative year. The overall medium-term survival rate was 88.9 +/- 1.7%. It was 100% after correction of truncus arteriosus without interruption of the aortic arch; 94.2 +/- 1.5% after anatomical detransposition; 85.7 +/- 9.4% after commissurotomy of aortic stenosis; 79.2 +/- 8.3% for all the complex forms of interruption of the aortic arch; 75 +/- 9.7% for total anomalous pulmonary venous drainage and 42.9 +/- 18.7% after the Norwood palliative procedure of hypoplastic left heart syndrome. The authors conclude that early cardiac surgery saves the large majority of neonates suffering from complex congenital cardiac disease with poor prognosis. Survival stabilises one year after the operation. Other techniques or treatments are necessary to lower present surgical risk (8.5%) to that of surgery under cardiopulmonary bypass of children over 3 months of age (1.5%).

Closure of the zone of apposition at correction of complete atrioventricular septal defect improves outcome

OBJECTIVE

Outcome after correction of atrioventricular septal defect depends to a great deal on the postoperative function of the left atrioventricular valve. The related role of the zone of apposition ('cleft') has been debated: should it be closed (bileaflet repair) or should it be left untouched (trileaflet repair)? This study aims to answer the question by comparing the outcome of patients treated according to these two approaches.

METHODS

We reviewed all our patients who underwent repair of complete atrioventricular septal defect from 1984 to 1997 and selected those in whom the closure of the zone of apposition in principle would have been possible. Two groups with similar characteristics were constituted: group I (n=63), where the zone of apposition was deliberately not closed as part of a trileaflet repair (postoperative open zone of apposition) and group II (n=96), where it was electively closed as part of a bileaflet AV valve repair (closed zone of apposition). Since we changed from a trileaflet to a bileaflet repair in 1987, the two groups differ in terms of size and length of follow-up. Outcome was compared with regard to survival and freedom from reoperation for left atrioventricular valve incompetence. Late atrioventricular valve function was evaluated by Echo-Doppler. For statistical analysis, we used Chi-square or Fisher's exact test, the Mann-Whitney test and the log-rank test for comparison of Kaplan-Meier curves. The difference was considered statistically significant with a P-value of 0.05 or less.

RESULTS

Early mortality was 9.5% (6/63) in group I and 3.1% (3/96) in group II (P=0.16). Actuarial survival after 1, 4 and 8 years was 80.4, 68.4 and 64.8%, respectively, for group I. Actuarial survival for group II was 94.7, 92.1 and 92.1% (P=0.0002). Freedom from reoperation for left atrioventricular valve regurgitation was 90.2, 85.6 and 77.8% for group I at the same time interval. It was a constant 97.9% for group II (P=0.0016). At reoperation, left atrioventricular valve regurgitation was present through the open zone of apposition in 63% of group I cases. The follow-up is 96% (126/131) complete. An increase in degree of left atrioventricular valve incompetence was noted in 28% (11/39) of group I cases and in 9% (8/87) of group II cases (P=0.0131).

CONCLUSION

This study demonstrates the advantage of closing the zone of apposition ('cleft') as part of repair of complete atrioventricular septal defect. Survival, freedom from reoperation for left atrioventricular valve incompetence and over-all outcome were more favourable in patients of group II. The zone of apposition should be surgically addressed whenever the morphology of the left atrioventricular valve allows for closure without producing stenosis.

