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Introduction: Surgical procedures performed for congenital heart disease are usually complex and variable. The aims of this paper were to analyse patient demographics in a centre that caters to congenital cardiac surgery, compare departmental standards to international centres, and investigate the relationship between patient volume and clinical outcome., Methods: A total of 163 patients who presented to the Cardiac, Thoracic and Vascular Surgery Department of the National University Hospital , Singapore between 2002 and 2006 were identified and studied retrospectively. Patient demographics were analysed. The mortality rates and patient volume were compared with those observed at international centres., Results: The mean annual patient volume was 32.6 cases. The mean age of the patients was 15.7 years, with the oldest patient being 73 years old. 57.1 percent of the patients were Chinese, 23.3 percent were Malay and 19.6 percent were Indian and other races. Foreigners made up nearly half of the patient cohort (45.4 percent). Atrial septal defect was found to be the most common diagnosis (n is 64), with the secundum being most commonly involved (76.9 percent). The commonest postoperative morbidities encountered were arrhythmias and pleural effusions. Patient volume was not found to be a significant factor affecting clinical outcomes., Conclusion: With a growing population of adults with congenital heart disease and a significant number of foreign patients, improvements to our resources and infrastructure need to be considered in order to cope with the increasing demands. Despite having a low patient volume, the centre is still able to provide congenital heart surgery with good clinical outcomes that are comparable to those of international centres with similar or higher patient volumes.

Introduction: Stroke is a debilitating complication of cardiac surgery. Many intraoperative and postoperative factors predict the likelihood of post-cardiac surgery stroke. We evaluated preoperative parameters, seeking correlations with adverse neurological outcome following cardiac surgery. We investigated the possibility of preoperative carotid ultrasonography to select patients for carotid endarterectomy pre- or intraoperatively., Methods: We conducted a retrospective analysis of 61 patients who suffered stroke post-cardiac surgery from 2003 to 2006. Data was collected for patient and disease characteristics, preoperative status, intraoperative events and postoperative course. Postoperative neurological complications were subdivided into three groups: mild/temporary events, moderate events such as seizures, and severe events such as stroke. A mild/temporary event was defined as a focal neurological deficit of less than 24 hours in duration., Results: A total of 2,226 cardiac cases were retrospectively evaluated. The frequency of stroke was 61 patients (2.7 percent). The mean age of these patients was 63.7 +/- 7.4 years, and 40 (65.6 percent) were males. Logistic EuroSCORE, left ventricular ejection fraction (as determined by two-dimensional echocardiogram) and aortic cross-clamp time were significantly correlated with postoperative neurological complications, with a p-value of less than 0.05 for all subgroups. There was a significant correlation between the presence of preoperative carotid disease (as proven by pre- and postoperative carotid ultrasonography) and postoperative neurological events (p-value equals 0.033). However, atrial fibrillation did not correlate with postoperative stroke., Conclusion: The stage of cardiac disease (risk factor level, ejection fraction and presence of carotid stenosis) correlates with stroke and may predict an adverse neurological outcome.

Introduction: We compared the accuracy of clinical nodal (cN) status N0-1 with that of pathological nodal (pN) status obtained from systematic mediastinal lymph node dissection (SMLD) in primary non-small cell lung cancer., Methods: Data from 22 consecutive patients, who underwent lung cancer resection and SMLD of at least three mediastinal lymph node stations, from November 2001 to May 2003, were ana1ysed retrospectively. Only patients with cN0-1 status on computed tomography (CT) referred for surgery, were included in this study., Results: Mean age of patients was 66.6 +/- 8.1 years with a male to female ratio of 17:5. Mean number of lymph node stations dissected was 5.8 +/- 1.8. 41 percent had squamous cell carcinoma, 45.5 percent had adenocarcinoma, and 4.5 percent each had large cell carcinoma, bronchioalveolar carcinoma or a lymphoepithelial carcinoma. pN2 metastases were found in 27.3 percent of patients. The sensitivity of cN0-1 was only 12.5 percent, with a specificity of 92.9 percent and an area under the receiver operating characteristics curve of 0.53. The positive and negative predictive values of cN0-1 status were 50 percent and 65 percent, respectively, with an accuracy of 59 percent. 41 percent of patients were understaged with 27.3 percent in pathological stage III. Curative resections were achieved in 59 percent of patients., Conclusion: The sensitivity of cN0-1 status based on CT alone is extremely poor when compared with pN status from SMLD. Based on cN0-1 status alone without SMLD, 27.3 percent of patients in pN2 would have been understaged. We recommend that all patients with cN0-1 status should undergo SMLD of at least three appropriate mediastinal node stations, for more accurate staging.

