Twenty Years of Repair of Ventricular Septal Defects in Ghana.

BACKGROUND: Ventricular Septal Defect (VSD) is the commonest congenital heart disease. Without appropriate treatment, it is associated with significant morbidity and mortality. Surgical repair under cardiopulmonary bypass has been the standard treatment. Results of such treatment is not readily available from the West African sub region. We analysed the outcome of surgical repair of VSDs carried out in this Centre over a 20-year period. PATIENTS AND METHODS: A retrospective study was done for all patients who had surgical repair of VSD from January 1993 to December 2012. RESULTS: There were a total of 207 patients, with 6 and 23 of them operated on in the first and last years of the study respectively. There were 121 (58.5%) males and 86 (41.5%) females. The mean age was 10.0 ± 10.5 (11 months - 55 years), with a median of 7 years. The modal class interval was 0 - 5 years (46.4%). Most of the VSDs were perimembranous 168 (81.1%), followed by outlet VSDs 19 (9.2%), muscular VSDs 11 (5.3%) and inlet VSDs 9 (4.4%). Fifty-four cases (26%) had associated congenital cardiac anomalies that needed concomitant surgical intervention, with the commonest being Pulmonary Stenosis (PS) 21 (10.1%), followed by Patent Ductus Ateriosus (PDA) 10 (4.8%). The complication rate was 6.4% (13 cases), comprising a morbidity of 4.4 % (9 cases) and early mortality of 2.0% (4 cases). The morbidity was due to bleeding requiring re-exploration 2 (1.0%), residual VSD requiring re-do 3 (1.4%), complete heart block requiring permanent pacemaker implantation 2 (1.0%), acute renal failure requiring dialysis 1 (0.5%), sternal wound infection requiring debridement 1 (0.5%). The mortality was due to pulmonary hypertension. CONCLUSION: With a morbidity of 4.4% and early mortality of 2.0%, the outcome of surgical repair of VSDs from this study is good. Children with VSDs must be offered repair as soon as possible to avoid the numerous complications that usually follow untreated VSDs.

Thoracic endometriosis syndrome.

BACKGROUND: Thoracic endometriosis syndrome is a rare constellation of different pathological entities arising from intrathoracic endometriosis. Reports from centers in Africa are scanty. Varying theories have been proposed but none satisfactorily explains the varying clinical manifestations. OBJECTIVE: To describe the demographics, pathological spectrum, and outcome of treatment of patients seen at a single centre in West Africa with intrathoracic endometriosis. METHODS: Twelve women who were seen at Ghana's National Cardiotharacic Centre with intrathoracic endometriosis from 2004-2012 were retrospectively reviewed. RESULTS: The age range was from 24 - 39 years with a mean of 32 ± 5 years. Pelvic endometriosis was confirmed in 8 (66.7%) of the patients, 2 (16.7%) had ectopic endometrial tissue at the umbilicus and one (16.7%) had ectopic endometrial tissue at the mons pubis. Seven (58.3%) of the patients had undergone prior uterine surgery before the clinical onset of thoracic endometriosis. The right hemithorax was involved in all 12 (100%) patients studied. Pneumothorax was present in six (50%) women, hemothorax in five (41.7%) and hemopneumothorax in one (8.3%). Three of the four patients who benefited from video assisted thoracoscopy had abrasive pleurodesis followed by hormonal therapy. The rest of the patients had chemical pleurodesis with or without hormonal therapy. CONCLUSION: Thoracic endometriosis may be more prevalent in West Africa than previously believed. Outcome of treatment is satisfactory using a multidisciplinary approach.

Management of intrathoracic oesophageal perforation: analysis of 16 cases.

Intrathoracic oesophageal perforation remains a life-threatening lesion that requires early diagnosis and the appropriate intervention in order to reduce morbidity and mortality. Management depends largely on the cause of the perforation, the integrity of the oesophagus and the time lapse between the perforation and the commencement of treatment. Our aim was to evaluate the management options that were employed in the treatment of patients with oesophageal perforation and the outcome. The records of 16 patients (11 males and 5 females) who had been operated on from 1994-2009 were retrospectively reviewed. Their ages ranged between 2-66 years (mean 36.4). Malignant oesophageal perforations were excluded from the study. The aetiology was iatrogenic in 10 (62.5%), foreign bodies five (31.2%) and spontaneous one (6.2%). Six patients (37.5%) presented within 24 h of their injury and 10 (62.5%) presented after 24 h. Thoracotomy and intrathoracic primary repair was possible in five (31.2%) cases. Oesophagectomy, cervical oesophagostomy and feeding gastrostomy were carried out in 11 (68.8%). Oesophageal substitution was by colon, routed retrosternally. One patient (6.2%) died after oesophagectomy from overwhelming sepsis. Oesophageal perforation is a life-threatening condition. Early diagnosis and the institution of prompt and appropriate treatment ensure good outcome.

