Abstracts Najaarsvergadering 6 november 2009

Nederlandse Vereniging
voor Thoraxchirurgie
Mercatorlaan 1200
3528 BL UTRECHT
Tel: Fax: Email: website:
030 - 282 31 75
030 - 282 31 76
secretariaat@nvtnet.nl
www.nvtnet.nl
Nederlandse Vereniging
voor Thoraxchirurgie
Najaarsvergadering
Domus Medica
Mercatorlaan 1200
3528 BL UTRECHT
Vrijdag 6 november 2009
Tel:
030 - 282 39 11
Domus Medica Utrecht
Inhoudsopgave
Sponsors
2
Organisatie, accreditatie, ALV
3
Programma en Zaalindeling
4
Abstracts
6
Routebeschrijving Domus Medica
20
Notities
22
1
Sponsors
Organisatie, accreditatie, ALV
Dit congres wordt mede mogelijk gemaakt door:
Drs. A.B.A. Vonk
Krijnen Medical Innovations B.V.
Abstractcommissie
Prof. dr. J.G. Maessen (voorzitter)
Prof. dr. P.H. Schoof
Prof. dr. L.A. van Herwerden
Drs. P. Klein
P. Segers
ATS Medical
Synthes b.v.
Vascutek b.v.
Cardiac Care
Inschrijving en accreditatie
Alle leden van de Nederlandse Vereniging voor Thoraxchirurgie wordt verzocht de presentielijst te
tekenen.
Datascope BV
Deze najaarsvergadering wordt geaccrediteerd en gewaardeerd met 8 punten.
Maquet Netherlands bv
Baxter B.V.
Sorin Group Nederland bv
Ethicon, Johnson & Johnson
De leden die voor accredidatie in aanmerking komen ontvangen na het tekenen van de presentielijst een deelnamebevestiging per mail.
Algemene Ledenvergadering
Toegang tot de algemene vergadering hebben alle gewone leden van de vereniging, alle bestuursleden, alle ereleden, alle senior leden alsmede de voorzitter en secretaris van de Juniorkamer.
Medtronic b.v.
Edwards Lifesciences b.v.
Nycomed bv
Fysicon medical technology
Covidien Nederland B.V.
Zoll International holding b.v.
2
3
Programma en Zaalindeling
Programma en Zaalindeling
9.15 – 9.45 uur Ontvangst en inschrijving
Foyer
9.45 – 10.45 uur Wetenschappelijke vergadering
Auditorium 5 en 6
9.45 uur B.M.J.A. Koene
EVALUATION OF THE EUROSCORE RISK
SCORING MODEL
14.00 – 15.00 uur Presentatie en discussie over 2 nieuwe richtlijnen
- Richtlijn klepchirurgie (gebaseerd op de ESC-richtlijn
voor klepchirurgie)
- Richtlijn management van antistollingsbehandeling in
de hartchirurgie (gebaseerd op de “Guideline on
antiplatelet and anticoagulation management in
cardiac surgery” van de EACTS).
