Three-year outcomes of surgical valve replacement with Dafodil™ pericardial bioprosthesis: Dafodil™-1 trial.

Background: The Dafodil™-1 trial was designed to evaluate the clinical safety and performance of Dafodil™ pericardial bioprosthesis for replacing diseased native or prosthetic aortic or mitral valves in patients with advanced valvular heart disease (VHD). Methods: The Dafodil™-1 trial was a prospective, multicenter, first-in-human clinical trial. Patients were enrolled if they had advanced VHD requiring aortic valve replacement (AVR) or mitral valve replacement (MVR) with or without concomitant valve surgery and having surgical risk scores <4%. Major adverse cardiac events (MACE), including all-cause death, myocardial infarction (MI), and stroke; and hemodynamics were analyzed. Results: A total of 136 patients (aortic: 67 and mitral: 69) were enrolled in the trial (with mean age-AVR group: 60.2 ± 8.3 years and MVR group: 49.7 ± 14.4 years). A total of 134 patients (aortic: 66 and mitral: 68) completed the 3-year follow-up (total 300 per 100 patient-years of follow-up). The AVR group demonstrated a significant reduction in the mean pressure gradients from 51.2 ± 24.1 mmHg at baseline to 11.1 ± 6.0 mmHg at the 3-year follow-up (p < 0.0001). The mean effective orifice area (EOA) improved from baseline (0.9 ± 0.6 cm2) to 3-year follow-up (1.8 ± 0.4 cm2) (p < 0.0001). In the MVR group, the mean indexed EOA (iEOA) increased significantly from baseline (0.7 ± 0.4 cm2/m2) to 3-year follow-up (1.1 ± 0.4 cm2/m2) (p < 0.001). There was significant improvement in New York Heart Association functional class and mean SF-12 scores in both groups. At 3-year follow-up, the MACE incidence was 2.3% per 100 patient-years (1.3% strokes per 100 patient-years and 1.3% deaths per 100 patient-years) for AVR group and 4.7% per 100 patient-years (0.6% strokes per 100 patient-years and 4.0% deaths per 100 patient-years) for MVR group. No cases of MI, structural valve deterioration and prosthetic valve endocarditis were reported. The AVR and MVR groups achieved 89.6% and 79.7% MACE-free survival, respectively at 3-year follow-up. Conclusions: The Dafodil™-1 trial demonstrated satisfactory outcomes of clinical safety, hemodynamic performance, and quality-of-life metrics. Additionally, no incidence of structural valve deterioration and very low rates of valve thrombosis during the 3-year follow-up period of Dafodil™-1 first-in-human trial indicated acceptable valve durability up to three years and similar outcomes are warranted for longer follow-ups as a primary goal. Clinical Trial Registration Number: https://www.ctri.nic.in/Clinicaltrials/showallp.php?mid1=18377&EncHid=&userName=CTRI/2017/07/009008, CTRI/2017/07/009008.

Novel technique of left atrial appendage occlusion-a pilot study.

A clot in the left atrial appendage (LAA) is an important cause of cardio-embolic stroke. Concomitant occlusion of the LAA during cardiac surgery is found to have reduced postoperative stroke. A study was designed to observe the results of LAA occlusion in 17 patients undergoing coronary artery bypass graft surgery (CABG) and aortic valve replacement (AVR). The LAA was occluded epicardially with a SIRONIX 60-mm linear noncutting stapler (Healthium Medtech Pvt limited, Peenya, Bengaluru). The effectiveness of occlusion was confirmed by trans-esophageal echocardiography and at 2 years of follow-up with trans-thoracic echocardiography. There was no re-canalization of the LAA, and the patients remained in sinus rhythm. Concomitant LAA occlusion with a linear stapler during cardiac surgery is a safe, feasible, and reproducible option.

Hydrodissection in chronic pulmonary endarterectomy.

In our series of surgical pulmonary endarterectomies done for chronic thromboembolic pulmonary hypertension, we have incorporated the principle of hydrodissection with the aid of a carbon dioxide (CO2) mist blower which is routinely used for off-pump coronary artery bypass (OPCAB) surgeries. This added method of endarterectomy will help to achieve optimum clearance of thrombic load with basic cardiac surgical instruments. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01476-w.

Medium-term outcomes of a modified technique for RSOV-VSD subset.

Rupture of sinus of Valsalva (RSOV) aneurysm to right ventricular outflow tract or main pulmonary artery is commonly associated with subaortic ventricular septal defect (VSD). A standard surgical approach described is double patch closure. We have adopted the principle of transaortic direct closure of VSD with prosthetic patch closure of sinus defect; this novel technique is used for past 15 years with good long-term results. We believe this technique appropriately addresses the embryo-pathological basis of RSOV-VSD complex.

Novel technique of achieving hemodynamic stability during systemic to pulmonary artery shunt.