Permanent complete heart block following surgical correction of congenital heart disease.

BACKGROUND: The risk of complete heart block (CHB) from congenital heart repairs in Ghana is unknown. This information is important for referring physicians and in pre-operative counselling of patients and facilitates the process of obtaining informed consent for such repairs. OBJECTIVES: This study was undertaken to determine the incidence of permanent post-operative CHB requiring pacemaker implantation; and the post-operative problems related to the pacemaker. DESIGN: Retrospective study design. SETTING: The National Cardiothoracic Centre (NCTC), Korle-Bu Teaching Hospital, Accra, Ghana. METHOD: Review of all patients who had intra-cardiac repair of congenital heart disease known to predispose to post-operative complete heart block from January 1993 to December 2008 was carried out with computation of the frequency of complete heart block according to the intra-operative diagnoses. RESULTS: Six out of 242 patients (2.5%) developed permanent post-operative CHB. All underwent closure of a large perimembranous ventricular septal defect (VSD) either as an isolated defect (2 of 151 or 1.3%) or in the setting of conotruncal anomalies (4 of 73 or 5.5%). The dominant parental concern relating to the implanted device was the financial implications of future multiple surgeries to replace a depleted pulse generator. CONCLUSION: Permanent post-operative complete heart block occurred in 1.3% of patients undergoing VSD repair and 5.5% of those undergoing repair of conotruncal anomalies (Fallot's tetralogy). The dominant anatomic risk factor was a large perimembranous VSD as an isolated defect or as part of a conotruncal anomaly. Permanent pacemaker implantation in this setting is attended by a low morbidity.

Outcome of thrombolysis for massive pulmonary embolism.

BACKGROUND: Deep vein thrombosis is increasingly being diagnosed in Ghana. The commonest complication that leads to death is pulmonary embolism. The mortality rate from massive pulmonary embolism is high even with intervention. Thrombolysis is recommended in massive embolism. OBJECTIVE: To determine the outcome of thrombolysis in the management of massive pulmonary embolism in patients admitted to the Cardiothoracic Intensive Care unit. METHOD: A retrospective audit of the patients who were admitted to the Intensive care unit of the National Cardiothoracic centre with a diagnosis of massive pulmonary embolism between 1st January 2003 and 31st September 2007. RESULTS: Seventeen patients were admitted with the diagnosis of massive pulmonary embolism of which 14 were thrombolysed. Commonest clinical presentations were dyspnoea in 17(100.0%) and hypotension in 12(70.3%) of the patients. Streptokinase was used in 13(92.9%) and urokinase in 1(7.1%) of the patients. The main complications of thrombolysis were bleeding in 12(85.7%), hypotension in 10(71.4%) and nausea and vomiting in 7(50.0%) of the patients. Postthrombolysis, the respiratory function deteriorated in 12 (85.7%) of the patients which required mechanical ventilation. The overall mortality rate was 35.3%. Three patients died before thrombolysis. Of the 14 (82.4%) who were thrombolysed 3(21.4%) died within 8 hours. CONCLUSION: The mortality rate of patients with massive pulmonary embolism is high even after thrombolysis. The commonest complication of thrombolysis was bleeding.

Predictors of post operative bleeding and blood transfusion in cardiac surgery.

