Surgical removal of an ectopic haemodialysis catheter in the brachiocephalic artery: a case report.

Percutaneous central vein catheterization is commonly performed to access venous circulation for various clinical indications. However, unintentional arterial puncture may occur which can result in catastrophic complications. We report a case of an inadvertent right brachiocephalic artery cannulation in a 77-year-old lady planned for haemodialysis via a percutaneous internal jugular vein vascular access performed under ultrasound guidance. As an intravascular stent is not favourable in view of the close proximity of the right common carotid artery to the site of puncture as well as the risk of massive bleeding upon simple removal of the catheter, an open surgical removal via a median sternotomy was performed. Acquiring the competency in procedural skills, an understanding of the surgical anatomy and anticipating impending complications are of paramount importance in preventing as well as in mitigating the above complication.

Syndrome of ventricular septal defect and aortic regurgitation - A 22-year review of its management

Abstract Introduction: The presence of aortic regurgitation (AR) in the setting of ventricular septal defect (VSD) has always been a management challenge. Methods: This is a retrospective study looking at patients who underwent VSD closure with or without aortic valve intervention between January 1st, 1992 and December 31st, 2014 at the Institute Jantung Negara. This study looked at all cases of VSD and AR, where AR was classified as mild, moderate, and severe, the intervention done in each of this grade, and the durability of that intervention. The interventions were classified as no intervention (NI), aortic valve repair (AVr), and aortic valve replacement (AVR). Results: A total of 261 patients were recruited into this study. Based on the various grades of AR, 105 patients had intervention to their aortic valve during VSD closure. The rest 156 had NI. All patients were followed up for a mean time of 13.9±3.5 years. Overall freedom from reoperation at 15 years was 82.6% for AVr. Various factors were investigated to decide on intervening on the aortic valve during VSD closure. Among those that were statistically significant were the grade of AR, size of VSD, age at intervention, and number of cusp prolapse. Conclusion: We can conclude from our study that all moderate and severe AR with small VSD in older patients with more than one cusp prolapse will need intervention to their aortic valve during the closure of VSD.

3D Rapid Prototyping Heart Model Validation for Teaching and Training - A Pilot Project in a Teaching Institution

Abstract Introduction: Rapid prototyping is a process by which three-dimensional (3D) computerized surface models are converted into physical models. In this study, a 3D heart bio model was created using the rapid prototyping method and the accuracy of this heart model was assessed by clinicians. Methods: The two-dimensional images of normal heart from gated computed tomography scan datasets were used to create a 3D model of the heart. The slices were then processed using the software BioModroid and printed with the 3D printer. The evaluation of the model was performed by a questionnaire answered by four cardiothoracic surgeons, 12 cardiologists, five radiologists, and nine surgical registrars. Results: Eighty-six percent of the anatomy structures showed in this model scored 100% accuracy. Structures such as circumflex branch of left coronary artery, great cardiac vein, papillary muscle, and coronary sinus were each rated 77%, 70%, 70%, and 57% accurate. Among 30 clinicians, a total of 93% rated the model accuracy as good and above; 64% of the clinicians evaluated this model as an excellent teaching tool for anatomy class. As a visual aid for surgery or interventional procedures, the model was rated excellent (40%), good (50%), average (23%), and poor (3%); 70% of the clinicians scored the model as above average for training purpose. Overall, this 3D rapid prototyping cardiac model was rated as excellent (33%), good (50%), and average (17%). Conclusion: This 3D rapid prototyping heart model will be a valuable source of anatomical education and cardiac interventional management.

Syndrome of Ventricular Septal Defect and Aortic Regurgitation - A 22-Year Review of its Management.

INTRODUCTION: The presence of aortic regurgitation (AR) in the setting of ventricular septal defect (VSD) has always been a management challenge. METHODS: This is a retrospective study looking at patients who underwent VSD closure with or without aortic valve intervention between January 1st, 1992 and December 31st, 2014 at the Institute Jantung Negara. This study looked at all cases of VSD and AR, where AR was classified as mild, moderate, and severe, the intervention done in each of this grade, and the durability of that intervention. The interventions were classified as no intervention (NI), aortic valve repair (AVr), and aortic valve replacement (AVR). RESULTS: A total of 261 patients were recruited into this study. Based on the various grades of AR, 105 patients had intervention to their aortic valve during VSD closure. The rest 156 had NI. All patients were followed up for a mean time of 13.9±3.5 years. Overall freedom from reoperation at 15 years was 82.6% for AVr. Various factors were investigated to decide on intervening on the aortic valve during VSD closure. Among those that were statistically significant were the grade of AR, size of VSD, age at intervention, and number of cusp prolapse. CONCLUSION: We can conclude from our study that all moderate and severe AR with small VSD in older patients with more than one cusp prolapse will need intervention to their aortic valve during the closure of VSD.