Historically, the Blalock Taussig (BT) shunt has been an off-pump procedure. For the last two decades, the number of BT shunt operations has come down globally with the adoption of neonatal early corrective surgery. BT shunts are still performed for augmentation of pulmonary arterial (PA) growth or as a part of univentricular palliation. Many infants do not tolerate PA branch clamping while undergoing the graft to PA anastomosis, necessitating institution of cardiopulmonary bypass (CPB). Since the threshold to go on CPB for shunt placement is quite low at most institutions, our technical modification described can avoid deleterious effect of CPB. Our point of interest is to maintain lung perfusion by adopting few principles of off-pump coronary artery bypass surgery.

Tips for southpaw cardiac surgery trainees.

The right-handed surgeons/mentors face difficulties when it comes to training left-handed cardiac surgical trainees. Those who are left dominant and non-ambidextrous have to devise their own ways to operate safely and expeditiously. These are some suggestions that can help mentors to plan a proper training program for a left-handed trainee and for the trainees to overcome their shortcomings.

Lipomatous hamartoma of mitral valve.

Primary cardiac tumors are very rare, and tumors arising from cardiac valves are extremely rare. We present a case of lipomatous hamartoma of the mitral valve in a young female. This is the 6th case of lipomatous hamartoma of the mitral valve to be reported. We discuss the operative and histopathological findings.

A rare case of left ventricular outflow tract mass.

Thrombus formation in left ventricular outflow tract (LVOT) of a normal heart is a very rare occurrence. A 23-year-old male who presented with syncope, on evaluation found to have obstructing mass in the LVOT. His heart was otherwise normal. His investigations were not contributory except for significant eosinophilia. Due to recurrence of syncope he underwent emergency surgery for extraction of the mass, which on histopathological examination was found to be organizing thrombus. His eosinophil count normalized after the surgery. Tests for hypercoaguable states and investigations for known cause of eosinophilia were normal. There was no recurrence of thrombus or eosinophilia at 6 months after surgery. He was diagnosed to have obstructive LVOT thrombus in a normal heart secondary to transient eosinophilia. Presentation of this interesting case with literature on left ventricular thrombus and eosinophilia is discussed.

Acute severe mitral regurgitation following balloon mitral valvotomy: echocardiographic features, operative findings, and outcome in 50 surgical cases.

OBJECTIVE: To analyze the echocardiographic and operative findings with respect to mitral valve anatomy in individuals undergoing emergency surgery for acute severe mitral regurgitation (MR) following balloon mitral valvotomy (BMV). In addition, the clinical profile and outcomes are highlighted. BACKGROUND: Acute severe MR is a major complication of BMV. There are only a few reports which have studied the echocardiographic and operative findings in this setting. In addition, optimal timing of surgery is uncertain. METHODS: Prospective study of 50 consecutive patients undergoing emergency mitral valve replacement (MVR) for acute severe MR following BMV. RESULTS: In 3855 patients who underwent BMV, acute severe MR developed in 50 cases (1.3%) and was referred for emergency MVR. Hypotension (72%), hypoxia (64%), orthopnea (14%), and pulmonary edema (12%) were the clinical manifestations. Severe MR was secondary to anterior mitral leaflet tear in 36 cases (72%), paracommisural tear with annular involvement in seven cases (14%), posterior mitral leaflet tear in five cases (10%) and chordal tear in two cases (4%). The correlation between two-dimensional transthoracic echocardiography (2D-TTE) and operative finding for mitral valve calcification was found to be strong (r = 0.862), in contrast to submitral fusion, where it was found to be moderate (r = 0.536). In-hospital mortality was 12%. Mortality was higher in patients whose time to surgery was ≥24 hr when compared to those who underwent MVR within 24 hr (P < 0.001). CONCLUSIONS: Hypotension and hypoxia are the predominant manifestations of acute severe MR following BMV. Anterior mitral leaflet tear is the most common etiology for severe MR. 2D-TTE underestimated the severity of submitral disease. Early MVR (<24 hr) is recommended for optimal outcome.

Aorto-left ventricular tunnel: uncommon site of origin and management.

Cases of aorto-ventricular tunnel involving the right ventricle and more commonly, the left ventricle have been described. The site of origin is located above the right coronary cusp and occasionally, the left. We describe an aorto-left ventricular tunnel in a 16-year-old girl, with aneurysmal expansion into the right ventricular outflow tract. Its aortic origin was above the commissure of the right and noncoronary cusps of the aortic valve.

Pulmonary artery bypass for in-stent stenosis following angioplasty for isolated pulmonary Takayasu arteritis.

Pulmonary artery (PA) stenosis due to Takayasu Arteritis (TA) is usually managed by angioplasty techniques. We present a patient with isolated PA stenosis with TA with in-stent stenosis. The surgical management and pathophysiology of this disease are reviewed.

A technique for repair of atrioventricular canal defect in dextrocardia.

