Tricuspid atresia with normal axis on ECG palliated with a central shunt; a case report.

BACKGROUND: Tricuspid Atresia is the 3rd commonest cyanotic congenital Heart disease. It is characterized by lack of communication between the right atrium and right ventricle. The treatment often requires a palliative systemic to pulmonary shunt before definite surgery. The use of a central shunt via a median sternotomy is suggested here as an alternative to other traditional shunts via a thoracotomy. METHOD: The management of a 3-month-old boy who presented with dyspnoea, fever, cough and cyanosis is presented here as obtained from Clinical records. RESULT: Following resuscitation, a central shunt (Ascending Aorta to main Pulmonary Artery) was constructed and the patient did well despite a turbulent post-operative period. CONCLUSION: The management of tricuspid atresia likes other cyanotic heart disease is daunting but palliative treatment is possible in our environment and definitive treatment where possible affords a fairly satisfactory prognosis.

Cardiac pacemaker treatment of heart block in Enugu a 5-year review.

BACKGROUND: Symptomatic heart block is a treatable cardiac cause of death which occurs globally. In Nigeria it is increasingly diagnosed and treated with permanent artificial cardiac pacemaker insertion and pulse generator implantation, sometimes after a period of misdiagnosis and inappropriate treatment. METHODS: Twenty-three patients who were diagnosed with symptomatic heart block and surgically treated with permanent artificial cardiac pacemaker in National Cardiothoracic Centre, Enugu, between April 2001 and March 2006 had their case notes retrospectively reviewed and information entered into a proforma. This was analyzed. Patients diagnosed with symptomatic heart block but not treated with artificial cardiac pacemaker insertion were excluded from the study. There were eight such patients who could not afford the cost of surgical treatment during the period under review. RESULTS: The mean age of the patients was 70 years and the commonest presentation was shortness of breath (100%). Hypertensive heart disease was present in 65% of the patients and a history of chronic chloroquine usage was positive in 73% of the patients. Predominant pretreatment pulse rate was in the range of 30-40 per minute (43%) while 21% of the patients had pulse rate below 30 per minute. These categories of patients commonly had Stoke-Adams syndrome. Sixty-seven per cent of the patients had predominantly systolic hypertension on admission and 16% had hypotension. Third degree heart block was present in 65% of the patients and 89% of all patients needed pre-pacing haemodynamic stabilization with positive inotropic/chronotropic drug(s). Treatment consisted of permanent endocardial pacing in 65% and epicardial pacing in 35% of the patients with equally good response in symptoms, haemodynamic parameters and electrocardiographic features. CONCLUSION: Permanent artificial cardiac pacing is, the reliable treatment of symptomatic heart block and should be included in the National Health Insurance Scheme list.

Cardiac Pacemaker Treatment of in Enugu a 5-Year. Review

Background: Symptomatic heart block is a treatable cardiac cause of death which occurs globally. In Nigeria it is increasingly diagnosed and treated with permanent artificial cardiac pacemaker insertion and pulse generator implantation; sometimes after a period of misdiagnosis and inappropriate treatment. Methods: Twenty-three patients who were diagnosed with symptomatic heart block and surgically treated with permanent artificial cardiac pacemaker in National Cardiothoracic Centre; Enugu; between April 2001 and March 2006 had their case notes retrospectively reviewed and information entered into a proforma. This was analyzed. Patients diagnosed with symptomatic heart block but not treated with artificial cardiac pacemaker insertion were excluded from the study. There were eight such patients who could not afford the cost of surgical treatment during the period under review. Results: The mean age of the patients was 70 years and the commonest presentation was shortness of breath (100). Hypertensive heart disease was present in 65of the patients and a history of chronic chloroquine usage was positive in 73of the patients. Predominant pre-treatment pulse rate was in the range of 30-40 per minute (43) while 21of the patients had pulse rate below 30 per minute. These categories of patients commonly had Stoke-Adams syndrome. Sixty-seven per cent of the patients had predominantly systolic hypertension on admission and 16had hypotension. Third degree heart block was present in 65of the patients and 89of all patients needed pre-pacing haemodynamic stabilization with positive inotropic / chronotropic drug(s). Treatment consisted of permanent endocardial pacing in 65and epicardial pacing in 35of the patients with equally good response in symptoms; haemodynamic parameters and electrocardiographic features. Conclusion: Permanent artificial cardiac pacing is the reliable treatment of symptomatic heart block and should be included in the National Health Insurance Scheme list

Pregnancy after heart valve replacement--case report.

