Recent Advancement in Non-surgical Interventional Treatment in Congenital Heart Disease at National Institute of Cardiovascular Disease (NICVD)-a Tertiary Care Hospital of Bangladesh.

Background: Treatment of Congenital Heart Disease (CHD) is either Surgical or Interventional. Medical management is mainly symptomatic / palliative. Although surgery is the main mode of treatment but in the recent past non-surgical Interventional method is replacing it because of its multiple advantages over surgical procedures. Since 2005, we started our journey in National Institute of Cardiovascular Diseases with a PDA device closure. In this article we tried to review the success rate of the interventional procedures in this hospital. Methods: The aim of this retrospective study is to review the short term & Intermediate outcome of the non surgical interventional treatment of congenital heart diseases. We included all the interventional rocedures done in this Institute since 2005 upto December 2013. Results: During this period, we performed total 150 cases of patent ductus arteriosus (PDA) device, 20 cases of PDA Coil closure, 60 cases of atrial septal defect (ASD) device, 90 cases of Balloon Pulmonary Valvuloplasty (BPV), 20 cases of Balloon Aortic Valvuloplasty (BAV), 22 cases of Coarctation Balloon Angioplasty, 35 cases of Mitral Valvuloplasty (PTMC), 15 cases of Balloon Atrial Septostomy. Almost all of our intervention procedures were successful except one case of mortality related to procedure of PDA device closure, 4 device embolization (2 ASD & 2 PDA) and one case of PDA coil with persistent Intravascular hemolysis. All the embolized devices were subsequently retrieved surgically with repair. All other patients of interventional treatment are enjoying new life without any morbidity. Conclusion: Thus, we concluded that interventional methods of suitably selected case of congenital heart disease may be an alternative lucrative safe & effective option of remedy for many of the congenital heart diseases.

A Case Report on Unilateral Double Testicles.

A unilateral double testicle is a rare anomaly characterized by migration of one testicle towards the opposite inguinal canal. The commonest erratic development is the more or less incomplete descent of the testicle along the normal route of descent, which is known as cryptorchidism. In ectopia of the testicles, as opposed to cryptorchidism, the displaced testicle does not descend along the usual route but as it migrates downwards it moves into an entirely abnormal position. Usually the migrating testicle remains on its own side of the body but may end up in an unusual position e.g. in the superficial tissue of the inguinal region above the external ring, in the area of the base of the penis, in the upper part of the thigh, in the region of perineum or in the pelvic cavity. In this case, the right and left testicles were found to descend together on the right side, whereas the left side of the scrotum was entirely empty. The case was treated with 'Bilateral Transeptal Subdartos Orchidopexy'. The case reported here is evidently one of extreme rarity as there are about 148 reported cases since the first described by Von Lenhossek in1886.

Management Strategy and Outcome of Epidural Haematoma in Relation to Volume.

Epidural Haematoma (EDH) develops in 1-3% of all major head injuries and most common in the young. This crosssectional descriptive study was done to find out the management strategy and outcome of EDH in relation to clot volume. This study was performed from December'2006 to November'2007, by purposively selecting 77 cases of EDH from the Department of Neurosurgery, Dhaka Medical College Hospital (DMCH), Dhaka. The study showed that highest number of patients was in most active period of life, with male predominance (Male: Female =7.5:1). Causes of EDH were mostly due to assault (37.7%), followed by RTA (32.5%) and fall from height (29.8%). The study showed Patient having EDH Volume (EDHV) > 30ml will have 8.55 times more chance of having unfavorable outcome than patient having EDHV < 30 ml. Patient having EDHV > 30 ml will have 187.83 times more chance of requiring surgical intervention than those having EDHV <30 ml, which is statistically highly significant (p<0.001). Mortality rate of EDH can be reduced by giving early management either conservative or surgery. Delay in the management of EDH patients with poor level of consciousness and EDHV >30 ml has adverse effect on mortality and morbidity.

Single Stage Urethroplasty for Proximal Hypospadias with Chordee.