Introduction: Off-pump coronary artery bypass grafting (OPCABG) is gaining widespread acceptance as the preferred choice for myocardial revascularisation. However, no definite data exist as to whether it is better than conventional CABG. We aimed to study the efficacy of the procedure in our patients, which constituted of a predominantly Asian population., Methods: Between January 2000 and December 2002, 1062 patients underwent isolated coronary artery bypass in our institution. 184 patients (17.3 percent) underwent OPCABG. Patients were preoperatively prospectively risk stratified under the EuroSCORE risk assessment model under high, medium and low risk classes thereby making them comparable. Post-operative complications, intensive care unit stay, hospital stay, types of grafts done were then analysed in these different risk classes., Results: The incidence of off-pump procedures showed a gradual increase over the last three years in this institution. A reduction in the number of post-operative complications, hospital stay, intensive care unit stay and mortality in the off-pump group was observed. Certain differences were found to be statistically significant., Conclusion: Off-pump CABG is a safe and viable alternative to conventional CABG as a treatment modality for surgical coronary revascularisation.

Myxoma is the most common type of primary tumours of the heart in adults. Majority of these myxomas are found in the left atrium, followed by the right atrium and ventricles. We describe herein a patient who had a left atrial myxoma with interesting investigational results.

Enzymatic dissolution of haemothorax is highly effective in the evacuation of proteinaceous material from the pleural space. Its use in postcardiotomy haemothorax has not been described. We report the case of a 4-year-old girl with Fallot's Tetralogy diagnosed at birth. She underwent a total correction of Fallot's Tetralogy at 4 years of age. Chest X-ray taken post-operatively showed a large pleural collection in her right haemithorax. Repeated intraplueral infusion of purified streptokinase into the right upper pleural chest tube greatly reduced the extent of the right haemothorax. Enzymatic dissolution of haemothorax by purified streptokinase has proven to be a rapid and successful method of therapy. It has provided an alternative which is less invasive and has a low morbidity.

Congenital communications between the coronary artery and cardiac chambers are rare. The majority of cases present in adulthood. We report a patient with a coronary cameral fistula in which surgical closure of the fistula was performed at 10 weeks of age at a weight of 3.9 kg. We recommend early closure of coronary cameral fistula in symptomatic patients. Low weight or young age at presentation should not be a limiting factor.

The advent of the pacemaker has opened a whole new dimension to management in cardiology. Although its use has been well described in adults, its role in paediatric cardiology has proven to be equally exciting and challenging. We describe a case of a child with complex cyanotic heart disease who had an insertion of a cardiac pacemaker via the transvenous route, one of the youngest to be performed locally. This article also highlights the pertinent features of paediatric pacemaker therapy, including its indications and implantation technique.

Cardiac myxomas are rare and noted for their varied clinical manifestations. Consequently, the diagnosis is often unsuspected until the symptoms and signs become advanced and obvious, or when the diagnosis is made fortuitously during echocardiography. This report illustrates a case in point in which the diagnosis was made on transthoracic echocardiography and amplified using transesophageal echocardiography.

We report a case of mitral stenosis with a large left atrial thrombus which was obstructing pulmonary venous inflow where the conventional use of the pulmonary capillary wedge pressure as an approximation of the left atrial pressure during diagnostic cardiac catheterisation led to the over-estimation of the severity of mitral stenosis.

Thymomas are normally found in the superior mediastinum or the upper part of the anterior mediastinum. We report a case of thymoma arising in the inferior aspect of the anterior mediastinum. This case illustrates that thymic tissue may be found low in the anterior mediastinum and supports the practice of a median sternotomy approach for thorough mediastinal exploration in all cases of thymectomy.