10.00 uur A.L. van Duijn
ANTICOAGULATION AND STROKE IN PATIENTS
WITH A VENTRICULAR ASSIST DEVICE
10.15 uur A.F.L. Later
THE EFFECT OF ANTIFIBRINOLYTICS ON PLASMA
CYTOKINE LEVELS IN CARDIAC SURGERY
11.15 – 12.15 uur Algemene Ledenvergadering
11.15 – 12.15 uurAlternatief programma verzorgd door de juniorkamer
11.15 – 12.15 uur Alternatief programma NP’ers en PA’s
12.15 – 13.15 uur Lunch
13.15 – 14.00 uur Wetenschappelijke vergadering
13.15 uur M.A. Zandee
MINIMALLY INVASIVE MITRAL VALVE SURGERY
THROUGH RIGHT MINI ANTEROLATERAL
THORACOTOMY: RESULTS OF 221
CONSECUTIVE PATIENTS
13.30 uur B.P. van Putte
PREDICTORS OF 30-DAY MORTALITY AFTER
AORTIC ROOT REPLACEMENT WITH A
MECHANICAL VALVE PROSTHESIS IN A
SERIES OF 528 PATIENTS
4
Auditorium 5 en 6
Presentatie: R.M.J. Klautz
Met de visie van een cardioloog
15.00 – 15.30 uur Koffiepauze
10.30 uur N.J. Verberkmoes
THROMBOCYTOPENIA AFTER AORTIC VALVE
REPLACEMENT: COMPARISON BETWEEN
MECHANICAL AND BIOLOGICAL VALVES
10.45 – 11.15 uur Koffiepauze
13.45 uur A. Tjon
OUTCOME AFTER VALVE-SPARING AORTIC
ROOT SURGERY WITH THE REIMPLANTATION
AND REMODELING TECHNIQUE
15.30 – 16.15 uur Wetenschappelijke vergadering
Foyer
Auditorium 5 en 6
Boerhaavezaal 1 en 2
Pieter van Foreest-zaal (C4)
Foyer + Auditorium 1
Auditorium 5 en 6
Foyer
Auditorium 5 en 6
15.30 uur M.A. Soliman Hamad
PERIPHERAL VASCULAR DISEASE AS A
PREDICTOR OF SURVIVAL AFTER CORONARY
ARTERY BYPASS GRAFTING: COMPARISON
WITH A MATCHED GENERAL POPULATION
15.45 uur M.B. de Jong
INITIAL EXPERIENCE WITH A PORTABLE
DIGITAL DRAINAGE SYSTEM
16.00 uur M.A. Paul
POST-PNEUMONECTOMY SYNDROMES:
THE HEART, THE BRONCHUS OR THE VEINS?
16.15 uur Film
PNEUMONECTOMY IN THE LATE FORTIES
16.30 – 16.45 uur Tekenen voor accreditatie
16.45 – 17.00 uur Uitreiking assistentenprijs
Ter beschikking gesteld door Cardiac Care
en Maquet
16.30 uur Borrel
Foyer - Inschrijfbalie
Foyer
Foyer
5
Abstracts
Abstracts
9.45 uur
EVALUATION OF THE EUROSCORE RISK SCORING MODEL
Purpose
Measuring quality of institutions by means of mortality rates demands accurate risk scoring
models. Detection of differences in operative mortality is important to allow meaningful comparisons. We evaluated the predictive ability of the additive and logistic EuroSCORE.
Results
The area-under-the-ROC-curves showed good discriminatory power for the additive and logistic
EuroSCORE for all the groups. Cusum and VLAD analyses showed that the predicted mortality
was higher than the actual mortality in the AVR and CABG group. This was not true for the
mitral valve surgery group. Comparison of the additive and logistic EuroSCORE with the predicted probability showed that the logistic EuroSCORE was a better predictor of hospital mortality
especially in high risk patients (Fig 1). Both additive and logistic EuroSCORES overestimated the
operative risk in low risk patients. The additive EuroSCORE underestimated the risk in high risk
patients.
Methods
Data of isolated CABG, aortic and mitral valve surgery patients from 2004 till 2008 were
analyzed. The discriminatory power of the additive and logistic EuroSCORE was analyzed using
ROC-curves. Comparison of observed with predicted mortality was done by cusum analyses and
VLAD-curves. The predicted probability of hospital mortality was calculated using logistic regression analyses and compared with the EuroSCORE.
Conclusion
The additive and logistic EuroSCORE had a good discriminatory power meaning that most
deceased patients had a high EuroSCORE. For low risk patients they both overestimated the mortality. In high risk patients the logistic EuroSCORE was more accurate than the additive
EuroSCORE which underestimated the operative risk.
