ABSTRACT
Background: Mitral stenosis (MS) is a common valvular heart disease. Thromboembolism is one of the most serious consequences of mitral stenosis, particularly when it is accompanied with atrial fibrillation (AF). When linked with Left atrial appendage inactivity (LAAI), patients with sinus rhythm (SR) are also at risk for this condition. In mitral stenosis, LAA inactivity determined by S-wave is an independent predictor of thromboembolism. The aim of the study was to evaluate the Prevalence and Echocardiographic Predictors of Left Atrial Appendage inactivity in patients of Mitral Stenosis.Material & Methods:Sixty MS patients were evaluated by transthoracic echocardiography (TTE) and all patients underwent transesophageal echocardiography (TEE). The annular systolic (S-wave) and diastolic (Em- and Am-waves) velocities were recorded by tissue Doppler imaging (TDI). LAA inactivity was defined as LAA emptying velocity <25 cm/second determined by pulse wave Doppler at the junction of LA & LAA (TEE). Patients were divided into three groups; group A I (n = 18). Sinus rhythm (SR) and LAA emptying velocity ?25 cm/sec, group A II (n -22): SR and LAA emptying velocity <25cm/sec and group B (n = 20): atrial fibrillation.Results:Thrombus was detected in 14 patients and spontaneous echo contrast (SEC) was detected in 43 patients. Both S-wave and peak LAA emptying velocities were decreasing, while SEC frequency and density were increasing from group A to group B. There was a positive correlation between LAA emptying vs. S-wave and LAA emptying vs. Am velocities (p < 0.001, r= 0.708 and p<0.001, r=0.495). Multivariate regression analysis showed that only S-wave is the independent predictor of inactive LAA (p = 0.001, odds ratio = 0.133, 95% Cl =0.032-0.556). In patients with SR, the cutoff value of S-wave was 10 cm/sec for the prediction of the presence of inactive LAA (sensitivity: 92.3%, specificity: 95.3%).Conclusions:In individuals with severe mitral stenosis in sinus rhythm, there is a significant prevalence of left atrial appendage inactivity. The mean pressure gradient across the mitral valve, as well as S-wave are independent predictors of left atrial appendage inactivity. Inactivity of the left atrial appendage is an independent predictor of left atrial/left atrial appendage smoke and associated thrombus.
ABSTRACT
Introduction: Presently off- pump CABG has proved itself tobe a safe, cheaper and effective alternative of on- pump CABG.However, it requires manipulation, displacement, positioning& mechanical stabilization of the heart during grafting whichmay cause haemodynamic alteration. Study was done withthe objective of finding out the changes in Central VenousPressure (CVP); Mean Arterial Pressure (MAP); MeanPulmonary Arterial Pressure (MPAP); Right Ventricular EndDiastolic Pressure (RVEDP) & Left Ventricular End DiastolicPressure (LVEDP) while grafting the anterior, lateral &inferior surfaces of heart during off-pump CABG.Material and methods: Over one year time, 50 patients withLVEF ≥40%, undergoing off-pump CABG were monitoredfor the above parameters at various stages of their operation,namely:- 1. During manipulation & shunt introduction,2.During anastomosis without shunt, 3.During anastomosiswith shunt & 4.After anastomosis; while grafting the anterior,lateral & inferior surfaces of heart. These results werecompared with the baseline values of CVP, MAP, MPAP,RVEDP & LVEDP, to look for statistical significance.Results: During manipulation & shunt introduction; CVP(mmHg) significantly increased during Ramus grafting - 12±1.8(p<0.047); and also during OM grafting – 12.6±1.9 (p<0.045),when compared to a baseline value of 9±1.8. The MAP(mmHg) was significantly decreased during manipulation &shunt introduction in Diagonals - 70±5.8 (p<0.046), Ramus- 70±5.8 (p<0.048), OMs - 65±5.8 (p<0.028) & in the Rightterritory - 69±5.9 (p<0.032); as compared with baselineMAP of 76±11.7. During anastomosis without shunt also, theMAP(mmHg) significantly decreased while grafting LAD- 70±3.8 (p<0.048), Diagonals - 68±3.8 (p<0.039), OMs –71.8±4.8 (p<0.039) & Right sided arteries 70.8±4.6 (p<0.039),as compared with baseline MAP values. The MPAP(mmHg)was significantly increased – 18.3±3.7 (p<0.047) as comparedto the baseline value of 16±2.4 during manipulation & shuntintroduction in the OMs.Conclusion: During OPCABG there will be significantalterations in haemodynamics mostly due to mobilizationof the heart, which is necessary to visualise the targetvessels properly & stabilisation of the concerned areawith stabiliser. However, by observing the haemodynamicvariations constantly & by making necessary mechanical &pharmacological adjustments, unnecessary conversion to Onpump technique can be avoided.