There is an increased risk of thromboembolism, anticoagulant-related haemorrhage, foetal-wastage, and congestive cardiac failure in pregnant women with mechanical heart valves. Pregnancy in such patients is a high risk venture. In order to have a good outcome, the care of such patients must necessarily be multidisciplinary and in a well-equipped centre with adequate support services. One such patient who had mechanical mitral valve replacement in 1986 and was on warfarin anticoagulant presented in April 2003 with a first trimester pregnancy. She was in stable haemodynamic state and went through pregnancy without event. Delivery was by an elective caesarian section at 38 weeks gestation. The care of this patient during pregnancy, delivery, and puerperium is the basis of this report.

Oesophageal replacement in adult Nigerians with corrosive oesophageal strictures.

Literature dealing with the management of undilatable oesophageal strictures in Africa is either scanty or non-existent. This report reviews 73 cases of adult undilatable corrosive strictures treated by oesophageal replacement at the University of Nigeria Teaching Hospital (UNTH) Enugu over a 5-year period (March 1986 to February 1991). Almost all the cases were suicidal or parasuicidal. All the patients had colon transplants; the right colon was used in 68 patients while the left colon was used in five patients. The age range was 13 to 48 years with a mean of 26 years. There were 65 males and 8 females. Four patients died in the postoperative period, earlier on in our surgical experience, a mortality of 5%. Of the 69 survivors, 62 patients (90%) experienced no dysphagia after 6-9 months of follow-up. Four patients (6%) swallowed with some difficulty while three patients who could not swallow at all 6 months after surgery underwent further surgery, the strictured upper part of the transplants being replaced with myocutaneous tube grafts after which two patients were able to swallow. Major postoperative complications were proximal anastomotic leak 49% (34 patients) of survivors, wound sepsis 25% (17 patients), tension pneumothorax 7% (five patients), colon graft necrosis 4% (three patients), and Ascaris upper intestinal obstruction 4% (three patients). The short and medium term results after colon transplant for oesophageal corrosive strictures are good. Our experience emphasizes the fact that these patients are from the very low social class, usually ignorant and most default at the follow-up clinics, once they start swallowing.(ABSTRACT TRUNCATED AT 250 WORDS)

Life threatening iatrogenic major vascular injuries complicating groin hernia repair.

Major vascular injuries complicating groin hernia repairs are very rare. Five such cases seen at the vascular unit of the Department of Surgery, UNTH, Enugu, Nigeria over a five year period are presented. The patients all of whom were adults (age range 49-65) had initial problems of hypovolaemia due to massive blood loss followed by infection and anaemia. One of the patients died from irreversible shock while still in the Casualty Unit. The vascular injuries were dealt with by either primary repair, vein graft or dacron graft depending on the prevailing conditions e.g. presence or absence of infection. The other 4 patients who had surgery did well postoperatively and on 5 to 58 months follow-up. Emphasis is laid on the underlying causes of these iatrogenic injuries which include inexperience on the part of the operator and inadequate anaesthesia (often wrongly applied local anaesthesia). If this complication however occurs, the wound should be tightly packed and patient sent immediately to a unit with vascular surgical facilities.

Oesophageal replacement in paediatric patients.

Over a 5-year period from January 1986 to December 1990, 24 children aged between 16 months and 12 years with undilatable oesophageal stricture had oesophageal replacement with isoperistaltic colonic conduit. All the strictures followed accidental corrosive burns. The procedure was well tolerated; all the patients were able to swallow within 3 weeks of surgery. Major postoperative complications were threatening pneumothorax (two cases), gastric outlet obstruction due to Ascaris lumbricoides (two cases) and cervical fistula (eight cases) which closed spontaneously in each case. There were no operative or postoperative deaths. Twenty-two patients have been followed up for 2-59 months. Children tolerate oesophageal replacement well. The short-term and medium-term results are good, but anxiety over the fate of the retained native oesophagus is noted.

Anatomical sex conversion in a 21-year-old--case report and review of literature.

A case of anatomical sex conversion in a 21-year-old genotypic male Nigerian with ambiguous genitalia but who was reared as a girl is presented. The clinical features observed in this particular case and the result obtained after surgery, adjuvant hormone therapy and supportive psychotherapy are discussed. The relevant literature pertaining to the clinical entity is reviewed.

Sexual function in males following abdomino-perineal resection in Nigeria.

