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.

Aorto-bi-Femoral Bypass for Aorto-Iliac Occlusive Disease: Recent Experience at the National Institute of Cardiovascular Diseases (NICVD).

Background & Objectives: Aorto-bi-femoral bypass is one of the most important surgical strategies in vascular surgical practice. The procedure is employed in surgical revascularization for both stenotic and aneurysmal diseases involving the aorto-iliac segment. The present study was carried out to analyze our recent experiences with this procedure for aorto-iliac occlusive diseases (AIOD) at the National Institute of Cardiovascular Diseases (NICVD). Materials and Methods: Over a period of 3 years (April 2008 to March 2011), a total of 47 patients underwent aorto-bi-femoral or aorto-bisiliac bypass grafting for AIOD using a Y-graft prosthesis. The mean age of the patients was 46.4 years (range 25-75 years). Thirty eight of the patients were male and the remaining 9 were female. A retroperitoneal approach was used in 27 patients. In the remaining 20 patients, the operation was done using a transperitoneal approach. A Gelatin-coated Dacron Y-graft prosthesis was used in 43 (5 of which were silver-coated prosthesis) patients while PTFE (Polytetrafluoroethylene) prosthesis was used in the remaining 4 patients. The operation was carried out under epidural anesthesia with sedation in most cases. Results: The operation was well-tolerated in all patients. There was no intraoperative mortality in this series. Two patients died in the immediate post-operative period- one due to myocardial infarction and the other due to acute renal shut-down leading to renal failure accounting for a mortality rate of 4.3%. Wound infection and lymphorrhoea at the groin incision site were the two main immediate post-operative complications. There was no incidence of graft infection in this series. Twelve patients were available for post-operative follow-up up to 2 years. Out of them, 5 patients returned with occluded grafts 8-23 months after the operation. Three of these patients underwent graft excision with re-do Y-graft bypass. The remaining two were treated with extra-anatomic bypass (Axillobifemoral). Conclusions: Aorto-bi-femoral bypass is an effective surgical strategy for occlusive diseases involving the abdominal aorta and the iliac arteries. The procedure is well-tolerated with a low incidence of early post-procedural complications and graft failure. However, poor adherence of the patients to follow-up remains a significant obstacle for evaluating the long-term outcome of this procedure.

Congenital Absence of Pericardium: A Rare Case Associated with Severe Mitral Stenosis with Pulmonary Hypertension.

We report a rare case of congenital absence of pericardium in a 35 year old middle-aged man, who underwent closed mitral commissurotomy done for severe mitral restenosis developed after Percutaneous Transluminal Mitral Commissurotomy (PTMC) six months back. Operation was done under General Anaesthesia through left anterolateral thoracotomy. Pericardial defect was discovered intraoperatively. There was no clinical symptom that could be clearly related to the defect of the pericardial sac pre-operatively. The recovery of the patient was satisfactory and uneventful.

A Clinical Study on the Pattern of Mitral Valvular Disease in a Peripheral Tertiary Hospital in Bangladesh.