Atrial isomerism: a surgical experience

Most publications on atrial isomerism are autopsy or case reports. The authors review 41 consecutive children operated on from 1980 through to 1996 with emphasis on associated cardiac anomalies, surgical procedures and outcome. Left atrial isomerism was present in 23 patients. Interruption of the inferior vena cava (56%), atrio-ventricular septal defect (47%), common atrium (38%) and cor triatriatum sinistrum (30%) were the most common diagnoses. Biventricular repair was achieved in 17 children and total cavo-pulmonary connection in two. Three underwent staged palliation: modified Blalock-Taussig shunt for two and bidirectional Glenn anastomosis for one. The remainder received a cardiac pacemaker. One patient died early after repair. Two underwent reoperation to correct a regurgitant left atrio-ventricular valve: one of these, in another hospital, had peroperative death. Three died later. Actuarial survival rate after repair and total cavo-pulmonary connection that was stabilized after 2 years was 84%. In the 18 children with right atrial isomerism, pulmonary atresia or stenosis predominated (89%) with discordant ventriculo-arterial connection (72%), atrio-ventricular septal defect (72%), 'single' ventricle (55%) and extracardiac total anomalous pulmonary venous drainage (50%). Biventricular repair was achieved in two patients and complete Fontan circulation in eight. The other eight underwent various staged palliative procedures and correction of extracardiac total anomalous pulmonary venous drainage. Five patients died postoperatively: two in our unit after modified Blalock-Taussig shunt and total cavo-pulmonary connection, three in other hospitals after repair (n = 1) and Fontan (n = 2). Five died later. One was lost for review. Survival after repair and Fontan stabilized after 6 months at 49%. In conclusion, the cardiovascular malformations associated with left atrial isomerism can often be successfully corrected. Those accompanying right atrial isomerism usually preclude a biventricular repair, require staged palliation and carry a poor prognosis.

Truncus arteriosus: ten-year experience with homograft repair in neonates and infants

BACKGROUND

Early complete repair of truncus arteriosus with homograft reconstruction of the right ventricular outflow tract was performed and long-term results were evaluated.

METHODS

Review of 46 consecutive patients with truncus arteriosus who underwent primary correction between June 1987 and May 1997 was performed. Ages ranged from 21 days to 7.2 years (median, 62 days) and weights from 1.8 to 21.5 kg (median, 3.4 kg). Ten patients were operated on before 1 month of age, 20 between 1 and 3 months, 13 between 3 months and 1 year, and 3 at an older age. Associated cardiac conditions were encountered frequently, the most common being coronary artery anomalies (n = 16), truncal valve incompetence (n = 12), and interrupted aortic arch (n = 5). The right ventricular outflow tract was reconstructed with an aortic (n = 28) or a pulmonary homograft (n = 18).

RESULTS

There were two hospital deaths (4.3%). Both patients had severe truncal valve regurgitation and interrupted aortic arch together with other unfavorable conditions. Survival in uncomplicated truncus arteriosus was 100%. Follow-up was from 3 months to 10 years (mean, 36 months). There was one late death 4 months after the initial repair, presumably because of cardiac reason. Actuarial survival was 93% at 4 months and beyond. Actuarial freedom of reoperation in the 27 hospital survivors with aortic homografts was 43% at 75 months; it was 73% at 62 months in the 17 patients surviving with pulmonary homografts.

CONCLUSIONS

Neonatal or early infancy complete repair is the treatment with the best potential for survival. The homograft remains our conduit of choice to establish continuity between the right ventricle and the pulmonary artery. Management of severe truncal valve incompetence remains a surgical challenge.

[Prolonged endotracheal intubation after open heart surgery under the age of one year]

The aim of this study was to determine the impact of prolonged endotracheal intubation after open heart surgery in neonates and babies with respect to the cardiac diseases most frequently responsible and the reasons for delayed extubation and the related mortality. Intubation was considered to be prolonged if lasting over 48 hours. This was a retrospective study of all cases of open heart surgery performed before one year of age between 1991 and 1996. Prolonged intubation was noted in 43.1% of cases (266/617). The frequency was much higher than in children over 1 year of age: 8.3% (56/725). Truncus arteriosus (93.5%: 29/31), obstructed total anomalous venous drainage (93.3%: 14/15). Taussig-Bing anomaly (83.3%: 5/6), interruption of the aortic arch (78.9%: 15/19), double outlet right ventricle (61.1%: 11/18) and transposition of the great arteries (50.2%: 107/213) were the commonest responsible malformations. The reasons for delayed extubation, often multiple, were established in 222 cases: cardiogenic shock or circulating failure in 155 cases, pulmonary dysfunction in 142 cases, surgical complications in 65 cases and neurological complications in 14 cases. Twelve patients died: 5 of congestive heart failure, 3 of pulmonary hypertension, 2 of septic shock and 1 of diffuse stenosis of the pulmonary veins. The mortality rate was 4.5% (12/266) in cases of prolonged intubation and 5.2% (32/617) for all infants operated during the first year of life. The authors conclude that a large number of infants undergoing open heart surgery undergo prolonged intubation because of their poor preoperative status and the particularly severe effects of cardiopulmonary bypass at this age. However, the associated mortality was low in this series.

