Utility of portal vein pulsatility fraction in patients undergoing corrective surgery for tetralogy of Fallot.

BACKGROUND: Right ventricle dysfunction is common after corrective surgery for tetralogy of Fallot and is associated with significant morbidity and mortality. We aimed to determine whether an increased portal vein pulsatility fraction (PVPF) was associated with worse clinical outcomes. METHODS: In a prospective, observational, single-centre study, PVPF and other commonly used parameters of right ventricle function were assessed in patients of all ages undergoing corrective surgery for tetralogy of Fallot intraoperatively, with transesophageal echocardiography, before and after bypass, and post-operatively, with transthoracic echocardiography, at days 1, 2, at extubation, and at ICU discharge. The correlation was tested between PVPF and mechanical ventilation duration, prolonged ICU stay, mortality, and right ventricle function. RESULTS: The study included 52 patients, and mortality was in 3 patients. PVPF measurement was feasible in 96% of the examinations. PVPF in the immediate post-operative period had sensitivity of 73.3% and a specificity of 74.3% in predicting the occurrence of the composite outcome of prolonged mechanical ventilation, ICU stay, or mortality. There was a moderate negative correlation of PVPF with right ventricle fractional area change and right ventricle global longitudinal strain (r = -0.577, p < 0.001 and r = 0.465, p < 0.001, respectively) and a strong positive correlation with abnormal hepatic vein waveform (rho = 0.749, p < 0.001). CONCLUSION: PVPF is an easily obtainable bedside parameter to assess right ventricular dysfunction and predict prolonged mechanical ventilation, prolonged ICU stay, and mortality.

Implications of left atrial enlargement and patent foramen ovale creation on early surgical outcomes in patients with total anomalous pulmonary venous connection.

INTRODUCTION: In patients with total anomalous pulmonary venous connection (TAPVC), left atrium (LA) is small and suprasystemic pulmonary artery (PA) pressures may be present in some patients. In our study, we studied the relationship between surgical LA enlargement and patent foramen ovale (PFO) creation separately on the outcomes of patients with TAPVC. MATERIALS AND METHODS: Out of the 130 patients operated in our institute between January 2014 and December 2020, LA was enlarged in 60 patients. LA enlargement was done using a larger patch for atrial septal defect (ASD) closure. Thus, the LA volume was increased by shifting the patch towards the right atrium (RA). Suprasystemic or high PA pressures were present in 60 patients. In 33 patients, PFO was created. Early surgical outcomes were determined on the basis of vasoactive inotropic score (VIS), hours of ventilation, hours of inotropic support, intensive care unit (ICU) stay, and hospital stay. RESULT: Between the LA enlarged and nonenlarged group there was statistically significant less VIS score (18 [13-27.5] vs. 24 [18-30], p value .019), hours of ventilation (23 [16-46.5] vs. 26 [18-60], p value .039), hours of inotropic support (45.5 [30-72] vs. 55 [38-84], p value .038), and ICU stay (7 [5-9] vs. 8 [7-10] p value .0352) and statistically nonsignificant less hospital stay (11.5 [9-13] vs. 12 [9-14], p value .424). In patients with preoperative suprasystemic or high PA pressures, there was a statistically significant less VIS score (16 [11-23.5] vs. 18 [13-25], p value .044), hours of ventilation (20 [14-37] vs. 22 [18-39], p value .038), hours of inotropic support (34 [29.5-71] vs. 38 [30-78], p value .042), and hospital stay (9 [5-12] vs. 11 [9-14], p value .038) and statistically nonsignificant less ICU stay (7 [5.5-9] vs. 7 [6-9], p value .886) in the group with a PFO with respect to the other group in which no PFO was created. CONCLUSION: In patients with TAPVC, LA can be enlarged by using a large ASD patch and thus shifting the septum towards RA. Early surgical outcomes were improved with LA enlargement. In patients with suprasystemic or high PA pressures, leaving a PFO improved the postoperative outcomes.

Comparison of right ventricular outflow tract gradient under anesthesia with post-operative gradient in patients undergoing tetralogy of Fallot repair.