Proximal hypospadias with chordee usually requires two stage procedures: 1st stage is orthoplasty and ventral parking of prepucial skin and 2nd stage is urethroplasty after 6 months of 1st stage. The aim of this study is to describe and report the outcome of a single stage repair- Koyanagi Nanamura procedure for proximal hypospadias with chordee. Between January 2006 to December 2010, 44 boys with proximal hypospadias underwent repair using the Koyanagi Nanamura technique in Paediatric Surgery Department of Faridpur Medical College Hospital and Dhaka Medical College Hospital. The boys' age ranged from 1 to 7 years. The technique employs the use of lateral penile skin and extends into the inner preputial skin. This flap enjoys double blood supply from the base of the meatus as well as the preputial vessels. Follow-up period was 6 months. Satisfactory results were obtained in 39 (88.6%) patients. Three patients developed fistulae. Two patients developed meatal stenosis. Results were considered satisfactory when the boy achieves a glanular meatus, single forward stream, unimpeded voiding, good cosmesis, and no need for secondary surgery for the urethra. Koyanagi Nanamura procedure is a reliable procedure in which the lateral flaps have dual blood supply, which produces good results (88.6%) and is suitable for proximal forms of hypospadias with chordee.

Infantile Hypertrophic Pyloric Stenosis - Experiences of 77 Cases.

Infantile hypertrophic pyloric stenosis (IHPS) is the most common cause of gastric outlet obstruction in infants which needs surgical treatment. The aim of this study was to review the management of IHPS in our hospital to compare with other developed centers. This is a prospective analytical study carried out in the Department of Pediatric Surgery, Faridpur Medical College Hospital and Dr. Zahed Children Hospital at Faridpur, during the period of May 2002 to October 2010. Total 77 patients were treated by Ramstedt's pyloromyotomy after proper diagnosis and resuscitation. The male to female ratio was 10:1. Most of the patients presented to us within 40 days of age (90%).Younger one was 15 days and elder one was 69 days. In all cases diagnosis were done on clinical basis. The diagnosis is confirmed by barium meal x-ray in 71 cases and sonogram in 15 cases. Serum electrolytes were not estimated in all patients. There was moderate to severe dehydration in more than 60% cases. 71 cases were operated under general anesthesia and 06 cases were operated with local anesthesia. There was one postoperative death on 4th post-operative day. Oral feeding started after 8 to 10 hours postoperatively in all cases. Mucosal perforation occurred in 1 case and that was recognized and treated conservatively without any ill effect. Superficial wound infection encountered in 3 cases. Early diagnosis, preoperative correction of dehydration and electrolyte imbalance and experiences of surgeons play important role for management of IHPS.

Residual Ventricular Septal Defect after Surgical Repair of TOF—A Case Report.

Residual Ventricular septal defect after surgical repair for Tetralogy of fallot(TOF) can occasionally be heamodynamically important requiring re-intervention.Closed observation and followup make this defect heamodynamically insignificant, required no medication and no endocarditis.We describe one patient having residual defect after surgical repair of TOF.

Patients with Left Ventricular (LV) Dysfunction: Is OPCAB Advantageous over Conventional CABG in our settings.

Objective: Off-pump CABG (OPCAB) is a well established surgical procedure in Bangladesh now. Majority of Bangladeshi patients having CABG are undergoing OPCAB procedures these days. Patients with left ventricular dysfunction are known to be particularly at risk of complications after surgical coronary revascularization. Off-pump procedure can be considered in these patients, avoiding the potentially damaging effect of cardiopulmonary bypass (CPB). Patients with left ventricular dysfunction are thus thought to be ideal OPCAB candidates. This study is undertaken to check the advantage of OPCAB over conventional CABG of Bangladeshi patients with left ventricular dysfunction. Methods: This is a prospective clinical trial done in National Institute of Cardiovascular Diseases (NICVD), Dhaka during the period of January 2006 to Dec 2007. Among the 52 patients 26 patients underwent OPCAB with preoperative ejection fraction (EF) 35.2±3.2% and rest 26 patients had conventional bypass (CCABG) with preoperative EF 33.4±3.8%. Different variables were evaluated and compared. Echocardiography was used both pre and postoperatively to assess the LVEF, LVIDd and LVIDs and regional wall motion abnormality and to assess the presence or absence of ischemia or infarction. Data were collected by interview schedule and checklist. Data were analyzed by standard statistical methods. Results: In this small series of patients with left ventricular dysfunction, off-pump CABG was carried out with good early outcome; with low mortality and morbidity and significant improvement in postoperative left ventricular function. There was no significant difference between the groups in terms of change in EF, LVIDd and LVIDs. Conclusion: From this study it can be concluded that both the surgical strategies improved the myocardial function and early outcome in patients with left ventricular dysfunction. However OPCAB surgery has a somewhat better result regarding ventilation time and ICU stay. Thus both OPCAB and on pump surgery can be performed safely and effectively in patients with left ventricular dysfunction with good results and low mortality.

