Anomalous aortic origin of a coronary artery (AAOCA): A case report.

Anomalous Aortic Origin of a Coronary Artery (AAOCA) is a rare anomaly of the coronary artery with a considerable risk of sudden cardiac death due to ischaemia of the heart. Symptoms may include chest pain on exertion, breathlessness or dizziness. We encountered a case of a 46- year-old female who complained of exertional chest pain with a positive-stress test and subsequently diagnosed with AAOCA through CT angiography (CTA). She successfully underwent a coronary artery bypass graft (CABG) surgery using a saphenous vein graft with uneventful recovery. Right internal mammary artery (RIMA) was not used as it was flimsy and the flow was very poor.

Effect of different concentrations of benzyladenine and frequency of watering on growth and quality of Dracaena sanderiana and Codiaeum variegatum.

The effect of benzyladenine concentration and watering frequency on the growth and quality of Dracaena sanderiana and Codiaeum variegatum was evaluated. Plants were treated with different benzyladenine concentrations of (0, 75, 150, 225 or 300 mg l(-1)) and watering frequencies, daily, every 4, 7 or 10 days interval. Benzyladenine concentration and watering frequency interacted significantly for plant grade on both species. This interaction resulted in the highest grade at 225 mg l(-1) benzyladenine and daily watering for D. sanderiana and 150 mgl(-1) benzyladenine and daily watering for C. variegatum. No significant interactions between benzyladenine concentration and watering frequency were observed for photosynthesis rate, stomatal conductance, specific leaf area and fresh weight of either species. For D. sanderiana, the highest photosynthesis rate (5.70 mmolm(-2)s(-1)) occurred at 225 mg l(-1) and decreased with increasing watering frequency. For C. variegatum, the highest photosynthesis rate (4.49 mmolm(-2)s(-1)) was recorded with benzyladenine concentration of 150 mg l(-1), and photosynthesis rate was found independent of watering frequency. For both species, stomatal conductance was recorded highest at 225 mg l(-1), but watering frequency failed to influence stomatal conductance. For better quality, D. sanderiana should be sprayed with benzyladenine at 225 mg l(-1), and C. variegatum with benzyladenine at 150 mg l(-1) in combinations with watering at 4 days interval.

Coarctation of aorta repair at the National Heart Institute (1983-1994).

This retrospective study illustrates our approach to this problem over the years, from performing subclavian flap aortoplasty initially to the more accepted procedure now, which is resection and end-to-end anastomosis. Coarctation of aorta in our population is seen in a varying age groups and are also associated with other cardiac anomalies including both acyanotic and cyanotic congenital cardiac defects. Therefore a wide variety of surgical procedures were performed including resection of the coarcted segment and end-to-end anastomosis, subclavian flap aortoplasty, patch aortoplasty and synthetic tube graft interposition. Subclavian flap aortoplasty is not widely practised anymore in favour of resection with end-to-end anastomosis. Fifty four point four percent of patients had isolated coarctation, 10.5% had associated valvular defects, 28.1% had other simple congenital defects and 7.0% had associated complex cyanotic congenital defects. Perioperative mortality was 5.26% and is correlated with the younger age of patients at time of surgery and severity of cardiac failure at time of presentation. We did not see any difference in mortality for patients with complex congenital disease or between the different surgical procedures. However, we did find that in the early period when resection with end-to-end anastomosis was performed, there was a significantly higher incidence of morbidities.

Obstruction of mechanical heart valve--diagnosis, surgical treatment and outcome.

From 1982 till 1999, our department performed a total of 2970 heart valve replacements--92% of which were with mechanical heart valves. During this period, there were 8 patients who came to our department with mechanical heart valve obstruction. All these patients presented with signs of heart failure or compromised haemodynamic. Confirmatory tests included transthoracic or transoesophageal echocardiography and cine fluoroscopy. Seven patients were operated upon urgently. Four of the patients had valve thrombosis. The time interval between the initial implantation and presentation varies from 4 months to 11.3 years. Six of the seven patients who were operated on recovered well from the surgery.

Minimally invasive "pocket incision" aortic valve surgery.

A minimally invasive approach to aortic valve surgery through a transverse incision ("pocket incision") at the right second intercostal space was examined. Sixteen patients with a mean age of 30 years underwent this approach. The third costal cartilage was either excised (n = 5) or dislocated (n = 11). The right internal mammary artery was preserved. Cardiopulmonary bypass (CPB) was established with aortic-right atrial cannulation in all except the first case. Aortic valve replacements (AVR) were performed in 15 patients and one had aortic valve repair with concomitant ventricular septal defect closure. There was no mortality and no major complications. The aortic cross-clamp, CPB and operative times were 72 +/- 19 mins, 105 +/- 26 mins and 3 hrs 00 min +/- 29 mins respectively. The mean time to extubation was 5.7 +/- 4.0 hrs, ICU stay of 27 +/- 9 hrs and postoperative hospital stay of 5.1 +/- 1.2 days. Minimally invasive "pocket incision" aortic valve surgery is technically feasible and safe. It has the advantages of central cannulation for CPB, preservation of the internal mammary artery and avoiding sternotomy. This approach is cosmetically acceptable and allows rapid patient recovery.

Surgical experience with cardiac tumours at the General Hospital, Kuala Lumpur.

Fifteen patients underwent surgery for cardiac tumours in General Hospital Kuala Lumpur between October 1984 and June 1989. Twelve of the patients had cardiac myxomas and underwent excision under cardiopulmonary bypass. Two patients had sarcoma, of which one was excised. The other was inoperable. Another patient had a metastalic malignant melanoma which was inoperable. Of the patients 10 were female and five male. Their ages ranged from 16 to 60 years. All were symptomatic and the commonest mode of presentation was exertional dyspnoea and palpitations. Two presented with cerebral embolisation. The three patients with malignant tumours had constitutional symptoms at the time of surgery. All patients had echocardiography pre-operatively to confirm the diagnosis of cardiac tumour. Only one patient underwent preoperative cardiac catheterisation and angiography. The surgical approach in all patients was through a median sternotomy and all except one were operated under cardiopulmonary bypass. There was no intraoperative embolisation. There was one perioperative death. Fourteen patients were followed up for periods ranging from one to 44 months. Three patients with malignant cardiac tumours died. One had recurrence of myxoma 21 months after the initial surgery. We conclude that excision of cardiac myxomas carry a very small risk following which patients have good prognosis. Malignant tumours carry a bad prognosis. From our experience, we conclude that echocardiography is an extremely accurate tool in the diagnosis of cardiac tumours.

A qualitative analysis of pulsatile perfusion: effects on cortisol response to cardiopulmonary bypass surgery.

Continuous analysis of pressure waveform has enabled quantitative assessment of pulsatile perfusion in a series of 51 patients randomly allocated to "pulsatile" (N = 37) and "non-pulsatile" (N = 14) groups. Cortisol and hematocrit (PCV) were measured preoperatively, at 2 minutes and 30 minutes after the start of bypass and just prior to the end of bypass. Radial artery pressure, pulse pressure and dp/dt were recorded continuously on a specially constructed device. Though there was significant difference between the pulsatile and non-pulsatile groups in terms of pulse pressure (P less than 0.001) and dp/dt (P less than 0.01), no difference was demonstrated in terms of mean arterial pressure (P greater than 0.4), total plasma cortisol (P greater than 0.9) and PCV corrected plasma cortisol (P greater than 0.8). Multiple regression analysis of cortisol and change in cortisol with pulse pressure dp/dt and mean arterial pressure failed to show any correlation. We found a normal cortisol response to surgery irrespective of the quality of pulsation.