BMJA Koene, MESH Tan, MA Soliman Hamad, FJ ter Woorst, E Berreklouw, AHM van Straten
Catharina Hospital Eindhoven
Figure 1. EuroSCORE predictive ability
6
7
Abstracts
Abstracts
10.00 uur
ANTICOAGULATION AND STROKE IN PATIENTS WITH A VENTRICULAR
ASSIST DEVICE
AL van Duijn1, AJC Slooter1, L Peelen2, E Sukkel3, JR Lahpor3, WM van den Bergh1
1
Department of Intensive Care, University Medical Centre Utrecht, the Netherlands
Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht,
the Netherlands
3
Department of Heart and Lung, University Medical Centre Utrecht, the Netherlands
2
Purpose
The purpose of this study has been to investigate the association of anticoagulation and thromboembolic stroke in VAD (ventricular assist device) patients. Currently, the first version of the
article is being written.
Methods
We studied all 127 patients who received a VAD in the University Medical Centre Utrecht until
July 2009. Based on available patient data, the occurrence and type of a stroke was determined.
Patients without a stroke (controls) were censored at the moment of heart transplantation, VAD
explantation or death. The coagulation at these moments was used for comparison. Subjects
were classified according to levels of aPTT ratio and INR. The Fishers Exact test was used to
detect differences in baseline characteristics and coagulation levels.
Results
In total, 123 patients were taken into analyses. Forty-one strokes occurred in 24 patients,
leaving 99 controls. Except for preoperative cardiac index there were no significant differences in
baseline characteristics. Comparing case control status with the categories of both coagulation
markers at the moment of event, we found no significant association.
Conclusion
Ventricular assist devices (VAD) are successfully and increasingly used in patients with end stage
heart failure. Despite technical improvement and experience, the high incidence of stroke remains
a major concern. The optimal risk/benefit analysis of anticoagulation in these patients has yet
to be determined; further prospective research should be performed to investigate the role of
anticoagulation and stroke in VAD patients.
8
9
Abstracts
Abstracts
10.15 uur
10.30 uur
THE EFFECT OF ANTIFIBRINOLYTICS ON PLASMA CYTOKINE LEVELS IN
CARDIAC SURGERY
THROMBOCYTOPENIA AFTER AORTIC VALVE REPLACEMENT: COMPARISON
BETWEEN MECHANICAL AND BIOLOGICAL VALVES
AFL Latera, J van Peltb, EF Bruggemansa, FPHTM Romijnb, RJM Klautza
Albert HM van Straten1; Mohamed A Soliman Hamad1; NJ Verberkmoes1; Eric Berreklouw1; Joost
F Ter Woorst1; Elisabeth J Martens2 and M Erwin SH Tan1
Department of Cardiothoracic Surgery and
Universitair Medisch Centrum.
a
Department of Clinical Chemistry, Leids
b
Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
Department of Education and Research, Catharina Hospital, Eindhoven, The Netherlands
& Centre of Research on Psychology in Somatic Diseases, Department of Medical
Psychology, Tilburg University, The Netherlands
1
2
Purpose
In the light of the recent concerns about the use of aprotinin in cardiac surgery, the clinical advantages of antifibrinolytics need to be re-evaluated, including their possible immune modulating
effects. We measured the effect of tranexamic acid as well as aprotinin on the systemic inflammatory response after cardiac surgery.
Methods
28 Patients scheduled for first-time, non-complex heart surgery with use of cardiopulmonary
bypass (CPB) were randomised to receive either high-dose tranexamic acid, aprotinin, or 0.9%
saline solution intraoperatively. 10 Additional patients receiving dexamethasone but no antifibrinolytics intraoperatively were selected for comparison of effects. Plasma levels of 12 cytokines
and growth factors were assessed preoperatively, and at 6-, 12-, 24-, and 48-hours after the
start of CPB, using Evidence InvestigatorTM biochip array technology.
Results
IL-2, IL-4, IL-6, IL-8, IL-10, VEGF, IFN-c, TNF-a, MCP-1, and EGF plasma concentrations
significantly changed over time in all 4 treatment groups, whereas those of IL-1a and IL-1ß did
not change. Both aprotinin and dexamethasone significantly lowered TNF-a plasma levels when
compared with placebo to the same extent (mean difference -2.3 pg/ml, P=0.042, and -2.8 pg/
ml, P=0.009, respectively). Tranexamic acid did not significantly differ from placebo.