Significance of MRSA strains in community associated skin and soft tissue infections.

The study was conducted to determine the antibiotic susceptibility profile of community-associated methicillin resistant Staphylococcus aureus (CAMRSA) strains isolated from infections. S. aureus strains were isolated from clinical specimens using the standard procedures. CDC definition was used to classify CAMRSA. Antibiotic susceptibility test was done using Kirby-Bauer disk diffusion method. Double disk diffusion method (D-test) was used to detect inducible macrolide, lincosamide and streptogramin B resistance (inducible MLS B resistance ) . A total of 83 CAMRSA were isolated from abscesses and other skin infections in persons without known risk factors for MRSA infection. All CAMRSA were susceptible to vancomycin. Out of 83 CAMRSA, 13 (15.65%) were D-test positive (inducible MLS B positive) and 6 (7.23%) were positive for constitutive MLS B resistance. Eight strains (9.63%) were resistant to tetracycline and 26 (31.32%) strains were resistant to erythromycin. Increased rate of inducible clindamycin resistance among CAMRSA indicates the importance of identification of such strains by D test to avoid treatment failure when clindamycin is used.

Ventricular Septal Defect in Children with Down Syndrome-Two Case Reports.

The association of Down syndrome (DS) with congenital cardiovascular malformation is well established. Complete atrioventricular septal defects have been associated most commonly with DS. There are also reports of VSD, ASD, TOF and PDA with DS. We here reported two patients of Down syndrome with ventricular septal defect (VSD), underwent repair of VSD, diagnosis was suggested by echocardiography and confirmed by surgery and chromosomal study. Both the patient discharged from hospital with good result. Survival and quality of life have been improving in patient with Down syndrome after repairing VSD.

Total Anomalous Pulmonary Venous Connection (TAPVC) (Supra cardiac type)- A Case Study.

Repair of Total Pulmonary venous connection (TAPVC) continues to be associated to significant mortality and morbidity.We here reported a female patient of two and half years, underwent rechanneling of supracardiac TAPVC, diagnosis was suggested by Echocardiography and confirmed by catheter-angiography which allowed definition of the anatomy. The patient has got fluent pulmonary venous drainage and her heart function resumed to NYHA I. TAPVC should be operated on immediately at definite diagnosis, the fluency of common pulmonary vein-left atrium anastomosis and proper post operative care can ensure a satisfactory outcome.

Off Pump Complete Revascularization Through Left Lateral Thoracotomy (ThoraCAB): NICVD Experience.

Background: Conventional coronary artery bypass surgery (CABG) is associated with substantial morbidity caused by cardiopulmonary bypass (CPB) and median sternotomy. Here we described an innovative technique to perform complete revascularization through a left lateral thoracotomy without CPB (ThoraCAB). Methods: From September 2005 to December 2008 a total 83 patients underwent ThoraCAB in National Institute of Cardio Vascular Diseases (NICVD). The patient is positioned with the left side elevated to 45 degree. A 6 to 8 inches long incision is made over the left 4th or 5th intercostal space from just medial to the nipple to the anterior axillary line. The left internal mammary artery (LIMA) is harvested as a pedicle graft under vision. Distal coronary anastomosis is completed first on the beating heart using a stabilizer, followed by proximal anastomoses on the descending aorta. Peroperative and postoperative complication the arrhythmia hypotension wound infection death was observed. Results: Complete revascularization was achieved in all patients. The number of grafts averaged 2.18±1.08 per patients. One patient died (1.2%) due to severe respiratory acidosis. One patient (1.2%) was converted to CPB due to arrhythmia. No strokes were observed. Of these patients, 7.2% developed new onset postoperative atrial fibrillation. Conclusion: ThoraCAB has been feasible in the vast majority of the patients requiring CABG surgery. The prevalence of the post operative atrial fibrillation was low. Left lateral thoracotomy offers an attractive and effective alteration to Off Pump median sternotomy.

