Severe hypocalcaemia following coronary artery bypass grafting due to hypoparathyroidism

A 55 years old man was extubated on first postoperative day following coronary artery bypass grafting at 7:30 am. The same day at 5 pm, he became drowsy but arousable only on painful stimuli with severe generalized hypertonia and bilateral upgoing plantars. He was reventilated and a provisional diagnosis of cerebrovascular accident was made. CT scan of brain was normal except for bilateral basal ganglia calcification. On further investigations, he was found to be severely hypocalcaemic due to hypoparathyroidism. All symptoms resolved on the treatment of his hypocalcaemia. There was no history of neck surgery in this patient and the case additionally highlights important interaction between parathyroid hormone [PTH] in calcium metabolism

Clinical outcome of double valve repalcement with or without small aortic prosthesis

To determine the effect of aortic prosthesis size on clinical outcome of patients undergoing double cardiac valve replacement [DVR]. A quasi-experimental study. Cardiac Surgery Department, Punjab Institute of Cardiology, Lahore, Pakistan, from February 1996 to December 2008. One hundred and forty patients undergoing double cardiac valve replacement were divided into 2 groups. Group I, 75 [53.6%] receiving aortic prosthesis size of /= 21 mm size. All patients were prospectively followed-up for 12 years in order to study mortality and valve related complications. There were 94 males [67.1%] and 46 females [32.9%] with a mean age of 25.5 +/- 10 years. In Group I, 21 patients [28%] had aortic valve replacement [AVR] with 19 mm valve size and 54 patients [72%] had 21 mm size valves implanted. In Group II, 39 patients [60%] had AVR with 23 mm size valves implanted followed by 16 [24.6%] who received 25 mm size valves. Posterior mitral leaflet was preserved in 15 patients [20%] in Group I and 14 [21.5%] in Group II. Mortality was seen in 13 patients [9.3%]; of these 5 [3.6%] were in Group I and 8 [5.7%] were in Group II. Nine patients [6.4%] had incomplete follow-up [In Group I, 2 patients died in ICU, 2 died within 30 days of admission and one was a late death. In Group II, 1 patient died in ICU, 1 within 30 days of admission and 6 within 1 year of operation]. Double valve replacement with implantation of small aortic prosthesis has similar overall mortality as compared to patients having larger sized aortic valves

Outcome of double vs. single valve replacement for rheumatic heart disease

To compare the follow-up results of double valve replacement [DVR] i.e. mitral valve replacement [MVR] and aortic valve replacement [AVR] vs. isolated MVR or AVR for rheumatic heart disease. An interventional qausi-experimental study. Department of Cardiac Surgery, Punjab Institute of Cardiology, Lahore, from September 1994 till December 2007. Prospective follow-up of 493 patients with mechanical heart valves was carried out using clinical assessment, international normalized ratio and echocardiography. Patients were divided into three groups: group I having MVR, group II having AVR and group III having DVR. Survival, time and causes of mortality, and frequency of valve thrombosis, haemorrhage and cerebrovascular haemorrhage was noted in the three groups and described as proportions. Actuarial survival was analyzed by Kaplan-Meier method. There were 493 with 287 [58.3%] in group I, 87 [17.6%] in group II and 119 [24.1%] in group III. Total follow-up was 2429.2 patient [pt]-years. Of 77 [15.6%] deaths, 19 [3.8%] were in-hospital and 58 [11.8%] were late. In-hospital mortality was highest 4 [4.6%] in group II followed by 5 [4.2%] group III and 10 [3.5%] group I. Late deaths were 39 [13.4%] in group I, 9 [10.2%] in group II and 10 [8.3%] in group III. The total actuarial survival was 84.4% with survival of 83%, 85.1%, 87.4% in groups I, II and III respectively. On follow-up valve thrombosis occurred in 12 [0.49%/pt-years] patients; 9 [0.67%/pt-years] group I, 1 [0.22%/pt-years] in group II and 2 [0.31%/pt-years] in group III. Severe haemorrhage occurred in 19 [0.78%/pt-years]; 14 in [1.04%/pt-years] in group I, 3 [0.66%/pt-years] group II and 2 [0.31%/pt-years] in group III. Cerebrovascular accidents occurred in 34 [1.3%/pt-years]; 26 [1.95%/pt-years] in group I and 4 in groups II [0.89%/pt-years] and III [0.62%/pt-years] each. In patients with rheumatic heart disease having combined mitral and aortic valve disease DVR should be performed whenever indicated as it has similar in-hospital mortality and better late survival as compared to isolated aortic or mitral valve replacement

Biatrial myxoma and atrial septal defect

Myxomas are rarely associated with congenital cardiac anomalies. We report a case of a young female presenting with symptoms of atrial myxoma but having co-existing ASD visualized on 64 slice multidetector computed tomography [MDCT] prior to cardiac surgery. Patient had a successful resection of biatrial myxoma and ASD repair. This case is unique as the myxoma originated from the inferior margin of the ASD straddling the inferior limbus. Over the years due to the left to right shunt at the ASD, the myxoma was initially prolapsing and oscillating between the two atria. As it grew larger it obliterated the ASD and got stuck in the right atrium [RA] and continued to grow giving false impression of a right atrial mass. Multi detector computed tomography is an alternative diagnostic modality to the gold standard transesophageal echo-cardiograph for detection of an ASD in the presence of atrial myxoma. Biatrial myxoma with associated atrial septal defect has optimal postoperative results

Three pregnancies with mechanical heart valve and no follow-up in 10 years

Anticoagulation and proper INR [International Normalized Ratio] monitoring is essential for patients having mechanical heart valves; it is vital in these patients in order to prevent lethal complications such as valve thrombosis and systemic embolism. In pregnancy, it becomes even more important as pregnancy itself is a hypercoagulable state. This report describes a female patient having undergone mitral valve replacement with a Starr Edward metallic prosthesis. She came back to the operating surgeon after 10 years of valve replacement with a history of three uneventful healthy deliveries and no follow-up and INR monitoring during this period

Critical pathway, cardiac surgery in the third world

To set up a protocol in order to provide an efficient, cost effective system for Cardiac Surgery and to reduce the waiting list in straight forward Cardiac Surgical Operations. A prospective study in all patients with Patent Ductus Arteriosus [PDA] following the Critical Care Methodology. Department of Cardiac Surgery, Punjab Institute of Cardiology, Lahore. Main outcome measures: Effectiveness of critical care methodology, reduction of cost to hospital and patient and reduction in waiting list time for PDA surgery. From June 1994 till June 1999, one hundred and fifty consecutive patients of PDA had their operation planned as day case cardiac surgery. There were 90 females and 60 males. Their mean age was 6.55 +/- 0.56 years. 134 patients were less than 18 years, mean age 4.9 +/- 0.39 years. These patients were seen in the outpatient and were accessed by the surgeon, anesthetist and intensive care sister. The parents of the children were fully briefed about the preoperative preparation, operation and post operative course. The patients were admitted on the day of the operation and kept in the ICU for 6 hours and then shifted to the high dependency unit [HDU] and discharged on the second post operative morning. We found this method of day case surgery beneficial for the patient. In that it reduced the cost of the hospital stay, surgery and led to a reduction in the waiting list time for PDA. This did not lead to an increase in the morbidity as the patients were sent home to the community early. In third world countries like Pakistan where resources are limited this method is ideal provided everyone is willing to participate