De Vega's tricuspid annuloplasty for Ebstein's anomaly.

A case of Ebstein's anomaly as demonstrated by echocardiography and electrophysiological studies is discussed. In view of deterioration in tricuspid regurgitation and right ventricular dysfunction, successful surgical repair employing De Vega's tricuspid annuloplasty along with plication of the atrialised portion of the right ventricle is described. Intraoperative transesophageal echocardiography following the procedure revealed satisfactory repair and a significant decrease in tricuspid regurgitation. This simple technique appears to be effective in patients having anterior leaflet sufficiently large area and motion. Adequate long-term follow-up in a large series of patients is essential to confirm that it is also beneficial and durable.

Left atrial reduction and mitral valve replacement in a 5-year-old girl with severe mitral regurgitation and giant left atrium.

Giant left atrium associated with mitral valve disease has been implicated in the morbidity following mitral valve repair or replacement. Various methods including left atrial plication have been described to reduce the size of left atrium. Herein we describe our technique of left atrial reduction in a 5-year-old girl with severe mitral regurgitation and giant left atrium. She underwent mitral valve replacement and circumferential left atrial reduction with successful outcome.

Ross procedure in an infant.

The Ross procedure is gaining acceptance as the procedure of choice for aortic valve replacement in children. We present the case of a 4-month-old child (weight 3.2 kg) suffering from congenital valvar aortic stenosis who underwent a Ross procedure. We believe that this is the youngest patient to have undergone this procedure successfully in the Indian subcontinent.

Batista procedure as a bridge to cardiac transplantation.

A 37-year-old male patient with dilated cardiomyopathy and end-stage heart failure underwent Batista procedure. After 6 months, he underwent orthotopic heart transplantation. Though he did not survive the procedure, we conclude that Batista procedure may serve as a cost-effective biological bridge to cardiac transplantation.

Use of direct laryngoscope for better exposure in minimally invasive saphenous vein harvesting.

A direct laryngoscope-assisted technique of saphenous vein harvesting by tunnelling method is described. This technique provides better exposure through small incisions, thus reducing the chances of trauma to the vein due to excessive handling. The equipment used is inexpensive and readily available.

Ultrastructural and immunohistochemical analysis of early myocardial changes following transmyocardial laser revascularization.

BACKGROUND AND AIM OF THE STUDY: Transmyocardial laser revascularization (TMR) has demonstrated significant relief in patients presenting with refractory angina. However, the mechanism by which TMR improves clinical symptoms is unclear. This study analyzes the early immunohistochemical and ultrastructural features of the human myocardium following TMR. METHODS: Specimens of myocardium that contained laser channels were removed in toto at autopsy from three male patients, ages 41, 57, and 65 (mean age 55.8) who had died 1 to 11 days (mean 6.8) following laser revascularization. Consecutive parallel sections of specimens were stained with cell-type specific antibodies to CD3 (to identify T-lymphocytes), CD68 (macrophages), Factor VIII (endothelial cells), and myosin (myocytes). Additionally, adjacent areas of myocardium that contained laser channels were processed and analyzed by transmission electron microscopy. RESULTS: The internal lining surface of laser channels was composed of vacuolized and condensed myocardial debris. No obvious connections were noted between laser channels and the ventricular cavity. No endothelialization of channels was observed, whereas the adjacent noninjured myocardium demonstrated microvessels lined by well-preserved endothelial cells. The laser channels were surrounded by zones of necrotic cardiomyocytes. CONCLUSIONS: Our observations suggest that laser channels are not lined by endothelial cells during the early stages following TMR. Mechanisms other than direct myocardial perfusion from the ventricular cavity by patent endothelialized channels may explain the immediate relief from angina provided by TMR.

Transmyocardial laser revascularization.

TMLR is effective as an isolated procedure in patients with ungraftable vessels and is a useful adjunct to CABG in patients with diffuse and small-vessel disease requiring endarterectomies. The optimal subset of patients who will benefit from isolated TMLR are those primarily with angina rather than congestive failure, who have protected myocardium and uncompromised left ventricular function.

Left atrial reduction for chronic atrial fibrillation associated with mitral valve disease.

Currently available surgical procedures to control chronic atrial fibrillation associated with mitral valvar disease are not always successful. The size of the left atrium is a major factor in the initiation and maintenance of atrial fibrillation. Here we describe a case of ablation of atrial fibrillation with left atrial reduction and pulmonary vein isolation in a patient with mitral valve disease.

Symptomatic lipoma in the right atrial free wall. A case report.