Conclusion
Aprotinin attenuates postoperative pro-inflammatory levels TNF-a to the same extent as dexamethasone, whereas tranexamic acid does not. A common anti-inflammatory effect of tranexamic
acid and aprotinin through inhibition of fibrinolysis seems therefore unlikely.
Purpose
Some concerns about the postoperative decrease in platelet count after aortic valve replacement
(AVR) have been recently raised. We retrospectively analysed the data of our patients after AVR
concerning postoperative platelet count.
Methods
Data of all patients undergoing AVR with (n=829) or without (n=1230) coronary artery bypass
grafting (CABG) in a single centre between January 1998 through May 2009 were analyzed.
The lowest platelet count (minimum platelet count) within the first five postoperative days was
determined.
Results
Four hundred one patients received an ATS mechanical prosthesis (ATS), 791 patients a St
Jude mechanical prosthesis (SJ), 618 patients a Carpentier-Edwards Perimount bioprosthesis
(CEP), 213 patients a Medtronic Freestyle stentless bioprosthesis (FRE) and 36 patients a Sorin
Freedom Solo stentless bioprosthesis (SFS). Using multivariate linear regression model, the
following independent risk factors for a lower postoperative platelet count were revealed: age,
body surface area, active endocarditis, preoperative platelet count, duration of extracorporeal
circulation, number of grafts, valve size and the number of transfused FFP and RBC. Entering the
type of prostheses into the multivariate linear regression analysis together with the other risk
factors, patients with CEP and FRE valve prosthesis had a lower minimum postoperative platelet
count than those having mechanical prostheses (ATS and SJ).
Conclusion
Patients undergoing aortic valve replacement with a Carpentier-Edwards Perimount bioprosthesis
and those with a Medtronic Freestyle stentless bioprosthesis have a lower minimum platelet
count within the first five postoperative days compared to the ATS and St. Jude mechanical
prostheses. No differences were found between the Sorin Freedom Solo and all other valve
prostheses.
10
11
Abstracts
Abstracts
13.15 uur
13.30 uur
MINIMALLY INVASIVE MITRAL VALVE SURGERY THROUGH RIGHT MINI
ANTEROLATERAL THORACOTOMY: RESULTS OF 221 CONSECUTIVE
PATIENTS
PREDICTORS OF 30-DAY MORTALITY AFTER AORTIC ROOT REPLACEMENT
WITH A MECHANICAL VALVE PROSTHESIS IN A SERIES OF 528 PATIENTS
MA Zandee, A Yilmaz, TL de Kroon
Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
Division of Cardiothoracic Surgery, St. Antonius Ziekenhuis Nieuwegein, The Netherlands
Purpose
Evaluation of short-term results after port-access mitral valve surgery.
Methods
From November 2005 to July 2009, data of 221 consecutive patients were obtained retrospectively from medical charts and follow-up completed.
Results
Indication for operation was mitral stenosis in 10 (5%) patients and mitral regurgitation in 211
(95%) patients. The pathology of valve disease was was degenerative disease in 160 (72%),
reumatic or sclerotic disease in 25 (11%), annular dilatation in 24 (11%), ischemic disease in 2
(1.0%) and congenital in 1 (0.5%) patients. Nine patients (4.1%) had post-endocarditis lesions
and one patient had active endocarditis. Six (3%) patients had prior sternotomy. Valve repair was
achieved in 177 (80%) while 45 patients had replacement. Repair rate for degenerative disease
was 88%. Concommitant procedures were pulmonary vein isolation in 16 (7.2%), primary ASD
closure in 15 (6.8%) and TVP in 5 (2.3%).
