Surgical repair of post-infarction ventricular septal rupture: determinants of operative mortality and survival outcome analysis

Background and Objective: Ventricular septal rupture [VSR] is one of the fatal complications of myocardial infarction [MI]. Surgery provides the maximum survival benefit. Our objective was to investigate the risk factors of surgical mortality and to do the survival analysis in the past six years at our hospital

Methods: All the patients operated at CPE Institute of Cardiology Multan Pakistan, between 2009 and 2015 for repair of post MI VSR were analysed retrospectively for demographics, comorbidities, operative and post operative outcomes. The primary outcome was 30 days mortality. The follow up was done till April 2017 and the follow up data was obtained from hospital records and by telephoning the patients. SPSS was used for statistical analysis. P value < 0.05 was considered significant

Results: A total of 31 patients were operated for VSR repair with a mean age of 57.19 +/- 7.73 years. Eighteen patients also had a concomitant coronary artery bypass grafting [CABG]. The operative mortality in this series was 25.8% Univariate analysis showed that pre-operative ejection fraction [E.F] [p value 0.010] and cardiogenic shock [p value 0.031] were a significant risk factors for operative mortality while on logistic regression analysis only the cardiogenic shock was found to be an independent risk factor for operative mortality with the odds ratio of 2.17. Low ejection fraction only acted as a confounding variable. The mean survival at six years was 34 months with a survival rate of 28.6%. The additional CABG did not confer any survival benefit

Conclusion: The patients in cardiogenic shock pre-operatively have a high operative mortality. Low ejection fraction [E.F] acts as a confounding factor. Concomitant CABG does not confer any survival benefit

Surgical repair of partial atrioventricular septal defect

Objective: To review the results of surgical correction of partial atrioventricular septal defect and associated cardiac comorbidities

Methods: Retrospective case analysis of electronic database of department of paediatrics cardiac surgery, CPEIC, Multan was done. Forty consecutive patients operated for partial atrioventricular septal defect repair from September 2011 to October 2016 were included. Mean age was 14.67+/-7.96 years. 60% [24] patients were male. Regarding echocardiographic findings, pre-operatively 40% [n=16] had mild, 47.5% [19] had moderate and 12.5% [n=5] had severe mitral valve regurgitation. There were 25% [n=10] patients having moderate tricuspid valve regurgitation. Pulmonary hypertension was moderate in 57.5% [n=23] cases and severe in 7.5% [n=3] cases. Among other associated lesions 10% [n=4] patients had secundum ASD, pulmonary artery stenosis was seen in 5% [n=2] patients. Another 5.0% [n=2] patients had bilateral SVCS. While one patient had PDA and one patient had associated common atrium

Results: Post-operatively there were 19 cases [47.5%] having no mitral valve regurgitation while 18 [45%] patients showed mild and 7.5% [n=3] had moderate mitral valve regurgitation. Only one case had moderate tricuspid valve regurgitation post-operatively, while 22.5% [n=9] cases had mild tricuspid regurgitation. Complete heart block and left sided brain infarct developed in one case. There was no mortality, reoperation, residual atrial shunt or left ventricular outflow tract obstruction

Conclusion: Repair of partial AV canal carries good overall results with minimal mortality however earlier repair is suggested to reduce post- operative morbidity further

Doubly committed subarterial ventricular septal defect repair: an experience of 51 cases

Objective: To review the surgical outcome of doubly committed subarterial [DCSA] ventricular septal defect repair

Method: Data of 51 patients of doubly committed sub arterial Ventricular septal defect from January 2012 to June 2017 that were referred to Chaudhary Pervaiz Elahi institute of Cardiology Multan was retrospectively reviewed using electronic database. All patients were operated by first author. In our study, we segregated patients into four main groups depending on presence or absence of aortic structural defect and degree of aortic valve regurgitation. Group-A comprised of nineteen [37%] patients who neither had aortic structural nor functional abnormality while GroupB had six [11.7%] patients, having aortic valve cusp prolapse without aortic regurgitation. Group-C and Group-D consists of seventeen [33.3%] and nine [17.6%] patients respectively depending upon degree of aortic regurgitation. Furthermore, six [11.7%] patients among these 51 had associated defects as well

Results: Group-A patients had no aortic valve regurgitation post operatively and at follow up of 22.6 months [1.8 years] as well. In Group-B, aortic valve was not addressed and aortic regurgitation was also not present post operatively or on follow up of 33.6 months [2.8 years]. Similarly, in Group-C aortic valve was not addressed, these patients also did not show progression of disease on regular follow up of 18 months [1.5 year]. While, in Group-D, eight patients underwent aortic valve repair and one patient had aortic valve replacement. Aortic regurgitation improved significantly in all patients of this group and remained, unchanged on follow up of 22.7 months [1.8 years]