INTRODUCTION: In spite of the recent advances in heart surgery, patients undergoing cardiac surgery with cardiopulmonary bypass are at risk of developing significant post-operative bleeding and substantial blood requirements. OBJECTIVE: To evaluate the impact of some perioperative predictors of post-operative bleeding, and blood transfusion after heart surgery and offer suggestions on preventive measures. DESIGN AND METHODS: A prospective analytical study. The perioperative factors studied were haemoglobin level, international normalised ratio (INR), platelet count, and total bypass time. Eighty-seven consecutive patients who underwent heart surgery in the year 2004 were selected. Each patient had laboratory work up which included full blood count, clotting profile, kidney and liver function tests. The total blood loss within the first twenty-four hours and the total units of blood transfused before the patient was discharged were also recorded. RESULTS: Pre-operative haemoglobin was significant in determining the total units of blood received by a patient. Increasing total bypass time caused a significant increase in the percentage reduction of the pre-operative platelet count (p <0.004). However even though there was an increasing trend of post-operative bleeding with increase in total bypass time, this was not significant from the analysis (p<0.069). The percentage reduction in platelet count and immediate postoperative platelet count were significant predictors of postoperative bleeding (p <0 .009) and (p <0.003) respectively. CONCLUSION: Pre-operative haemoglobin, percentage reduction in the platelet count after cardiopulmonary bypass and immediate postoperative platelet count are significant predictors of postoperative bleeding and blood requirements.

Impalement injuries of the chest.

Impalement injuries of the chest are uncommon in civilian practice with few reports in the literature. We report three cases of thoracic impalement seen over a 5 year period with unusual underlying mechanisms. In two of the cases, the impalement was obvious; in the third, the impalement was concealed having occurred 5 months earlier. In Case 1, the underlying mechanism was a high-speed road traffic accident. The patient was impaled by a metallic square pipe piled by the roadside. In Case 2, the gun-housing of a locally-made rifle gave way as it was fired and allowed a reverse ejection of the barrel during recoil that impaled the hunter's chest. In Case 3, a domestic assault with an old umbrella caused an impalement injury as one of the umbrella spokes broke off, penetrated and lodged in the left chest going unnoticed for 5 months. Persistent chest pain and haemoptysis led to a request for chest radiographic examination upon which the foreign body was discovered. Massive haemoptysis brought the patient to emergency thoracotomy. All three patients underwent thoracotomy with a successful outcome.

Synchronised cardioversion for chronic atrail fibrillation.

SUMMARY OBJECTIVE: To determine whether elective cardioversion was successful in establishing sinus rhythm in patients with chronic atrial fibrillation and the energy used for the cardioversion using a monophasic defibrillator. DESIGN: This is a retrospective descriptive study. SETTING: Intensive care unit of the National Cardiothoracic Centre, Korle-bu Teaching Hospital. SUBJECTS: Twelve consecutive patients referred by physicians with chronic atrial fibrillation which had not responded appropriately to pharmacological agents. METHOD: Using the intensive care admissions and discharge register and report book, the patients case notes were retrieved. The pre-cardioversion echocardiography diagnosis and drugs were noted. The results of cardioversion, and the current rhythm status were also reviewed. RESULTS: There were twelve elective cardioversions for chronic atrial fibrillation during the period under investigation. All the patients were on warfarin with INR-2.2-2.8. Eight of the patients had initial echocardiographic evidence of thrombi in the left atrium. Sinus rhythm was established in 9(75%) of the patients. The mean energy used for the cardioversion was 384.4+/-167.7J. Of the 3 with failed cardioversion, one was later successfully cardioverted to sinus rhythm. On review, 9(75%) of the patients are still in sinus rhythm 6 months to 15 months after cardioversion. Six of these patients continue with oral amiodarone however. CONCLUSION: Synchronized cardioversion for chronic atrial fibrillation is safe and may be successful after failure of pharmacologic cardioversion in patients where sinus rhythm is desirable.

Surgical management of constrictive pericarditis.

SUMMARY BACKGROUND: Constrictive pericarditis is a disease characterized by marked thickening and dense scarring of the pericardium with pericardial sac obliteration, or calcification of the pericardium. Without treatment this disease is characterized by high morbidity and mortality. OBJECTIVE: To review the surgical management of constructive pericarditis and the post operative challenges. METHODS: Eleven patients who had pericardiectomy for constructive pericarditis between 2000 and 2005 were studied. Data was obtained from the operating theatre register, histopathological reports and patient's case notes. RESULTS: The mean age was 33 years with a range of 14 to 53 years. There were seven males (63.6%) and four females (36.4%). Seven (63.6%) out of the eleven patients operated were treated for pulmonary tuberculosis. The cause of pericardial constriction in four patients (36.4%) was undetermined. Follow up period was between 4-59 months. The mean follow up was 17.5 months. Seven patients (63.6%) were off diuretics and had no exercise intolerance. Patients were classified using the New York Heart Association (NYHA) n (NYHA) functional and therapeutic classification in class I-V. Two patients preoperatively in class III are now in class I after surgery on low dose diuretics. One patient who had calcific constrictive pericarditis and came in class III was now in class II with diuretics after 3 years of follow up. There was no postoperative mortality. One patient was lost to follow up. CONCLUSION: Pericardiectomy is a useful procedure for constrictive pericarditis and was beneficial to all the patients in this study with an improvement in their functional capacity. Intensive peri-operative monitoring and management reduced morbidity and mortality.