Follow-up was achieved in 93%. In hospital mortality was 4 (1.8%). Three other patients died
(two non-cardiac cause) during the mean follow-up of 635 days (90-1421). Eight (3.6%) patients
were reoperated due to recurrent regurgitation and one (0.5%) patient due to thrombosis in the
left atrial appendage. After follow-up 74.6% of all patients were in NYHA class I or improved at
least one class.
Conclusion
Our serie shows a high repair rate, low mortality and general good functional recovery after portaccess mitral valve surgery.
12
BP van Putte, S Siddiqi, MAAM Schepens, RH Heijmen and WJ Morshuis
Purpose
Aortic root replacement with a mechanical valve prosthesis is a widely accepted surgical technique. This study aims to evaluate short-term outcome of this approach and to identify predictors
of 30-day mortality.
Methods
We retrospectively analyzed a consecutive series of 528 patients (mean age: 54 ± 13 years)
who underwent aortic root replacement for aneurysm (83%), acute type A dissection (15%) or
endocarditis (2%) in the period between 1974 and 2008. The mean time of follow-up was 5.5 ±
6.5 years (range 0-32.9). Concomitant aortic surgery was performed in 71%, coronary revascularization in 18% and mitral valve surgery in 3%. Selective antegrade cerebral perfusion (SACP)
was applied in 25% and deep hypothermic circulatory arrest (DHCA) in 28% of patients. SPSS
version 15.0 was used for statistical analysis.
Results
Overall 30-day mortality was 3.2%: 2.5% for elective surgery and 6.5% for emergent surgery.
Morbidity included resternotomy for bleeding or tamponade (20%), pacemaker implantation
(3.6%), myocardial infarction (4.0%) and neurological damage (1.6%). Multivariate analysis
revealed myocardial infarction (p<0.001) and the lack of usage of glue (p=0.018) as independent predictors of 30-day mortality. Subanalysis of the SACP and the DHCA patients revealed
infarction (p=0.005) and coronary artery disease (p=0.45) for SACP and wrapping (p=0.035) for
DHCA as independent risk factors.
Conclusion
Aortic root replacement with a mechanical valve prosthesis can be performed safely with low
mortality and acceptable morbidity. Perioperative myocardial infarction is the strongest independent risk factor of 30-day mortality.
13
Abstracts
Abstracts
13.45 uur
15.30 uur
OUTCOME AFTER VALVE-SPARING AORTIC ROOT SURGERY WITH THE
REIMPLANTATION AND REMODELING TECHNIQUE
PERIPHERAL VASCULAR DISEASE AS A PREDICTOR OF SURVIVAL AFTER
CORONARY ARTERY BYPASS GRAFTING: COMPARISON WITH A MATCHED
GENERAL POPULATION
A Tjon, MT Letsch, DR Koolbergen, MG Hazekamp, MIM Versteegh, RJM Klautz
Dept. of Cardio-Thoracic Surgery, Leiden University Medical Center, Leiden
Purpose
In this study we report and compare the results of valve sparing aortic root surgery with the
reimplantation technique as described by David (reimpl) and the remodeling technique as described by Yacoub (remod) concurrent with or without aortic leaflet repair (AVP).
Methods
From January 1999 43 patients underwent reimpl (of which 10 with AVP (reimpl+AVP)) and
19 a remod (of which 7 with AVP (remod+AVP)). Mean age for the reimpl was 49,4 (19-67),
for the remod 58,1 (40-75). Etiologies were root aneurysm (reimpl 32/43, remod 11/19) and
acute aortic dissection (reimpl 11/43, remod 8/19). Clinical and echocardiographic follow-up was
complete with a mean follow-up of 4,2 years.
Results
Early mortality in the reimpl group was 1/43, in the remod group 1/19. Late mortality was respectively 1 and 3. At follow-up 7 patients developed AoI grade 3 or more (reimpl (1), remod (3),
remod+AVP (3)), 7 developed AoI grade 2 (reimpl (1), reimpl+AVP (3), remod (1), remod+AVP
(2)) and in all others (n=42) the AoI was grade I or less. 5 patients were reoperated, all in the
remod group. Only 2 patients were in NYHA class III (reimpl) and all others in I or II.