Effect of Tranexamic Acid after Cardiac Surgery in Children.

Background: The antifibrinolytic drug tranexamic acid (TA) decreases blood loss in Pediatric patients under going cardiac Surgery. However its efficacy has not been extensively studied in children. Method: We examined 750 children under going cardiac surgery form 2004 to 2007 in National Institute of Cardiovascular Diseases (NICVD), 379 children in the Tranexamic Acid group (TA) and 371 included in placebo (P) group. After induction of anesthesia and prior to skin incision, patients received either tranexamic acid (10mg/kg followed by 1mg/kg/hr) and saline placebo. After admission to intensive care unit total blood loss and transfusion requirements during the first12 hours were recorded. Result: Children who were treated with tranexamic acid had 24% less total blood loss (26±7 vs 34±17 ml/kg) compared with children who received placebo (p<0.05). Additionally, the total transfusion requirements, total donor unit exposure and financial cost of blood components were less in the tranexamic acid group. Conclusion: Tranexamic acid can reduce perioperative blood loss in children undergoing cardiac surgery.

Comparison of sputum induction with broncho-alveolar lavage in the diagnosis of smear-negative pulmonary tuberculosis.

Sputum microscopy and AFB-culture being gold standard and a fundamental tool for diagnosis of pulmonary tuberculosis (PTB) has got its limitation of low sensitivity. Fibreoptic bronchoscopy (FOB) has been widely recommended as the diagnostic procedure of choice in smear negative patients. But bronchoscopy is an invasive procedure, costly, not readily available in our country and needs expertise. Several studies abroad have directly compared the yield of sputum induction (SI) with 3% saline (NaCl solution) with Bronchoalveolar lavage (BAL) through FOB in smear-negative suspected PTB patients and showed that SI was a low cost, safe and well tolerated procedure with equal efficacy to BAL through FOB for the diagnosis of PTB in such patients. For the first time a prospective comparison was conducted in Bangladesh to see the yield of sputum induction (SI) and BAL in 52 selected smear- negative patients of suspected PTB. Each of the samples of induced sputum and BAL fluid were examined for AFB by Ziehl-Neelsen's method. Samples of both SI and BAL from 20 patients were cultured for AFB in Lowenstein-Jensen medium for 6 weeks irrespective of their induced sputum smear being positive or negative for AFB. Data were managed and analyzed using computer program SPSS version 10.0. Agreement of SI and BAL was tested using Pearson Chi-square and Kappa test. The results showed that the yield of SI were significantly more than that of BAL (p<0.05).The AFB smear results from specimens obtained by SI and BAL were in agreement in 75% cases (p=0.02).Statistical analysis of the yield of culture results from SI and BAL group with Fishers Exact test showed they were in agreement in 90% cases (p=0.0001) and was measured by Kappa test as significant (p=0.0004). The sensitivity of AFB-smears in samples from SI and BAL were 74% and 58% respectively. The specificity of smear positivity and of culture was assumed to be 100%. SI is a safe procedure with considerable diagnostic yield and a high agreement with the results of BAL through FOB for the diagnosis of PTB. SI offers an alternative or additional approach to the diagnosis of smear-negative suspected PTB patients and would enhance sensitivity for the diagnosis of tuberculosis.

Aspects of Infection in Intensive Care Unit - Prevention and Control.

Intensive Care Unit (ICU) is the most vulnerable area in the hospital premises. Hospital acquired infections in critically ill patients as well as of transmission of infections from a patient to another patient or to the health care workers or vice versa can occur in ICU. ICUs combine physicians, nurses and allied health professionals to manage patients with life threatening single or multiple organ system failure, including stabilization after surgical interventions. It is a continuous management including monitoring, diagnosis, and support of failing vital functions as well as the treatment of the underlying disease. Here we have to discuss the source of infection and their effective control measurement in intensive care unit. Ventilator associated pneumonia (VAP) as well with other sources is most common nosocomial infection having 33% mortality in ICU.