ABSTRACT
Introduction: It is not uncommon in patients, havingrheumatic mitral and aortic valve disease, to undergo mitralvalve replacement with aortic valve replacement that is,double valve replacement (DVR) operation who oftenhave severe cardiac dysfunction optimized with medicalmanagement before surgery. In this retrospective studywe investigated 60 such patients, who underwent DVRoperation with either conventional cold blood cardioplegiawith St Thomas 2 solution (STH), or del Nido cardioplegia(DN) over five years and compared the effects of the twotypes of cardioplegia during perioperative and postoperativeperiod with simultaneous comparative study betweenchanges of cardiac performances in the patients with largerleft ventricle as compared to those with less enlargedones.Material and methods: For this retrospective study, the dataof 60 patients of DVR over five years, in Medical College,Kolkata, India, were retrieved for study. The cases wereplaced into 2 groups: STH and DN according to cardioplegiaused during DVR. Demographic, echocardiographic, andseveral perioperative and postoperative data of the two groupsof patients, were collected. Differences between perioperativebehaviour between STH and DN groups and post operativechanges in the echocardiographic parameters betweenpredominantly mitral stenosis (MS) and mitral regurgitation(MR) patients, were analyzed.Results: The aortic cross clamp (CC) and cardiopulmonarybypass (CPB) time in both predominant MS and MR patientswas shorter in the DN than the STH groups. There was lessarrhythmia, less inotropic and ventilator support in the DNgroup. There was 10% mortality in the series with majoritybeing in the STH and MR predominant patients. Postoperativeimprovement of LVEF, reduction of LVIDS and LVIDDwere also observed in MS predominant in comparison toMR predominant patients after DVR in both STH and DNgroups.Conclusion: Use of DN has been found to have a betteroutcome and survival when compared to STH cardioplegiasolution. DVR could reversely remodel depressed heartswith relatively smaller LV volume and restore LV functionof relatively smaller LV of predominant MS patients betterin comparison to MR predominant patients with relativelydilated hearts.
ABSTRACT
Maintenance of sinus rhythm is superior to incidence of atrial fibrillation (AF) in patients with rheumatic heartdisease undergoing Closed Mitral Valvotomy (CMV). The present study was done to evaluate the effect ofprophylactic use of Magnesium Sulphate (MgSo4), intravenously (i.v) soon after opening the stenosed MitralValve using Tubbs dilators by Surgeon, in patients undergoing CMV. One hundred and twenty patients withMitral Stenosis (MS) (mitral valve area < 1cm2), normal mitral valvular apparatus, no mitral regurgitation,mitral score not more than 7/16 planned for CMV. These patients were divided in two groups of 60 each.Group (I) (n=60) received. MgSo4, 30 mg/kg diluted to 20 ml with normal saline soon after mitral valvotomyand Group - II (n=60) received 20 ml of normal saline. The standardized protocol for CMV was maintainedfor all the patients. Before surgery AF was observed in 56.67% of patients in group I and 48.33% of patientsin group II (p=0.46). Postoperatively in ICU, 30% of patients in group I and 70% of patients in group II hadAF(p<0.0001). A single prophylactic intra operative dose of i.v MgSO4 decreased post valvotomy arrhythmiain comparision to placebo group . Thus, a single dose of intraoperative MgSO4 can be used to decreasepostoperative arrhythmias in patients of M.S undergoing CMV