Conclusion
The reimplantation technique seems a more durable repair compared to the remodeling technique; this was not influenced if concomitant AVP was performed. Patients with acute aortic
dissection can have a valve sparing root reconstruction with low mortality; in our opinion this is
the operation of choice for young patients if the clinical situation allows it.
14
MA Soliman Hamad1; Cristina Firanescu1; Joost FJ ter Woorst1; M Erwin SH Tan1;
Eric Berreklouw1; Elisabeth J Martens2; and Albert HM van Straten1.
Department of 1Cardiothoracic Surgery, and 2Education and Research, Catharina Hospital,
Eindhoven, The Netherlands
Purpose
The most popular European scoring system in cardiac surgery, the EuroSCORE, uses the
extracardiac arteriopathy as a risk factor for early mortality. We studied the effect of peripheral vascular disease (PVD) on early and late mortality in a large group of patients undergoing
isolated CABG.
Methods
During a 10-year period (January 1998 through December 2007) 10 626 patients underwent
isolated CABG in our hospital. The primary endpoints of this study were early and late all-cause
mortality. For each year of the study period, general population cohorts were matched with the
patient groups for age and gender (expected survival).
Results
Out of 10 504 patients included in the analysis, 1222 (11.63%) patients had PVD. Peripheral
vascular disease (PVD) was not identified as an independent risk factor for early mortality with a
hazard ratio of 1.06 (0.70-1.60), P= .776. For late mortality, PVD was found as an independent
risk factor with a hazard ratio of 1.67(1.43-1.95), P<.0001. Patients without PVD had a better
survival than patients with PVD (log–rank P <0.0001) and even a better survival compared to
the normal Dutch population survival (p-value < .002). PVD patients had a worse than expected
survival (log-rank P<.0001).
Conclusion
Peripheral vascular disease is an independent risk factor only for late mortality but not for early
mortality. Compared to age and sex matched cohorts from the general Dutch population, the
10-year survival of patients with peripheral vascular disease was worse; whereas the survival of
patients with no peripheral vascular disease was better.
15
Abstracts
Abstracts
15.45 uur
INITIAL EXPERIENCE WITH A PORTABLE DIGITAL DRAINAGE SYSTEM
MB de Jong, A Huijbers, WH Steup
General surgery, Haga Hospital, The Hague
Purpose
Air leaks are one of the most common pulmonary complications after pulmonary resection and
they are the most frequent cause of prolonged hospital stay. The traditionally used analogue pleural drainage system may be interpreted differently by different bedside observers. More recently
a digital pleural drainage system has been developed. This system enables us to quantify the size
of air leaks in ml/min. The purpose of this study was to compare the use of a digital drainage
system with the analogue drainage system.
Methods
From January 2008 to December 2008 al data of patients undergoing pulmonary resections
were gathered retrospectively. They all received the analogue system. From January 2009 until
August 2009 we gathered the data from all patients undergoing pulmonary resections who
received the Thopaz® digital system.
Figure 1 Kaplan-Meier survival curves of patients with and without peripheral vascular disease and the
survival of the normal Dutch population.
*survival of the normal Dutch population matched for age and sex with the PVD groups
log rank no PVD – expected
log rank PVD expected
P= 0.002
P=<.0001
No PVD – PVD
P=<.0001
16
Results
Eighteen patients received the Thopaz®, 12 anatomical resections and 6 wedge resections. The
results were retrospectively compared with 26 patients who received the analogue system, 20
anatomical resections and 6 wedge resections.
The ability to assess the air leak status continuously afforded quicker chest tube removal in the
digital group (mean, 1.5 vs 4.3 days) and reduced hospital stay (mean 7 vs 10.7 days).
Conclusion
The digital system reduces hospital length of stay by more accurately and reproducibly measuring
air leaks resulting in a quicker removal of the chest tube.