3D Rapid Prototyping Heart Model Validation for Teaching and Training - A Pilot Project in a Teaching Institution.

INTRODUCTION: Rapid prototyping is a process by which three-dimensional (3D) computerized surface models are converted into physical models. In this study, a 3D heart bio model was created using the rapid prototyping method and the accuracy of this heart model was assessed by clinicians. METHODS: The two-dimensional images of normal heart from gated computed tomography scan datasets were used to create a 3D model of the heart. The slices were then processed using the software BioModroid and printed with the 3D printer. The evaluation of the model was performed by a questionnaire answered by four cardiothoracic surgeons, 12 cardiologists, five radiologists, and nine surgical registrars. RESULTS: Eighty-six percent of the anatomy structures showed in this model scored 100% accuracy. Structures such as circumflex branch of left coronary artery, great cardiac vein, papillary muscle, and coronary sinus were each rated 77%, 70%, 70%, and 57% accurate. Among 30 clinicians, a total of 93% rated the model accuracy as good and above; 64% of the clinicians evaluated this model as an excellent teaching tool for anatomy class. As a visual aid for surgery or interventional procedures, the model was rated excellent (40%), good (50%), average (23%), and poor (3%); 70% of the clinicians scored the model as above average for training purpose. Overall, this 3D rapid prototyping cardiac model was rated as excellent (33%), good (50%), and average (17%). CONCLUSION: This 3D rapid prototyping heart model will be a valuable source of anatomical education and cardiac interventional management.

Obstructive sleep apnoea and open heart surgery: a review of its incidence and impact to patients.

BACKGROUND: Obstructive sleep apnea (OSA) is a serious health disorder which contributes to cardiovascular complications, decreased work productivity, automobile accidents, and death. This condition is characterized by a temporary cessation of breathing resulting due to upper airway closure during a person's sleep. Strain to the heart caused by this repetitive hypoxic insult can lead to postoperative complications for patients undergoing heart surgery. Recognizing cardiac surgical patients with OSA is important. Early recognition and intervention such as use of BiPAP device can reduce the postoperative complications due to OSA. METHODS: The aim of this study is to identify the incidence of unrecognized OSA in cardiac surgical patients. This is a retrospective analysis of a prospective data of the study which was done between July 2012 and July 2013 in University Malaya Medical Center. All patients undergoing elective cardiac surgery were recruited and the demographic data, questionnaire and the portable sleep study results were obtained. Patients were followed up till 30 days to record any complications. Data were entered in SPSS version 17 and analysis was done. RESULTS: The incidence of OSA was 61.4% and 43.5% were moderate to severe OSA. There was male predominance of OSA (79%) with a mean age of 60 years. OSA subjects had shorter inter-incisor distance (4.18±0.6 cm) and larger waistline (94.1±12.1 cm). The STOP-Bang questionnaire has a sensitivity of 75.8% in predicting apnoa-hypopnea index (AHI) ≥5/hour. CONCLUSIONS: OSA can be diagnosed with a simple screening questionnaire and a bedside portable sleep study. Cardiac patients diagnosed with OSA can be pre-emptively given extra attention in managing their postoperative care.

Evolution of Cardiac Biomodels from Computational to Therapeutics.

Biomodeling the human anatomy in exact structure and size is an exciting field of medical science. Utilizing medical data from various medical imaging topography, the data of an anatomical structure can be extracted and converted into a three-dimensional virtual biomodel; thereafter a physical biomodel can be generated utilizing rapid prototyping machines. Here, we have reviewed the utilization of this technology and have provided some guidelines to develop biomodels of cardiac structures. Cardiac biomodels provide insights for cardiothoracic surgeons, cardiologists, and patients alike. Additionally, the technology may have future usability for tissue engineering, robotic surgery, or routine hospital usage as a diagnostic and therapeutic tool for cardiovascular diseases (CVD). Given the broad areas of application of cardiac biomodels, attention should be given to further research and development of their potential.