Conclusion: Early closure of doubly committed subarterial ventricular septal defect with appropriati aortic valve disease caa halt the process of disease progression

Tetralogy of Fallot repair in patients presenting after Infancy: a single surgeon experience

Objective: To determine the early surgical outcomes of Tetralogy of Fallot [TOP] repair in children and young adults operated after the age of one year

Methods: In this retrospective study, 307 cases of primary repair of Tetralogy of Fallot were done between September 2012 to February 2017, at CPE Institute of cardiology, Multan. Out of 307 operated patients, 4 [1.3%] patients had previous modified Blalock Taussig shunts, 2 [0.6%] associated ASD with TOF, 3 [0.9%] co-association of TOF with PDA, 2 [0.6%] had large conal arterial branch crossing the annulus, 3 [0.9%] had dextrocardia with situs inversus, 12 [3.9%] TOF with double outlet right ventricle [DORV], 2 [0.6%] were associated with complete AV canal defect, 8 [2.60%] with absent pulmonary valve syndrome, 15 [5.5%] I with left pulmonary artery stenosis. Data of post-operative complications and operative parameters was recorded for all patients

Results: Mean age of operated patients was 9.56+/-4.89 years. Post-operative complications occurred in 7.8% of patients. Most common post-operative complications were pleural effusion with a frequency of 12[3.9%] patients, and complete heart block in one patient. Insignificant small residual VSD was diagnosed in 8 [2.6%] patients. One moderately large VSD was closed surgically after one year of 1st surgery. Moderate to severe pulmonary valve regurgitation was diagnosed in 114 [37.1%] patients. Mild to moderate tricuspid regurgitation in 15 [4.8%] patients and moderate right ventricular outflow tract obstruction [RVOT] in 16 [5.2%] patients. Thirty-day mortality was only four [1.3%]

Conclusion: Surgical correction of Tetralogy of Fallot [TOF] in children after one year carries good operative outcomes with minimum morbidity and mortality

Outcome after surgical repair of partial anomalous pulmonary venous connection

Objective: To review the operative results of 55 cases of partial anomalous pulmonary venous connection [PAPVC]

Methods: This retrospective case series of 55 cases of PAPVC operated from January 2011 to June 2016 at CPE Institute of cardiology, Multan. Baseline characteristics of patients, their operative findings and results were retrieved from the hospital record

Results: Operation for PAPVC was performed in 55 patients. Patient's age varied from 3-28 years [mean 12.56 +/- 7.49], their weight was 9-62 kg mean [25.61 +/- 16.28]. There were 41[74.5%] males and 14[25.5%] females. 49[89.0%] patients had right sided PAPVC associated with ASD moreover 3[5.4%] cases had right pulmonary vein draining into right atrium. While there was only one case having left sided PAPVC [1.8%] and two cases [3.6%] of bilateral PAPVC [4%]. Reassuringly, there was not a single mortality. However, one patient developed junctional rhythum, which was successfully controlled on amiodarone. SVC obstruction having 6mmHg gradient was observed in one case however patient is doing well and is on follow up since 9 months

Conclusion: Surgical correction of PAPVC generally carries highly reproducible results with low morbidity

Diagnostic value of total leukocyte count and neutrophil percentage in suspected cases of acute appendicitis

To define the role of serum markers of inflammation total leukocyte count, neutrophil percentage in diagnosis of acute appendicitis. Study Cross sectional analytic study. Surgical emergency and surgical unit-lV Nishtar Hospital Multan during July 2005 to March 2006. Study was carried out on 50 patients of either sex, above the age of 13 years presented with pain right side of the abdomen. These patients were subjected to complete blood examination including TLC and DLC. Of the 50 patients, 39 patients [78%] had TLC raised above 10.000 per mm[3] out of which 36 [72%] had inflamed, gangrenous or perforated appendicitis and 3 [6%] had normal appendicitis confirmed on histopathology. 11 patients had TLC below 10.000 per mm[3]. They all had inflamed appendicitis confirmed on histopathology. The sensitivity and specificity of TLC in the diagnosis of acute appendicitis were 76.6% and 33.3% respectively. The positive and negative predictive value were 92.3% and 9% respectively. The leukocytosis was attributed to the neutrophils leukocytosis associated with lymphopaenia. In this study there were 3 [6%] patients who had TLC below 10.000 mm[3] but they had neutophils to lymphocyte ratio 3.5:1 or above. They had inflamed appendices on histopathology. Laboratory test of white cells count and neutrophil percentage are more effective in supporting clinical diagnosis of acute appendicitis