Twenty-six male patients who had abdomino-perineal resection for ano-rectal carcinoma between 1980 and 1988 were interviewed during their follow-up visits. Emphasis was on their sexual function. The age range was between 19 to 40 years with a mean of 27 years. Eight patients (31 pc) had complete loss of sexual function. Eighteen patients (69 pc) had complete or partial sexual function. 15 patients (57 pc) had normal sexual function. Compared to what obtains in developed countries, cancer of the ano-rectum is relatively commoner in the young in our region. A good proportion of these will develop impaired sexual function after abdomino-perineal resection. It is important that this probable complication be discussed fully with the patient before the operation, since the loss of sexual function in a young male is a major form of morbidity in this sub-region.

Invasive thymoma and myasthenia gravis in a three-and-a-half-year-old boy: case report and literature review.

Thymomas are very rare tumours in the paediatric age group, characteristically slow growing and only few cases have been reported in the literature. The commonest disease associated with thymomas in the adult is myasthenia (MG). There are reports to suggest that this association does not occur in the paediatric age group. We report the unique case of a 3-years-7-month-old boy who presented with a very rapidly increasing mediastinal tumour. He developed Florid M.G. after excision through a median sternotomy. The histology of the excised tumour was that of a thymoma.

Results of Mustard's repair for dextro-transposition of the great arteries.

Dextro-Transposition of Great Arteries (d-TGA) was repaired by Mustard's operation in 69 patients during a 10 year period (1973-1982) in our institution. Ages at the time of surgery ranged from 3 months to 18 years, with a median age of 18 months. Factors that most affected mortality and morbidity were associated cardiac defect, the year of the operation and the age of the patient. Of the 69 patients, 26 (38%) had complex d-TGA. Early post-operative mortality was 2.38% for patients with simple transposition and 22% for the complex group. All early deaths occurred in the early part of series. Ten consecutive cases with complex transpositions in the late part of the series have done well. There were 5 late deaths--4 from the early series and these had complex transposition. Postoperative non-fatal complications included arrhythmia which occurred in 6 patients (9%). The rhythm abnormality was temporary in 2 and permanent pacing was required in 2 other patients (2.9%). There were 3 cases of late caval obstruction and 4 cases of late pulmonary venous obstruction--six of these seven patients were less then 12 months of age. Postoperative renal failure occurred in patients in the early series but was not seen in the late series. Three children developed postoperative pulmonary edema due to large bronchial collateral arteries and underwent successful collateral vessel ligation subsequent to the Mustard operation. Two patients have demonstrated late tricuspid regurgitation, are presently in heart failure and may need valve replacement.(ABSTRACT TRUNCATED AT 250 WORDS)

Stroke syndrome in the young due to obliterative arteritis of extracranial carotid arteries. Clinical pathological profiles.

Transient Ischemic Attack (TIA) and Cerebrovascular Accidents (CVA) are rare in the young. Extracranial carotid arterial obstruction as a cause for CVA is even more exceptional. We present two cases of TIA and CVA in patients below the age of 30. They needed bypass graft and total excision of the artery. Histological diagnosis was arteritis. The clinical, laboratory and surgical data are presented.

Hypoxemia and pulmonary hyperperfusion due to systemic collateral arteries after total repair of transposition of the great arteries.

Two cases of hypoxemia and pulmonary hyperperfusion due to large bronchial collateral arteries after total repair of simple transposition of the great arteries (TGA) are presented. Pulmonary hyperperfusion was not present before total repair. Hypoxemia and congestive heart failure quickly abated after surgical ligation of these enlarged bronchial collateral arteries. The patients were totally corrected quite late (at 21 and 22 months respectively) by current standards. It is suggested that: (1) large bronchial collaterals may develop in patients with simple TGA especially if total correction is delayed; (2) preoperative angiographic evaluation of patients with simple TGA who come in for total correction late, should include special aortic root injection to exclude the presence of bronchial collaterals; (3) hypoxemia and pulmonary congestion after total correction of TGA by atrial switch procedure (Mustard or Senning) may in fact be due to bronchial collaterals and not obstruction of the pulmonary veins.

Bilateral semilunar valvotomies using inflow occlusion in a neonate.

The case of a neonate with critical pulmonary and aortic valve stenosis who underwent successful sequential valvotomies using one period of inflow occlusion is reported. This valvotomy technique performed in critically ill neonates, if carried out expeditiously, can result in the same degree of success as when used for single valvotomies.