Mitral valve repair in chronic severe mitral regurgitation: short-term results and analysis of mortality predictors.

INTRODUCTION: Mitral valve repair is the accepted treatment for mitral regurgitation (MR) but lack of resources and socioeconomic concerns delay surgical referral and intervention in developing countries. We evaluated immediate and short-term results of mitral valve repair for non-ischemic MR at our centre and aimed to identify the predictors of in-hospital and follow-up mortality. MATERIALS AND METHODS: The study was conducted at a tertiary-level hospital in South India. All patients >18 years with severe non-ischemic MR who underwent mitral valve repair over a period of 6 years were included. Perioperative data was collected from hospital records and follow-up data was obtained by prospective methods. RESULTS: There were 244 patients (170 males). Most of the patients were in the age group 31-60 years (76.6%). Aetiology of MR was degenerative (n = 159; 65.2%), rheumatic (n = 34; 13.9%), structural (n = 42; 17.2%), or miscellaneous (n = 9; 3.7%). All patients underwent ring annuloplasty with various valve repair techniques. One hundred patients (44.7%) underwent additional cardiac procedures. At discharge, MR was moderate in 4 patients; the rest had no or mild MR. The mean hospital stay of survivors was 7.1 days (SD 2.52, range 5-25 days). There were 9 in-hospital deaths (3.68%) and 10 deaths during follow-up (4.2%). The mean follow-up period was 1.39 years, complete for 87.6%. Pre-operative left ventricle ejection fraction (LVEF) <60% (p = 0.04) was found to be significantly associated with immediate mortality. Logistic regression analysis detected age (p = 0.019), female sex (p = 0.015), and left ventricular (LV) dysfunction at discharge (p = 0.025) to be significantly associated with follow-up mortality. CONCLUSION: Pre-operative LV dysfunction was identified as a significant risk factor for in-hospital mortality. Female sex, age greater than 45 years, and LV dysfunction at discharge were found to be significantly associated with follow-up mortality. Hence, it is important to perform mitral valve repair in severe regurgitation patients before significant LV dysfunction sets in for a better outcome.

Should all tubercular cavities be left alone? Lessons from a heart transplant.

Fungal infection after solid organ transplantation poses a diagnostic and therapeutic challenge. We present the case of a 50-year-old man who underwent orthotopic heart transplantation for dilated cardiomyopathy with a history of treated pulmonary tuberculosis 10 years pre-transplant. One year post-transplantation, he was admitted with recurrent productive cough and was evaluated to have intracavitory aspergillosis of the lung. He was started on medical therapy with reduction in immunosuppression, but succumbed later with allograft rejection and multiorgan failure. Management of invasive aspergillosis in immunocompromised host is a real challenge. Management protocol should be individualised.

"Not all bullae are synonymous with COPD"-a rare congenital anomaly described.

Hyperlucent areas with thin walls and absent vascular markings in chest X ray are described as radiological findings of a bullae. We present the case of an adult male referred for coronary revascularisation and bullectomy in the right lung. A non-smoker, without any significant past medical history, made us think of bronchial atresia. He was planned for coronary artery bypass grafting with close follow-up of lung anomaly. Clinicians should be aware of this entity in non-smokers with unilateral bullous lesion and calcification as other close clinical differentials warrant aggressive medical management.

Lifestyle practices, health problems, and quality of life after coronary artery bypass grafting.

