Clinical outcome of right ventricle outflow tract management for repair of Tetralogy of Fallot with three contemporary surgical strategies.

OBJECTIVE: To compare the early operative outcome of TOF repair with three contemporary repair strategies of RVOTO repair i.e. TAP, Mono-cusp construction (MC) in TAP and pulmonary valve repair. METHODS: Study is performed at Punjab Institute of Cardiology, Lahore from May 2016 to April 2020. Retrospective analysis of data was performed for patient who underwent TOF repair by three different strategies of RVOT repairs during TOF surgery based on z scoring for pulmonary valve annulus. Group-I underwent trans-annular patch repair, while Group-II and III underwent Mono-cusp repair with autologous pericardium and pulmonary valve repair respectively. Analysis of Variance (ANOVA) and Pearson Chi-Square (PCS) statistics were used to compare the three groups for numeric and categorical variables respectively. Post-hoc t-test and Bonferroni correction were performed for numeric data to compare two groups with each other. Chi-square test was used to perform comparison between groups for categorial variables. RESULTS: ANOVA for aortic cross clamp time, total CPB time, Post-operative mechanical ventilation time, ICU stay and hospital stay showed statistical difference among all three group with p-value less than 0.05 however post hoc T-test showed this variation is limited to post-operative mechanical ventilation only when groups compared with each other. PCS showed there was difference for incidence of difficult weaning from CPB when all three groups compared while there was no difference in operative mortality with p-value of 0.15. However, Group-II comparison with Group-I showed that weaning from CPB was superior in-Group-II with p-value of 0.016. Group-III showed the best statistics for all operative outcome variables among all three groups. Comparison of incidence of post-operative moderate pulmonary regurgitation before discharge between Group-II and Group-III showed significant difference with p-value of 0.0052. CONCLUSION: PV repair strategy should be employed for RVOT repair of TOF whenever feasible. MC repair showed fewer hours of postoperative mechanical ventilation and higher incidence of easy weaning from CPB when compared to TAP, however its impacts over ICU stay, Hospital stay and operative mortality is not profound in our TOF repair population.

Surgical outcome of repair of aortic valve prolapse and regurgitation associated with ventricular septal defect.

OBJECTIVE: To analyze the outcome of repair of aortic valve disease associated with various types of ventricular septal defect. METHODS: In a retrospective observational study design, data of seventy-two patients of ventricular septal defect (VSD) associated with aortic valve prolapse (AVP) and aortic regurgitation (AR) who was operated in Punjab Institute of cardiology from May 2016 to April 2020 was collected. Depending on presence of AR, all patients were divided in four groups. Group-I (VSD and AVP but no AR) had fifteen patients. Only VSD was closed in this group. Group-II (VSD and Mild AR) had forty patients, only VSD was closed in this group as well. Group-III (VSD and Moderate AR) had ten patients, VSD closure and aortic valve repair was done. Group-IV (VSD and severe AR) had seven patients. Aortic valve was repaired in five patients and replaced (AVR) in two patients along with VSD closure. Associated anomalies were addressed as well. RESULTS: Group-I: Twelve out of fifteen patients (80%) showed no post-operative AR. While two patients (13.3%) showed Trace AR. Single patient (6.6%) showed mild AR. There results were unchanged after mean follow up of 36 months. Group-II: Eight out of forty patients (20%) had no AR, while eight (20%) had trace AR. Twenty-three (57.5%) patients had mild AR. Single (2.5%) patient had moderate AR. After follow up of 24 months the patient with moderate AR progressed to severe AR. We are planning to do Aortic Valve Replacement (AVR) in this case. Rest of cases showed no progression of disease. Group-III: Two out of ten patients (20%) had no AR, four (40%) had trace AR, while four (40%) had mild AR. Mean follow up was 42 months (2.5 years). Neither trace nor mild AR progressed to severe or moderate AR. Group-IV: Among seven patients, five underwent repair while two had AVR. Out of five patients who underwent aortic valve repair, four patients (57.1%) were declared mild AR, while severe AR was converted to moderate AR in single patient (14.28%). Mean follow up was 18 months. The moderate AR patient has progressed to severe AR for last six months and we are planning to do AVR in this patient. Postoperative echo of patients with AVR showed adequately functioning aortic valve with AVPG mean 10 mmHg and 15 mm Hg respectively, with no residual AR. CONCLUSIONS: Aortic regurgitation associated with VSD is a congenital lesion with continuously active aortic valve disease resulting in significant morbidity and mortality. Early diagnosis, effective treatment and meticulous follow up decelerate and in most cases arrest the disease process.

Surgical repair of congenital coronary artery fistula: A case report.

Coronary artery fistula is an exceedingly uncommon congenital disorder characterized by fistulous communication of a coronary artery with asystemic or pulmonary vessel or a heart chamber. Small fistulas are asymptomatic and benign while large fistulas present in a variety of ways like heart failure, arrhythmias or endocarditis. We report here a rare case of eight years old girl who presented to us with history of shortness of breath and palpitation. Her echocardiography revealed a moderately large right coronary artery fistula that was opening into right ventricle. Angiography later confirmed its presence. We surgically closed it with a pericardial patch on cardiopulmonary bypass. The girl showed uneventful recovery and her postoperative echocardiography revealed no residual fistula. She was discharged on 5th postoperative day and her follow up was also unremarkable.

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.

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 Group-B 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 appropriate management of aortic valve disease can 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 (TOF) 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%) 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.

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.

Comparison of effectiveness and cost of patent ductus arteriosus device occlusion versus surgical ligation of patent ductus arteriosus.

OBJECTIVES: Comparison of effectiveness and cost of transcatheter occlusion of patent ductus arteriosus (PDA) with surgical ligation of PDA. METHODS: This retrospective comparative study was conducted in the pediatric cardiology department of Ch. Pervaiz Elahi Institute of Cardiology Multan, Pakistan. Data of 250 patients who underwent patent ductus arteriosus (PDA) closure either surgical or trans-catheter closure using SHSMA Occluder having weight >5 kg from April 2012 to October 2015 were included in this study. SPSS version 20 was used for data analysis. Quantitative variables were compared using independent sample t-test. Chi-square test and fishers exact was used for qualitative variables. P-value <0.05 was considered statistically significant. RESULTS: There were one hundred and twenty (120) patients who underwent transcatheter occlusion of PDA using SHSMA occluder (PDA Device Group) and one hundred and thirty (130) patients who underwent surgical ligation of PDA (Surgical Group). Incidence of residual shunting was two (1.5%) in surgical group and 0 (0.0%) in PDA Device group for one month follow up period. There were 4 (3.1%) major complications in surgical group. The rate of blood transfusions were high in surgical group (p-value 0.04). Hospital stay time was significantly less in PDA Device group (P-value <0.001). Total procedural cost was 110695+1054 Pakistani rupees in PDA Device group and 92414+3512 in surgical group (p-value <0.001). The cost of PDA device closure was 16.52% higher than the surgical ligation of PDA. There was no operative mortality. CONCLUSION: The transcatheter closure of PDA is an effective and less invasive method as compared to the surgical ligation. There is a lower rate of complications and the cost is not much high as compared to surgical PDA ligation.

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.