Benign non-myxomatous neoplasms of the heart are rare, and lipomas are among those least often encountered. We report the case of a 38-year-old man who presented with palpitations of recent onset, and was found to have a lipoma attached to the free wall of the right atrium. The successful surgical excision of the lipoma is described.

Benign carotid body tumor presenting with Horner's syndrome. A case report.

A 28-year-old woman presented at our institution with a mass on the left side of her neck and Horner's syndrome. The mass was successfully removed with preservation of the carotid arteries; histopathologic examination confirmed that it was a benign carotid body tumor. This case emphasizes that, with care, the carotid arteries and cranial nerves can be preserved despite the hazards of carotid tumor excision.

Thoracotomy approach for congenital and acquired heart defects: its possible applications in the current era.

From April 1975 to February 1995, 305 patients (260 females and 45 males) underwent open heart surgical procedures through the thoracotomy approach. Their ages ranged from 4 months to 55 years (mean age 21.8 +/- 13 years). Two hundred and ninety-seven patients were operated through the right and eight through the left thoracotomy approach. Two hundred and sixteen patients had congenital heart disease and 89 patients had acquired heart diseases, which included ostium secundum defect (190 patients), sinus venosus defect (11 patients), partial atrioventricular (AV) canal defect (5 patients), complete AV canal (1 patient), ventricular septal defect (4 patients), Tetralogy of Fallot (3 patients), anomalous origin of left coronary artery from pulmonary artery (3 patients), mitral valve lesions (83 patients), including tricuspid valve lesions (5 patients) and coronary artery disease (2 patients). Postoperative recovery was observed to be faster (mean hospital stay 7.8 days vs mid-sternotomy 9.6 days), infection rate lower (0.35% vs median sternotomy 2.56%), postoperative drainage lower (148.8 +/- 86.2 mL vs median sternotomy 587 +/- 112.6 mL), and cosmetically found to be much more acceptable in the female population. There have been seven early and one late postoperative deaths which were unrelated to the operative approach. We conclude from this experience that thoracotomy can be safely used as an access for a wide variety of open cardiac surgical operations on the atrial and (upper) ventricular septae, AV valves, right ventricular outflow tract, and coronary artery reconstruction in some situations. It is also useful in some emergency and redo operations with distinct advantages over the median sternotomy approach. We feel its use should be increased as newer subsets of patient populations are being subjected to primary and redo cardiac operations.

Extensive endarterectomy, onlay patch, and internal mammary bypass of the left anterior descending coronary artery.

The incidence of diffuse disease requiring multiple endarterectomies is high among the Oriental population. The technique of LAD endarterectomy and reconstruction is difficult, and often it is a challenging problem. From June 1987 to September 1994, 2376 patients from seven countries underwent coronary artery bypass graft surgery, among whom 610 patients had endarterectomy. One hundred thirty-six patients underwent LAD endarterectomy, and among them, 69 had extensive endarterectomy. The LAD was reconstructed with IMA onlay patch in 41 patients and with saphenous vein onlay patch in 28 patients. Three patients had evidence of postoperative myocardial infarction and seven patients died in the postoperative period. Twelve patients were postoperatively restudied and in all of them, the graft to LAD was patent. Use of internal mammary artery onlay patch after endarterectomy is advantageous since it may be associated with higher long-term patency and low incidence of reoperation. To our knowledge, this has not been reported anywhere.

[Rupture of the posterior wall of the left ventricle after mitral valve prosthesis]. / Razryvy zadnei stenki levogo zheludochka posle protezirovaniia mitral'nogo klapana.

Rupture of the posterior wall of the left ventricle after mitral valve prosthetics is a rare (0.6%) but a dangerous and death-threatening complication. Injury to the fibrous ring in the anatomically hazardous zone (at 4-5 o'clock of an imaginary clock-face) is the most frequent cause of the ruptures. Surgical correction of this complication will be successful only with the use of extracorporeal circulation and repeated cardioplegia. Preservation of the posterior cusp and subvalvular apparatus is a reliable measure preventing rupture of the posterior wall of the left ventricle.

Rupture of the posterior wall of the left ventricle after mitral valve replacement.

During a 20 year period from 1970 to 1989, 1100 patients underwent mitral valve replacement. Rupture of the posterior wall of the left ventricle occurred in seven patients (0.6%); four in the operating room and three in the postoperative room. It was possible to institute CP bypass in six patients and in all of them bleeding was controlled successfully, with repair by an external approach. Only one patient survived. We believe that institution of CP bypass and reinfusion of cardioplegic solution is a major determinant of the outcome.