Background: Rheumatic mitral valvular disease (MVD) is a common cause of cardiovascular morbidity and mortality in Bangladesh. Many patients are diagnosed late, get maltreated, and develop complications, which can be minimized if early diagnosis could be made. Objectives: The study was carried out to determine the common symptoms and signs of mitral valvular disease in our population, to find out the incidence and pattern of complications, to list the pattern of valve lesions, to identify the common findings in different investigations and to find out the causes of delay in diagnosis. Methods: Fifty consecutive cases of isolated MVD of rheumatic origin admitted in Rajshahi Medical College Hospital, Rajshahi, Bangladesh, from July, 2002 to March, 2003 were included. Detailed history was taken, and clinical examination was performed. Chest skiagram, 12-lead ECG and echocardiography were performed in all patients. Other investigations include complete blood counts, anti-streptolysin O (ASO) titre, C-reactive protein (CRP), blood sugar, serum creatinine and routine urinalysis. Results: The peak incidence of MVD was found in the third decade (34%), 14 (28%) patients were <20 years of age. Thirty two (64%) patients had poor socio-economic condition. A previous history suggestive of rheumatic fever was found in 28 (56%). Twenty six (52%) patients received treatment from the registered medical practitioners and/or from the hospitals, 11 (22%) consulted with the quacks only, 5 (10%) had treatment from both sources. Significant delay was found in 28 (56%) patients. Illiteracy and ignorance was found to be the cause in 14 (28%) cases, poverty in 12 (24%) and misdiagnosis in 7 (14%). Six (12%) patients adopted indigenous treatment. Forty three (86%) patients experienced moderate to severe limitation of day-to-day activities all had breathlessness. Palpitation, fatigue and cough were found in 49 (98%), 45 (90%) and 42 (84%) cases respectively. Nineteen (38%) patients had haemoptysis, 15 (30%) had dysphagia. Apex beat was normally situated in 32 (64%), and shifted in 16 (32%) cases. Forty two (84%) patients had left parasternal heave and palpable P2 was found in 41 (82%) patients. Diastolic thrill was palpable in 28 (56%) cases, systolic thrill in 8 (16%) patients. The first heart sound (S1) was loud in 34 (68%) and soft in 8 (16%) cases. Mid-diastolic murmur of MS was audible in 46 (92%) cases, pansystolic murmur of mitral regurgitation in 19 (38%) patients and pansystolic murmur of tricuspid regurgitation in 10 (20%). Opening snap was found in 30 (60%), and presystolic accentuation in 27 (54%) cases. Roentgenographic study revealed moderate to huge enlargement of cardiac shadow in 29 (58%), straightening of the left border of the heart with fullness or outward bulging of the pulmonary conus in 43 (86%), double contour of the right border in 35 (70%), upper lobe diversion of pulmonary vasculature in 31 (62%), Kerley B lines in 10 (20%) and pulmonary oedema in 16 (32%) patients. The ECG showed P-mitrale in 32 (64%), atrial fibrillation in 14 (28%) and atrial flutter in 2 (4%) cases. Echocardiography revealed thickening of mitral valve leaflets in all patients, changes in subvalvular apparatus in 28 (56%) and calcification in mitral valve apparatus in 3 (6%) cases. Mitral valve area was <1 cm2 in 33 (66%), 1.0 to 1.4 cm2 in 14 (28%) and e”1.5 cm2 in 1 (2%) patients. The left atrial size was 41 to 50 mm in 20 (40%) and >50 mm in 10 (20%) cases. Two patients had left atrial thrombus. Evidence of pulmonary hypertension was found in 34 (68%) patients. Conclusion: Rheumatic MVD and the accompanying complications can be detected with an appreciable degree of accuracy by skillful clinical assessment and judicial use of simple investigations like roentgenography, electrocardiography and echocardiography which are available in many parts of our country at affordable costs. So every effort should be made to utilize these invaluable resources to tackle this public health problem more efficientlly.

Personal series with clinical review of fracture penis.

Penile fracture is an uncommon Urological emergency. In flaccid state it allows significant degree of deformation without any injury to the vital structures but in erected state it is vulnerable to blunt injury. The tumescent corpora cavernosa may have got injured due to nonphysiological bending of penile shaft. The true incidence of penile fracture is not known even in western countries. It is either under reported or hidden for potential social embracement. We have reviewed all of our cases of penile fracture and has been conducted a retrospective study in the Department of Urology, Bangladesh Medical College, Dhaka. The study period was from October 2001 to January 2006. The sample size was 23. All patients have got classical history of penile fracture. The time between the onset of symptom and seeking of medical care ranges from 02 hours to 07 days. The diagnosis was made on the basis of history and clinical examination only. All the patients were underwent surgery. The potency was well preserved in all of our patients. The local tissue healing process is better among the patients, reported earlier. The overall result is excellent.

External carotid ligation in extensive haemangioma of tongue & lip.