The ability to save data and present curves for the entire course of treatment will be an advantage for research in the field of lung surgery.
17
Abstracts
Film
16.00 uur
16.15 uur
POST-PNEUMONECTOMY SYNDROMES: THE HEART, THE BRONCHUS OR
THE VEINS?
PNEUMONECTOMY IN THE LATE FORTIES
MA Paul1, MAJM Huijbregts2, JWA Oosterhuis1
department of surgery, VU university medical center, Amsterdam
MA Paul, KJ Hartemink, JWA Oosterhuis
departments of 1) surgery and 2) cardiothoracic surgery, VU medical center, Amsterdam
Pneumonectomy requires considerable physiological and anatomical adaptations. These changes
may lead to several compression syndromes.
I. Kinking and narrowing of the airway is caused by displacement of the trachea with stretching of
the remaining bronchus over fixed structures, such as the spinal column or the descending aorta.
It occurs mostly in young people, especially after right pneumonectomy. Repositioning of the
mediastinum with the insertion of spacers is curative.
In the archives of the NOS (Dutch Broadcast Society) a 7 minute silent film was found which
clearly shows all aspects of a pneumonectomy. This film was dated 1938 and does not reveal
any name or institution. However, the intraoperative use of penicillin powder reveals it should be
dated in the late forties.
II. Intermittent kinking of the left pulmonary veins may follow right pneumonectomy The symptom
is acute pulmonary edema, position dependant. Dynamic ultrafast magnetic resonance (MR) imaging is required to obtain this diagnosis. Also in these patients, repositioning of the mediastinum
using spacers is curative.
III. Elevation of the right hemidiaphragm, especially after phrenic nerve injury, can cause compression of the heart. The clinical picture varies from collaps on exercise, due to compression of
the left ventricle, to right- sided heart failure caused by atrial compression. In one patient elevation of the right hemidiaphragm caused rotation of the heart with opening of the oval foramen.
The intracardiac shunting resulted in severe hypoxia.
This type of compression syndrome is easily treated by plication of the diaphragm.
Conclusion
Late onset dyspnea after pneumonectomy may have various causes, all caused by excessive
displacement of mediastinal structures. CT scanning is sufficient for the diagnosis of bronchial
compression, the other compression syndromes require MR imaging. Surgical correction provides immediate relief.
18
19
Routebeschrijving Domus Medica
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Bij het tweede stoplicht rechtsaf de Papendorpseweg blijven volgen.
U houdt rechts aan en neemt de 1e afslag rechts.
Aan het eind van deze weg rechts en met de bocht mee naar links.
Na ca. 100 meter neemt u de eerste inrit naar rechts. Hier bevindt zich de parkeergarage van
Domus Medica.
Vanuit Breda (A27 / A2):
Bij knooppunt Everdingen richting Utrecht-West (A2). Bij knooppunt Oudenrijn volgt u Ring
Utrecht (zuid).
Neem afrit 16 Nieuwegein / Papendorp.
Aan het einde van de afrit linksaf (Papendorpseweg).
Bij het tweede stoplicht rechtsaf de Papendorpseweg blijven volgen.
U houdt rechts aan en neemt de 1e afslag rechts.
Aan het eind van deze weg rechts en met de bocht mee naar links.
Na ca. 100 meter neemt u de eerste inrit naar rechts. Hier bevindt zich de parkeergarage van
Domus Medica.
Vanuit Den Haag / Rotterdam (A12):
Bij knooppunt Oudenrijn volgt u Ring Utrecht (zuid). Neem afrit 16 Nieuwegein / Papendorp.
Aan het einde van de afrit linksaf (Papendorpseweg).
Bij het tweede stoplicht rechtsaf de Papendorpseweg blijven volgen.
U houdt rechts aan en neemt de 1e afslag rechts.
Aan het eind van deze weg rechts en met de bocht mee naar links.
Na ca. 100 meter neemt u de eerste inrit naar rechts. Hier bevindt zich de parkeergarage van
Domus Medica.
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