Peripheral gangrene in African children: a clinical report of twelve cases

Clinical observations of 12 cases of peripheral gangrene in children are reported. All patients presented with ischemia of one or more limbs without any history of trauma, vascular injury or snake bite. Prior to their admission, all these children had received some form of traditional "African" therapy. By means of exclusion severe vasospasm secondary to the traditional treatment was considered the causative factor of the peripheral gangrene in all the children. Surgical exploration of the arteries with a Fogarty embolectomy catheter in two patients and medical treatment in six patients was attempted. The overall results were disappointing, with most resulting in incapacitating amputations.

Early and long-term results for correction of total anomalous pulmonary venous drainage (TAPVD) in neonates and infants

OBJECTIVE

To present our 17-year experience of surgical repair of total anomalous pulmonary venous drainage (TAPVD) in 71 consecutive neonates and infants, with particular emphasis on the role of preoperative pulmonary venous obstruction (PVO), the management of postoperative pulmonary hypertensive crises and the long-term results.

PATIENTS AND METHODS

From July 1977 to May 1994, 36 newborns and 35 infants, aged between 1 and 300 days, had repair TAPVD in our Department. Fifty-four patients had decompensated heart failure, whereas three were moribund. The anomalous drainage was supracardiac in 32 (45%), cardiac in 17 (24%), infracardiac in 17 (24%) and mixed in 5 infants (7%). Major associated cardiac anomalies coexisted in nine cases. Forty-five (63%) exhibited signs of PVO. The repair was performed under moderate hypothermia in 15 and deep hypothermic arrest in 56 patients. In case of postoperative pulmonary hypertensive crises, artificial hyperventilation with high oxygen concentration, sedation and relaxation, inotropic support and afterload reduction with phentolamine were applied selectively. The actual follow-up is based on functional symptomatology and cardiac echo-doppler studies.

RESULTS

Six children (8.5%) died early: four perioperatively, two on the 2nd and 10th postoperative day, respectively. Poor preoperative condition, operation before 1987 and preoperative PVO were the main incremental risk factors for death. No death occurred among the last 38 cases. There were complications in 45 patients, in particular pulmonary hypertensive crises in 27. Two patients died late, after 80 and 118 days, respectively, of progressive intrapulmonary vein fibrosis: the second despite reoperation. The risk of late death approaches zero after 6 months. Among the 63 survivors, 56 (86%) are asymptomatic and without medication, 3 months-17 years after operation. Five have mild symptoms with ordinary physical activity. Two are lost to follow-up.

CONCLUSIONS

Early repair of TAPVD with aggressive management of pulmonary hypertensive crises carries low operative mortality nowadays. Preoperative PVO as a risk factor has been neutralized since 1987. Long-term results are gratifying: no late death after 6 months, no reoperation and functional good results. Progressive pulmonary vein fibrosis remains an unpredictable rare cause of death within the 1st year after surgery.

[Surgical repair of common truncus arteriosus with homograft. Short- and mid-term results]

Between July 1987 and July 1993, 25 consecutive children with truncus arteriosus underwent complete surgical correction with homografts. Nineteen were under 6 months of age and 4 had an associated interruption of the aortic arch. Ten pulmonary and fifteen aortic homografts were implanted. They were cryopreserved with the exception of two, fresh aortic homografts. The diameters of the homografts varied from 8 to 19 mms. Two children who had an interruption of the aortic arch, aged 24 and 31 days, died in the peroperative period. The postoperative course was uncomplicated in only 3 cases; 20 patients had complications, including 9 cardiogenic shocks and 8 pulmonary hypertensive crises. The medium-term results included one death 4 months after surgery in an infant with an interruption of the aortic arch, and 2 successful homograft replacements 3 and 12 months after the initial repair for mycotic infection in 1 case and valvular stenosis in the other. The mean follow-up of the other 20 patients was 23 months: 14 were in NYHA functional Class I, 4 are on the waiting list for replacement of their homograft for obstruction after an average period of 47 months. The authors strategy is to perform surgical correction of truncus arteriosus very early: immediately in the neonatal period in cases with uncontrollable cardiac failure, at 6 months at the latest. Small homografts make this aggressive attitude feasible, but with an operative mortality in the first 6 months of life of 10.5% (2/19).(ABSTRACT TRUNCATED AT 250 WORDS)

