Double annulus enlargement, Rastan-Manouguian's technique: a case report.

A 35-year old female patient underwent a double valve replacement. The operative findings revealed a small aortic annulus (about 17 mm in diameter). In order to implant the adequate-size prosthetic valve, the aortic and mitral annulus were enlarged using the technique described by Rastan and Manouguian. The annulus were enlarged with a patch of gel-sealed dacron graft. After the enlargement, the prosthetic valve No. 23A and 31M could be implanted in the aortic and mitral annulus, respectively. This is an effective technique to enlarge the aortic and mitral annulus in a double valve replacement procedure. The annular diameter could be increased approximately 30 per cent.

Effect of different oral anticoagulant intensities on prothrombin fragment 1 + 2 in Thai patients with mechanical heart valve prostheses.

The minimal intensity of oral anticoagulant required for antithrombotic protection in patients with a mechanical heart valve is still debatable, and that of the Westerner may not be directly applied to Thai patients. Our preliminary clinical review suggested that International Normalized Ratio (INR) 2-3 might be enough but it needs further supporting evidence. Therefore, we studied the effect of different anticoagulant intensities, expressed as INR, on the in vivo coagulation activation by measuring prothrombin fragment 1 + 2 (F1 + 2) in 116 patients with mechanical heart valve replacements. The patients had received warfarin for not less than one month with different intensities. The mean +/- S.D. of F1 + 2 level in 30 normal controls was 0.7 +/- 0.17 nmol/L. After excluding two outliers, the maximum linear correlation between INR and F1 + 2 was -0.658 (p < 0.001) when only patients whose intensities were lower than INR3 were taken into account. Adding more data from the patients having higher intensities decreased the correlation coefficient. The patients were subsequently classified by INR values in the range INR 1.1-1.9, 2-3 and 3.1-4.2. The F1 + 2 in each group was 0.6 +/- 0.30, 0.28 +/- 0.13 and 0.24 +/- 0.13 nmol/L respectively. The F1 + 2 in the first group did not differ from normal (p = 0.119) but was higher than the others (p = 0.000). The latter two groups had no difference between them (p = 0.112). Hence, from the laboratory point of view, we did not see additional benefit in the reduction of thrombin activation by the anticoagulant intensities higher than the range INR 2-3. The evidence supported that this therapeutic range might be enough for Thai patients with mechanical heart valves.

Intraoperative transesophageal echocardiography: preliminary experience at Siriraj hospital.

In order to evaluate the result of intraoperative TEE monitoring for cardiothoracic surgery, 113 patients were involved in this study. They included 65 males and 48 females, with an average age of 48.8 +/- 16.6 years, ranging from 10 to 74 years. The pre-operative diagnoses consisted of 41.6 per cent coronary artery disease, 34.5 per cent valvular disease, 12.4 per cent congenital heart disease, 8 per cent aortic aneurysm or aortic dissection, and 3.5 per cent of miscellaneous. The TEE appeared to provide accurate information by beating to changes in the left ventricular preload and contractility in all patients. The severity of valvular dysfunction, intracardiac air/mass, Swan Ganz catheter position, sites of congenital heart defect and aortic dissection were either assessed or reconfirmed during the operation. The ease of TEE technique was satisfactory, since unsuccessful attempt was observed in only 1.8 per cent. One patient died from rupture of thoracic aortic dissection which was related to TEE probe insertion. These data suggest the favorable result of intraoperative TEE as a valuable tool for monitoring in cardiothoracic surgery. Although the technique is simple, special precaution must be observed for patients suffering from acute aortic dissection.