Congenital heart disease with dextrocardia, situs solitus, is not uncommonly seen in paediatric cardiac surgery. An approach through the right atrium for correction of associated cardiac anomalies is needed in most of these cases. We present a technique for operating on this subset of patients wherein the heart can be displaced into the left pleural space allowing for surgery in an anatomical orientation that is familiar to the surgeon and emphasize the precautions to be taken following surgery.

Infected pseudoaneurysm involving a drug-eluting stent.

Stent infection following percutaneous transluminal coronary angioplasty is rare. We present such a case involving a drug-eluting stent placed in the left anterior descending coronary artery that was managed surgically with removal of the stent with concomitant coronary artery bypass grafting. Early surgical intervention directed at removal of the infected stent, debridement and distal vessel revascularisation is recommended to deal with the infection and prevent myocardial compromise.

A common trunk of origin of the right testicular and middle suprarenal arteries with a retrocaval course.

A common trunk of origin of the right testicular and middle suprarenal arteries with a retrocaval course was observed during the dissection of a male cadaver. The Common trunk (CT) arose from the anterior aspect of the abdominal aorta (AA) at the level of the right renal artery (RRA) and after a short course behind the inferior vena cava (IVC), the CT divided into right testicular and middle suprarenal arteries. The middle suprarenal artery (MSA) passed upwards behind the IVC to the right suprarenal gland. The right testicular artery (RTA) descended posterior to the RRA and anterior to the IVC. It then continued on its normal route distally with the right testicular vein. The awareness of such variations of testicular and middle suprarenal arteries and their unusual origin and course might complicate the interpretation of angiograms and surgical procedures in the posterior abdominal area.

Angiolymphoid hyperplasia with eosinophilia presenting as a giant axillary artery aneurysm.

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an unusual vascular tumor most frequently located in the superficial head and neck. Noncutaneous localization of this pathology in large arteries presenting as a pulsatile mass is extremely rare. We describe an adult male with a giant left axillary artery tumor secondary to ALHE. ALHE should be considered in the differential diagnosis of localized peripheral arterial masses, especially in young patients.

A comparative in vitro evaluation of cytotoxic effects of EDTA and maleic acid: root canal irrigants.

OBJECTIVE: The objective of this study was to compare aqueous solutions of ethylenediaminetetraacetic acid (EDTA) with that of maleic acid (MA) for their cytotoxic effect on Chinese hamster fibroblasts (V79) cells growing in vitro. STUDY DESIGN: Exponentially growing V79 cells were treated with various concentrations of EDTA (0.05% to 1.0%) or MA (0.05% to 1.0%) alone for 30 minutes. After treatment, the media was removed, cells were trypsinized, and the cytotoxic effect of EDTA or MA was analyzed by Pratt Willis test and MTT assay. Similarly surviving fraction (clonogenic assay) was performed by treating the V79 cells with different concentrations of EDTA (0.0025% to 0.25%) or MA (0.025% to 0.25%) for 30 minutes. The statistical significance between the various groups was evaluated using the one-way analysis of variance (ANOVA) and Student t test (unpaired) for 2 group comparisons. RESULTS: There was a significant (P < .01) decrease in the cell viability in a dose-dependent manner indicating the cytotoxic effect of both EDTA and MA when compared with the control group. However, all the dilutions of EDTA were significantly (P < .01) more cytotoxic over that of MA in all 3 assays. CONCLUSION: This study for the first time, clearly demonstrated the significantly less toxic effect of MA at a comparable dose of EDTA, suggesting its potential for use as root canal irrigant.

The challenge produced by familial homozygous hypercholesterolemia when treating premature coronary arterial disease in the young.

BACKGROUND: Familial hypercholesterolemia is a monogenic, autosomal dominant disorder caused by mutations in the LDL receptor gene. Familial homozygous hypercholesterolemia results when both the alleles have the defective mutation. It is characterized by cutaneous and tendinous xanthomas, premature corneal arcing, and is associated with an increased risk of coronary arterial disease. It is also seriously underdiagnosed, resulting in delayed treatment. METHODS: We present a cross-sectional study of 5 patients with familial homozygous hypercholesterolemia who presented to the department of cardiology at Sri Jayadeva Institute of Cardiology, Bangalore, India. All of them underwent coronary angiography as part of the investigation of their angina. RESULTS: All 5 patients were in 2nd or 3rd decade of life, 4 being male, and 4 presenting with effort angina, the other having unstable angina. All had multiple tendinous xanthomas. The majority had significant high grade coronary arterial stenosis. Coronary arterial bypass grafting was necessary in 3, with the others undergoing percutaneous insertion of coronary arterial stents. CONCLUSION: Familial homozygous hypercholesterolemia is a potentially dangerous risk factor that can result in premature coronary arterial disease in children and young adults. This can result in severe morbidity and premature death in young individuals. We also emphasise the need to screen first-degree relatives and extended family members, this playing an important role in early detection and treatment. Despite recent advances in treatment using lipid lowering agents, the disease remains a significant challenge.