Anterior mediastinal abscess complicating septic arthritis

An 11-year-old boy with septic arthritis of both knees presented with an anterior mediastinal abscess extending suprasternally. This was drained through a suprasternal incision and the mediastinal cavity was intermittently irrigated with povidone iodine solution and packed with gauze. Staphylococcus aureus was the responsible organism. Antibiotic therapy comprised of cloxacillin and gentamycin. Recovery was uneventful. This is, most probably, the first report on an anterior mediastinal abscess complicating a distant septic arthritis. As for any infective mediastinitis, early diagnosis and aggressive treatment is mandatory for a patient's survival.

Emergency pulmonary resection for pneumonia. High morbidity and mortality

Emergency pulmonary resection was performed because of complicated pneumonia in eight patients (5 pneumonectomies, 2 lobectomies, 1 bilobectomy) over a 2-year period. The patients' age range was 5 months to 43 years. The indications were rapid aggravation of respiratory insufficiency in children with staphylococcal pneumonia and enlarging pneumatoceles, and massive hemoptysis in patients with chronic destructive pneumonia. Two patients died after pneumonectomy, one from contralateral aspiration and one from cardiogenic shock. Postoperative complications occurred in four cases--bronchopleural fistula and pyopneumothorax in three and thoracic empyema with massive chest-wall infection in one. Only two patients had an uneventful postoperative course. Complications of pulmonary necrosis in pneumonia may dictate urgent pulmonary resection, often pneumonectomy. Surgery will be life-saving in most cases, but high morbidity is to be expected.

Oesophagectomy for carcinoma of the oesophagus--early results

Oesophagectomy for squamous cell carcinoma of the oesophagus was performed in 25 consecutive patients over a 3.5 years period, for an overall resection rate of 11 pc. It was an Ivor-Lewis in 19 and a left thoracotomy in six. The stage of the disease was II in two, III in six and IV in 17 cases. Seventeen patients had uneventful postoperative evolution. Complications occurred in eight patients: heart failure in three, anastomotic leak in three, massive chest wall infection in two and four of these patients died: a mortality rate of 16 pc. All the 21 patients who left the hospital were able to take normal diet. The mortality of oesophagectomy for cancer can be as high as 30 pc but decreases with better selection of patients and surgical experience. Cure is rarely achieved. Resective surgery, when successful, offers the best palliation for dysphagia. Resectability rate in all African series is very low. There is a need for a more aggressive surgery therapeutic attitude. Our series shows that it is possible in our environment to achieve an acceptable operative morbidity and mortality. With increasing experience, results can only improve.

Misdiagnosis of aneurysms: a case report

Three cases in which aneurysms were misdiagnosed to less serous lesions are described. Attention is drawn to the possibility of these errors whose consequences can be fatal. Some of the problems associated with the handling of an inadvertently opened aneurysm are discussed.

Arterial aneurysms associated with human immunodeficiency virus (HIV) infection

The authors report four arterial aneurysms seen in three patients infected by HIV. The aneurysms affected: 1) the left common carotid artery in a young man HIV carrier, 2) the right common carotid artery and the abdominal aorta in a woman with AIDS, 3) the right common carotid artery in a patient with AIDS-related complex. The aetiology was found to be infectious, respectively: 1) staphylococcus epidermidis (certain), 2) tuberculosis or another undetected infection (possible), 3) staphylococcus epidermidis or syphilis (highly probable). A viral arteritis mechanism is also postulated in the second case. If this association of aneurysms with HIV infection is not fortuitous, an increase of aneurysm incidence in HIV infected population is to be expected.