Two patients were admitted in the surgical unit of Mymensingh Medical college Hospital on September 2005 & April 2006. The first case was a lady of 18 years presented with sudden huge enlargement of tongue & lower lip for 07 days resulting difficulty in deglutition & respiration. Since childhood she noticed multiple elevated bluish spots over the tongue, cheek & lips. The second case was a young man of 20 years presented with multiple diffuse swelling of lips, left side of face, cheek, lower eyelid since birth, which was gradually increasing in size. Colour Doppler evaluation of the lesions in both the cases revealed features suggestive of haemangioma. Bilateral external carotid artery ligation by skin crease incision at the level of upper border of thyroid cartilage was done in both the cases. In first case, tongue size reduced back to oral cavity in post operative period. After 04 weeks of operation tongue size became almost normal with only multiple bluish residual swelling. In second case, the swelling size gradually reduced in post operative period. Both the patients are under regular follow up.

Incidence and prognostic significance of right bundle branch block complicating acute myocardial infarction.

The incidence and hospital courseofacute myocardial infarction wereobserved among randomly selected 560 patients. The mean age of the patients was 53 +/- 6.67 years with male-female ratio 2.6:1. The incidence of right bundle branch block (RBBB) was 15% (84 out of 560 patients). New RBBB, old RBBB and RBBB of indeterminate age were observed in 33 (39.25%), 23 (27.40%) and 28 (33.25%) cases respectively. RBBB was isolated in 50 (60%) cases and bi-fascicular in remaining 34 (40%) cases. The rate of use of thrombolytic was greater in RBBB group than non-RBBB group (52% vs 30.67%, P < 0.05). The complications were more frequently observed in patients with RBBB: in-hospital mortality, 27.40% vs 10.90% (P < 0.01); use of temporary pacemaker, 15% vs 9% (P < 0.05); and heart failure, 50% vs 35% (P < 0.05). In sub-group analysis, in-hospital mortality rate was higher among bi-fascicular group than isolated RBBB group (P < 0.05). Thus it appeared from the results that the incidence of RBBB is relatively common i.e. 15% over all (84 out of 560) and 5.90% new (33 out of 560) and despite greater use of thrombolytics, some specific in-hospital complications were significantly higher in patients with RBBB than without, RBBB.

Fracture penis--a study of twenty cases.

During the period from June 1985 to December 1999 a total of 20 male patients of 17-52 years age group were managed for traumatic fracture of the penile shaft. Diagnosis in all cases was established by history and careful physical examination. All but one underwent early surgical intervention and repair of the fractured part. Twelve patients, who reported for treatment within 36 hrs. of injury had good results. Of the 7 patients, who reported after 36 hrs. of injury 4 had good and 3 had fair results. One patient who presented on the 7th day after injury didn't undergo surgery and developed fibrous chordee within next six months.

Role of ultrasonography and urinary cytology in diagnosing recurrence of superficial urinary bladder cancer compared to cystoscopy.

Urinary cytology, ultrasonogram of the urinary bladder and cystoscopy were done in 99 cases of urinary bladder cancer patients in the department of urology of Dhaka Medical College Hospital (DMCH), Dhaka, during the period from January 1997 to December 1998. Pre transurethral resection of bladder tumour (TURBT), urinary cytology was positive in 20.20% cases and ultrasound scan was positive in 96.9% cases. Histopathological examination revealed 95.96% as transitional cell carcinoma:- Grade I (3.0%), Grade II (62.6%) and Grade III (34.4%). During follow-up urinary cytology was positive in only one case whereas ultrasound scan was positive in 53.5% cases of whom only 21.6% patients had actual recurrent bladder tumours proved by cystoscopy. Statistical analysis of the three tests and histopathology showed significant variation though by Chi-square test the ultrasound scan is found superior to urinary cytology. We conclude when ultrasonography of the urinary bladder shows any suspected lesion it should be examined by cystoscope and biopsy should be taken from the suspected area for confirmation. Neither urinary cytology nor ultrasound scan can replace cystoscopic examination.