The efficacy of pre-operative erythropoietin therapy.

OBJECTIVE: To determine whether a single weekly low dose of erythropoietin (EPO), haematenics and antimalarials is effective in increasing the pre-operative haemoglobin of patients coming for potential blood losing surgery. DESIGN: A prospective observational study. SETTING: The Korle-bu Teaching Hospital, Accra, Ghana. SUBJECTS: Thirty one patients with low haemoglobin scheduled for potential blood losing surgery. RESULTS: A mean weekly dose of EPO administered of 10,840 +/- 640 IU raised the haemoglobin by 2-5g% above baseline levels in 28 (90.3%) of the patients. Twenty five (81%) of the patients had an uneventful normovolaemic haemodilution during their surgery. CONCLUSION: A single weekly dose of 150 ug/kg of EPO, haematenics, chloroquine (anti-malarial) and a high protein diet is efficacious in raising the pre-operative haemoglobin in Ghanaian patients.

Surgical Management of Constrictive Pericarditis

Background: Constrictive pericarditis is a disease characterized by marked thickening and dense scarring of the pericardium with pericardial sac obliteration; or calcifica- tion of the pericardium. Without treatment this disease is characterized by high morbidity and mortality. Objective: To review the surgical management of constructive pericarditis and the post operative challenges. Methods: Eleven patients who had pericardiectomy for constructive pericarditis between 2000 and 2005 were studied. Data was obtained from the operating theatre register; histopathological reports and patient's case notes. Results: The mean age was 33 years with a range of 14 to 53 years. There were seven males (63.6) and four females (36.4). Seven (63.6) out of the eleven patients operated were treated for pulmonary tuberculosis. The cause of pericardial constriction in four patients (36.4) was undetermined. Follow up period was between 4-59 months. The mean follow up was 17.5 months. Seven patients (63.6) were off diuretics and had no exercise intolerance. Patients were classified using the New York Heart Association (NYHA) n (NYHA) functional and therapeutic classification in class I-V. Two patients preoperatively in class III are now in class I after surgery on low dose diuretics. One patient who had calcific constrictive pericarditis and came in class III was now in class II with diuretics after 3 years of follow up. There was no postoperative mortality. One patient was lost to follow up. Conclusion: Pericardiectomy is a useful procedure for constrictive pericarditis and was beneficial to all the patients in this study with an improvement in their functional capacity. Intensive peri-operative monitoring and management reduced morbidity and mortality

Cardiopulmonary bypass in Jehovah's Witnesses.

Jehovah's Witnesses do not accept heterologous blood transfusion for religious reasons. Autologous transfusions are also rejected if there is no continuous contact between the circulation and the autologous blood. There is, therefore, the need to adopt methods which will avoid transfusion of heterologous blood in elective cases as far as Jehovah's Witnesses are concerned. We report two cases where pre-operatively administration of nutritional supplements, haematenics, erythropoietin, antimalarials and the modification of the extra-corporeal circulation bypass circuit allowed successful open-heart surgery using cardiopulmonary bypass.

Heart valve replacement; anticoagulation and pregnancy.

Three patients who had heart valve replacement surgery and were on anticoagulation therapy with warfarin presented with pregnancy, one patient in the first trimester and the other two patients in the second trimester All three patients were in good and stable haemodynamic condition and went through pregnancy without any Complications. Delivery in all three patients were by caesarian section. The management of these patient during pregnancy and delivery form the basis of this report. A scheme for anticoagulation therapy during pregnancy, delivery and the post-delivery period of such patients has also been presented.

Trachea stabilisation with autologous costal cartilage in acquired tracheomalacia: report of two cases.