Pleural exudate in a tropical hospital

In one hundred consecutive patients with non-purulent pleural exudates without apparent cause, the final diagnosis was tuberculosis in 58, malignancy in 20, pyogenic infection in four, cardiomyopathy in two, pulmonary infarction in one. The aetiology remained unknown in 15. The technique of "semi-open" pleural biopsy was performed under local anaesthesia. It accurately detected 70% of cancer and 69% of tuberculosis cases with a 9% complication rate and no mortality. Tuberculosis was seen at all ages but mainly between 20 and 39 yrs, where it represented 75% of cases. In this age group, malignancy was relatively rare: 10% of cases. In our environment of limited facilities, early chemotherapy trial for tuberculosis is justified for unknown pleural exudates in patients below the age of 40 yrs.

Pleural exudate in a tropical hospital

In one hundred consecutive patients with non-purulent pleural exudates without apparent cause, the final diagnosis was tuberculosis in 58, malignancy in 20, pyogenic infection in four, cardiomyopathy in two, pulmonary infarction in one. The aetiology remained unknown in 15. The technique of "semi-open" pleural biopsy was performed under local anaesthesia. It accurately detected 70% of cancer and 69% of tuberculosis cases with a 9% complication rate and no mortality. Tuberculosis was seen at all ages but mainly between 20 and 39 yrs, where it represented 75% of cases. In this age group, malignancy was relatively rare: 10% of cases. In our environment of limited facilities, early chemotherapy trial for tuberculosis is justified for unknown pleural exudates in patients below the age of 40 yrs.

Results of subxiphoid pericardiostomy in pericardial effusion

37 patients with pericardial effusions were managed by early subxiphoid pericardiostomy under local anaesthesia in most cases (31/37). The aetiology was pyogenic infection in 21, tuberculosis in 7, trauma in 3, cardiomyopathy in one. It was unclear in five patients. The effusion recurred in two patients (one with pyogenic, the other with traumatic pericarditis). An infant with pyogenic pericarditis developed pericardial constriction. The mortality, mainly due to associated infections or diseases, was related to aetiology: 0% for tuberculosis and trauma, 19% (4/21) for pyogenic infections, 80% (4/5) for unclear causes. Overall results were good in 28 patients. Subxiphoid pericardiostomy is a simple and safe procedure which allows a quick differential diagnosis and drainage of pericardial effusions.

Empyema thoracis in childhood in the tropics

The management of 25 children with empyema thoracis in Zimbabwe is discussed. The method adopted in 21 of these children using simple drainage and continuous irrigation with 0.1% solution of povidone iodine compared well with more aggressive methods. The method can be carried out easily in a rural environment. 2 of these 21 children died, one because of aspiration. The results among the survivors were good - excellent in 14 of the 21 children and fair in 2. There were no side effects attributable to the povidone iodine. The method failed in 3 patients who had to be dealt with surgically. Staphylococcus aureus was the commonest organism responsible for empyema.

Purulent pericarditis

Eleven children under 16 years of age with purulent pericarditis were seen in one hospital in one year. The condition was always secondary to a septic focus elsewhere, usually staphylococcal pneumonia; its incidence after pneumonia was 0.64%, but this may be an underestimate. Clinical diagnosis can be difficult in patients with pneumonia as the heart is not always enlarged. Persistent or progressive liver enlargement was an important diagnostic feature. The presence of excess pericardial fluid was easily confirmed by echocardiography. Early diagnosis and drainage followed by continuous irrigation with 0.1% povidone iodine solution usually resulted in rapid recovery, but two patients died.

Ruptured abdominal aortic aneurysm in a 24-year-old African woman. Unusual presentation--unknown aetiology

CASE REPORT

24-year-old black female presenting with progressive paralysis of the left lower limb. The clinical examination and investigations describe an extensive retroperitoneal mass. An exploratory laparotomy reveals a ruptured saccular infrarenal aortic aneurysm, a narrowing of the distal aorta and a complete obstruction of the left common iliac artery. The aneurysm was resected, an aortoiliac bypass and femorofemoral crossover bypass were performed, with success. The clinical presentation of this ruptured abdominal aneurysm is unusual. Its etiology is discussed: the findings are suggestive of Takayasu's disease.