INTRODUCTION: Severe coronary artery disease continues to be a major health problem in India, and coronary artery bypass grafting (CABG) is the accepted modality of treatment. Post-operative long-term quality of life depends on the healthy lifestyle practices and appropriate control of risk factors. We tried to bring out the patient awareness and their practices after the surgery and their implications on their quality of life (QOL). MATERIALS AND METHODS: Five hundred patients who completed 6 months after isolated CABG were interrogated for their lifestyle practices, health problems, and quality of life using a structured questionnaire. Those who underwent additional cardiac procedures, redo CABG, and coronary interventions after CABG were excluded. RESULTS: Eighty percent were in good functional class (NYHA I, II). Detailed evaluation showed that only 11.6% adhered to healthy lifestyle practices. Obesity, uncontrolled diabetes mellitus, uncontrolled hypertension, and hypercholesterolemia continued to be problems in 9.6, 20.2, 35, and 48.4%, respectively. Quality of life was assessed to be good in 27.6%, average in 46.4%, and poor in 26%. Psychological evaluation showed that 23% were significantly anxious and 20% had significant depression. Pre-operative diagnosis and left ventricular function at discharge influenced the QOL. Unhealthy lifestyle practices and failure to attain risk factor reduction adversely affected the quality of life. CONCLUSION: This study emphasises the need for aggressive counselling as well as continuing health education to improve patient awareness about adopting healthy lifestyle practices after CABG to improve the quality of life.

The Hemi-Fontan operation: A critical overview.

The hemi-Fontan (HF) operation is a staging procedure in the journey towards an ultimate Fontan palliation. Although popular in the Western world, it has found limited application in the developing world. In this review we discuss the indications, techniques, merits, and demerits of this procedure along with its present day role in developing world where there is lack of awareness about this operation.

Successful management of multiple infected sub-mitral aneurysms of left ventricle.

Sub-mitral aneurysms are rarely reported clinical entity. Though a variety of etiologies are proposed, congenital weakness of the mitral valve annulus is the most widely accepted one. A 17-year-old boy with sub-mitral aneurysm presented with severe mitral regurgitation, which was diagnosed by echocardiography and successfully managed surgically. The aneurysm wall was positive for Staphylococcus aureus, and patient was treated with intensive antibiotics.

Severe mitral regurgitation after intracardiac repair of tetralogy of Fallot: a rare complication and management.

Tetralogy of Fallot (TOF) with additional ventricular septal defect (VSD) forms a difficult surgical subset. Commonly, additional VSD is in the muscular septum and direct visualization may be difficult during surgical repair especially in arrested heart. Consequently, direct closure of these defects is performed based upon preoperative imaging and/or intraoperative transoesophageal echocardiogram. We hereby report an unforeseen occurrence of traumatic acute severe mitral regurgitation after TOF repair possibly during closure of additional muscular VSD. We discuss the possible mechanism of this unprecedented complication, which was promptly diagnosed and managed with good surgical outcomes.

Cortriatriatum with classical Raghib complex: a rare anatomic association.

Cortriatriatum with Raghib's complex is a rarely reported entity. An 18-month-old baby who presented with tachypnea and cyanosis was diagnosed to have cortriatriatum sinistrum along with a persistant left superior caval vein draining to the left atrium through an unroofed coronary sinus. The child underwent successful surgical correction with excision of the cortriatriatum and baffling of the left superior caval vein to the right atrium.

Unusual left ventricular pseudoaneurysm in a child after disseminated bacterial infection.

Left ventricular pseudoaneurysms are rare in children. A six-year-old boy developed left ventricular pseudoaneurysm despite successful control of sepsis. The pseudoaneurysm was diagnosed by two-dimensional echocardiography and detailed by computed tomography. The child underwent successful surgical correction with partial excision and plication of the aneurysmal sac.

Pericardiectomy in children <15 years of age.

