Rupture of the left-ventricular free wall may not always result in immediate irreversible hemodynamic collapse. We report a series of five patients (4 male, 1 female; age 59-79 years) successfully operated for postinfarction free-wall rupture with good long-term results. Two patients presented with syncopy and acute tamponade three days after an acute myocardial infarction. In two patients with atypical chest pain and congestive heart failure, a large pericardial effusion and an extreme localized thinning of a myocardial scar region was seen several weeks after an uncomplicated myocardial infarct. In one patient a pseudoaneurysm was detected, which developed asymptomatically within three weeks after a posterior myocardial infarct. In all cases myocardial rupture was suspected after an echocardiographic examination. At surgery a hemopericardium and a localized rupture site were found. The surgical procedure included closure of the defect by direct suture or patch, CABG in 3 cases, and mitral valve replacement in one patient. The postoperative course was uneventful, only one patient needed IABP for 24 hours. Three patients returned to NYHA functional class I, one patient to class II, and one patient to class III. The latter patient died of heart failure 17 months postoperatively, and the other patients are still alive 4,18,24, and 26 months postoperatively. Thus clinical representation of left-ventricular free-wall rupture after myocardial infarction can be highly variable. But close cooperation between experienced echocardiographers and surgeons may allow successful corrections with good long term-results.

Current videoendoscopic technology and percutaneous techniques of exposure and dissection have been successfully applied to abdominal surgery with favorable results. Application of this technology to our practice of thoracic surgery is the basis of this report. Video-assisted thoracic surgery was performed in 36 patients for the following indications: Raynaud's syndrome, undefined pulmonary nodule, persisting spontaneous pneumothorax, T-1 bronchial carcinoma, and mediastinal cyst. Videoendoscopic surgical procedures were accomplished using double-lumen endotracheal anaesthesia and a percutaneous stapling device. Procedures performed using this technique include thoracic sympathectomy, wedge or keel excision, blebectomy, lung apex stapling, parietal pleurectomy, and dissection of the mediastinal cyst. Median operating time was 45 min (range, 15 to 90 min). Tissue diagnosis was obtained in all patients. Median diameter of excised nodules was 10 mm (range, 7 to 70 mm). There were no operative deaths. The single complication was a prolonged air leak. This new method of thoracic surgery appears to benefit the patients. For us it proved a secure way to perform thoracic surgery. Our case of removal of a benign cyst in the posterior mediastinum shows that video-assisted thoracic surgery has expanding applications in the field of general thoracic surgery.

Background: Current videoendoscopic technology and percutaneous techniques of exposure and dissection have been successfully applied to abdominal surgery with favourable results. Applications of this technology to our practice of thoracic surgery is the basis of this report.

A 41-year-old woman was admitted to the hospital for obstetric surgery. A preoperative chest x-ray film showed a mediastinal mass. After examinations with echocardiography, computed tomography, and magnetic resonance imaging, we removed a cyst that was 2.7 x 3.5 cm in size by thoracoscopic means. The patient left the hospital 3 days after the operation.

Peripheral undefined pulmonary nodules have become a favorable indication for the videoendoscopic approach in thoracic surgery. In our latest experience, we also successfully applied this technique in centrally located lesions of the lung. In reviewing our first 29 cases, we looked for preoperative features of videoendoscopic resectability. From March 1992 to September 1993, 29 patients underwent videothoracoscopy for undefined pulmonary nodules at our hospital. This group consisted of 17 men and 12 women (aged 25 to 77 years). Pulmonary nodules of this group of patients were defined as centrally located when close attachment to the segmental or subsegmental bronchopulmonary unit was observed and/or the distance to the visceral pleura exceeded 10 mm. Nodules that did not meet any of these criteria were hence interpreted as peripheral lesions. In the course of 21 excisions of peripheral lesions, we had to convert to open thoracotomy only once for anatomic reasons. When using the video-assisted thoracic surgery (VATS) approach for centrally located lesions, we succeeded in removing four of six. We failed only if the lesions were located in the upper lobe but could easily apply the technique for centrally located lesions in the lower lobes. In conclusion, undefined peripheral pulmonary nodules are a favorite indication for VATS. Centrally located pulmonary nodules of the lower lobes can often be managed easily by VATS, especially if the interlobar fissure extends to the stem of the pulmonary artery. Centrally located pulmonary nodules in the upper lobes may not be suitable for the VATS approach due to the special anatomic arrangement of the upper lobe segmental arteries and bronchioles.