Post-operative tracheomalacia is a life threatening condition whose management is challenging. Surgical procedures which have been suggested in the literature to manage the condition include tracheostomy, staged thyroid reductions and the use of artificial stents either within the lumen of the tracheobronchial tree or as external support. We report the successful management of two patients using autologous costal cartilage to support the tracheal wall.

Rupture of sinus of Valsalva aneurysm: case report.

Sinus of Valsalva aneurysms are uncommon. Aortic sinus aneurysm may be complicated by endocarditis or rupture. A 26 year old native Ghanaian presented with dyspnoea, raised jugular venous pressure (JVP), tender hepatomegaly, peripheral oedema, a thrill and a continuous murmur at the upper left sternal edge. Two-dimensional doppler echocardiography with colour flow mapping revealed a large aneurysm of the right sinus of Valsalva (4 cm diameter) that abutted the right ventricular out-flow tract with distortion of the pulmonary valve. Colour flow revealed left to right shunting of blood from the aortic root into the right atrium. A year later he presented with a febrile illness, weight loss, night sweats and was diagnosed as having culture negative infective endocarditis. Following a course of antibiotics, he underwent successful cardiopulmonary bypass surgery with repair of the ruptured aneurysm of the right sinus of Valsalva.

Cardiopulmonary bypass in sickle cell anaemia without exchange transfusion.

To minimize sickling during cardiopulmonary bypass, exchange transfusion is frequently recommended peri-operatively for patients with homozygous sickle cell anaemia to reduce the circulating concentration of HbS. We report the successful management of two children both aged 12 years with sickle cell anaemia (homozygous SS), several sickle cell crises and multiple blood transfusions who underwent cardiopulmonary bypass for mitral valve replacement. No pre- or intra-operative exchange transfusions were employed in the two cases. Furthermore, moderate hypothermia in both cases was not associated with adverse sequelae.

Atrial myxoma--a case report and review of the literature.

Myxomas are the most common primary cardiac tumours. They are usually benign and have variable presentation. Although rare, atrial myxomas are the most important cardiac tumours to diagnose, as they have an excellent prognosis following surgical excision. We report a 56 year old man who presented with features of both right and left heart failure. Ausculation of the heart revealed an apical mid diastolic murmur. Two-dimensional colour flow Doppler echocardiography revealed a pedunculated left atrial myxoma that prolapsed into the mitral valve orifice in diastole producing functional mitral valve stenosis. The patient underwent a successful surgical excision of the tumour. The diagnosis and management of atrial myxomas is reviewed.

Delayed diagnosis and repair of total bronchial rupture: a report of two cases.

Two Ghanaian women, aged 21 and 29 years, who were involved in road traffic accidents sustaining blunt trauma to the chest and who had delayed diagnosis of their total bronchial rupture and underwent successful surgical repair 18 and 29 months, respectively after injury are reported with a review of the literature. We believe these to be the first reported cases of delayed diagnosis and successful repair of total bronchial rupture in Tropical Africa.

Sternocleidomastoid myocutaneous esophagoplasty.

Four cases of short segment non-malignant lesions involving the cervical esophagus, in whom dilatation procedure failed were managed surgically using a sternocleidomastoid myocutaneous flap as a patch to widen the stenotic segment. There were no operative deaths and no leakage of the repair. Barium swallow studies with fluoroscopy and esophagoscopy were used for postoperative follow-up. The follow-up periods ranged from 6 months to 5 years. There has been no restenosis or ulceration of the patch. The follow-up period is certainly too short to allow for any carcinomatous transformation of the skin patch. The simplicity of this method as against other more extensive surgical procedures, such as colon interposition, and also its efficiency should be reason enough for it to be considered as a viable alternative in short segment stenosis of the cervical esophagus, especially in those cases that defy dilatation.

Pericardial flap-plasty for protection of the tracheal anastomosis in heart-lung transplantation.

Infection or dehiscence of the tracheal anastomosis remains a dreaded and almost always fatal complication following heart-lung transplantation (HLTX). A technique of pericardial flap-plasty combined with application of fibrin sealant and topical antibiotics was developed and applied in three patients undergoing HLTX. The method allows for safe protection of the anastomosis even in the presence of severe ischemia and partial necrosis of the donor trachea at the same time avoiding laparotomy for mobilization of the omentum.