Between January, 2002 and December, 2011, 27 patients (19 boys) underwent pericardiectomy. The mean age was 9.3 ± 4.96 years (range 0.4 to 15 years) and the mean duration of symptoms was 16.9 ± 22.15 months. In all, 25 patients had dyspnoea; eight were in New York Heart Association (NYHA) class IV; six had bacterial pericarditis; and 18 were on anti-tuberculosis treatment, although only nine had records suggesting tuberculosis. There were nine patients who underwent pre-operative pigtail catheter drainage of pericardial fluid. Surgical procedures were complete pericardiectomy (n = 20), partial pericardiectomy (n = 6), and pleuropericardial window (n = 1).The mean pre-operative right atrial pressure was 20.4 ± 4.93 mmHg. There were six hospital deaths due to low cardiac output (n = 5) and arrhythmia (n = 1). The mean intensive care unit stay was 2.7 ± 1.2 days and mean post-operative stay was 9.9 days. The mean right atrial pressure dropped to 8.7 ± 1.15 mmHg. Adverse outcomes defined as death/prolonged intensive care unit stay, prolonged post-operative stay were not associated with sex, diagnosis of tuberculosis or pyopericardium, or the duration of symptoms or pre-operative right atrial pressure. Younger patients had prolonged intensive care unit stay (p = 0.03) but not increased mortality. Advanced NYHA class predicted death (p = 0.02). The mean follow-up was 23.1 ± 23.8 months. All except one survivor are in NYHA class I and off all cardiac medications. Despite adequate surgery, pericardiectomy in children is associated with a high mortality, which is related to delayed surgery and poor pre-operative general condition. No specific pre-operative variable other than worse pre-operative NYHA class is a predictor of survival. Therefore, early pericardiectomy should be undertaken in such patients.

Metastatic thymic carcinoid: does surgeon have a primary role?

Thymic carcinoids are rare mediastinal tumours. These are aggressive tumours that often present late and have poor prognosis. Primary surgical treatment is recommended even in metastatic tumours since the role of adjuvant therapy is not well established. We present a case of metastatic thymic carcinoid managed with surgical excision.

Arterial switch operation with unidirectional valved patch closure of ventricular septal defect in patients with transposition of great arteries and severe pulmonary hypertension.

OBJECTIVE: For patients with dextro-transposition of great arteries (d-TGAs), ventricular septal defect (VSD), and severe pulmonary arterial hypertension (PAH), the common surgical options are palliative arterial switch operation (ASO) or palliative atrial switch operation leaving the VSD open. We evaluated the role of ASO with VSD closure using a fenestrated unidirectional valved patch (UVP). METHODS: Between July 2009 and February 2011, six patients with TGAs, VSD, and severe PAH (mean age 39.8 ± 47.4 months, median 21, range 8-132 months), weighing 10.7 ± 9.2 kg (median 8.6, range 4.3-29 kg), underwent ASO with VSD closure using our simple technique of UVP. Mean pulmonary artery systolic pressure before the operation was 106 ± 12.7 mm Hg (median 107.5, range 95-126 mm Hg) and pulmonary vascular resistance was 9.5 ± 4.22 units (median 9.5, range 6.6-17.1 Wood units). RESULTS: There were no deaths. All patients had a postoperative systemic arterial saturation of more than 95%, although there were frequent episodes of systemic desaturation due to right-to-left shunt across the valved VSD patch (as seen on transesophageal and transthoracic echocardiograms). Mean follow-up was 10 ± 7.6 months (median 7.5, range 1-22 months). At most recent follow-up, all patients had systemic arterial saturation of more than 95% and no right-to-left shunt through the VSD patch. In one patient, the follow-up cardiac catheterization showed a fall in pulmonary artery systolic pressure to 49 mm Hg. CONCLUSION: Arterial switch operation with UVP VSD closure is feasible with acceptable early results. It avoids complications of palliative atrial switch (arrhythmia and baffle obstruction) and partially or completely open VSD.

Atrial switch operation in the current era: modifications and pitfalls.

Although rarely performed today, atrial switch operations continue to have an important role in the management of some forms of congenital heart disease. In developing countries, delayed diagnosis and presentation of patients with transposition of the great arteries is not uncommon. For some patients who are referred for surgery beyond the newborn period, the atrial switch operations are still considered to be the best option. Also, as part of surgical repair of congenitally corrected transposition, an atrial switch operation is combined with arterial switch or the Rastelli procedure as an alternative to physiologic repair. In isolated ventricular inversion (atrioventricular discordance with ventriculoarterial concordance), the atrial switch operation alone leads to complete anatomical correction. Finally, management of late complications of atrial switch operations requires a thorough understanding of the procedures.

Aortico-right ventricular tunnel with anomalous right coronary artery.

Two patients with aortic right ventricular tunnel and anomalous origin of the right coronary artery from the tunnel are reported. The literature on this condition is reviewed.