BACKGROUND: Intra-cardiac repair for tetralogy of Fallot has some degree of residual right ventricular outflow tract (RVOT) obstruction. However, the measurement of this gradient intra-operatively might get affected by the depth of anesthesia which is important for the long-term outcome. AIMS: The primary aim was to compare intraoperative RVOT gradient post repair under two different anesthetic depths of 1% and 2% end-tidal sevoflurane. The secondary objective was to follow up the changes in RVOT gradient till 1 month postoperatively. Design: Observational study. Setting : Advanced Cardiac Centre of PGIMER, Chandigarh. METHODS: Following intracardiac repair, RVOT gradient was measured directly by placing needle into the right ventricle and pulmonary artery at sevoflurane 1%, and subsequently, at 2% end.tidal concentration while maintaining hemodynamic stability. These gradients were also measured using transesophageal echocardiography (TEE) (ClinicalTrials.gov NCT03234582). RESULTS: Twenty-one patients were included in this study that had intra-cardiac repair, of which pulmonary annulus was preserved for 15 cases. Mean RVOT gradients measured invasively and by TEE at end-tidal sevoflurane concentration of 1% and 2% were not significantly different (6.67 ± 4.16 mmHg vs. 6.76 ± 3.82 mmHg, P > 0.05 invasively and 13.01 ± 7.40 mmHg vs. 12.53 ± 7.11 mmHg, P > 0.05 by TEE, respectively). RVOT gradient measured by trans-thoracic echocardiography (TTE) postoperatively at the time of extubation and during follow-up at 1 month showed significant reduction (11.37 ± 6.00 mmHg, P < 0.05 and 9.23 ± 4.92 mmHg, P < 0.01 respectively). Six patients who underwent repair with transannular patch had significant pulmonary regurgitation (PR) following surgery, with no significant change in PR severity or RVOT gradient on increasing anesthetic depth. CONCLUSIONS: Postoperative RVOT gradient was not altered by changing depth of anesthesia provided systemic blood pressure was maintained. One month postrepair RVOT gradients were significantly reduced as compared to the intraoperative values.

Mixed type total anomalous pulmonary venous connection: Early results and midterm outcomes of surgical correction.

BACKGROUND AND AIM OF THE STUDY: The morphological heterogeneity of anomalous pulmonary venous drainage in mixed type total anomalous pulmonary venous connection (TAPVC) has important implications in preoperative diagnosis and surgical repair resulting in high mortality in these patients. METHODS: A retrospective review of 14 patients with mixed type TAPVC undergoing biventricular repair between January 2012 and December 2019 was conducted. A descriptive analysis was done, highlighting the anatomic variation, diagnostic and surgical approach, and surgical outcomes in these patients. RESULTS: The most common anatomic pattern was "3 by 1" (79%) followed by "2 by 2" (21%). The correct diagnosis by transthoracic echocardiography was made in 10 (71%) of the 14 patients. In contrast, preoperative computed tomographic (CT) angiography was performed in 10 patients and correct diagnosis was obtained in 8 (80%) of them. Pulmonary venous obstruction was seen in one patient before surgery. The in-hospital mortality was 14% (2/14). Four patients had pulmonary hypertensive crisis in the postoperative period. The average follow-up was 54 ± 27 months (range: 17-98 months) after surgical repair, and all surviving patients were asymptomatic. There was no late death. No clinically apparent sequelae were seen in six patients in whom isolated left superior pulmonary vein drainage was left uncorrected. CONCLUSION: An accurate diagnosis of anatomic pattern in mixed type TAPVC can be difficult to establish in all the patients before surgery. Detailed intraoperative assessment, individualized surgical approach, and aggressive perioperative management may reduce surgical mortality. Operative survivors have good midterm outcome.

Surgical repair of ruptured sinus of Valsalva aneurysm: 13-year single center experience.

BACKGROUND AND AIM: Untreated ruptured sinus of Valsalva aneurysms ultimately develop into heart failure, thereby affecting patients' survival. We retrospectively analyzed our 13-year experience of the surgical repair for ruptured sinus of Valsalva aneurysm to study the optimal surgical strategy, operative risk and long-term surgical outcome. METHODS: Twenty-six patients underwent surgical repair of ruptured sinus of Valsalva aneurysm from January 2008 to February 2020. Follow-up data were obtained from the outpatient department records and telephone calls. RESULTS: Patch closure of ruptured sinus of Valsalva aneurysm was done in all the 26 patients, most often through the transaortic (69%) and dual-chamber approach (23%). Aortic valve repair was done in one patient while seven patients underwent aortic valve replacement for associated significant aortic regurgitation. There was one in-hospital mortality because of noncardiac cause. The median duration of postoperative hospital stay was 8 days (range, 6-11 days). Follow-up data were available for 89% (23/26) patients. The mean follow-up period was 69 ± 43 months (range, 7-147 months). All survivors were in New York Heart Association functional Class I or II. There was no late death. One patient required rehospitalization for recurrent ruptured sinus of Valsalva aneurysm. There was no recurrent or new-onset significant aortic regurgitation and prosthesis-related complications in late follow-up. CONCLUSION: Surgical repair for ruptured sinus of Valsalva aneurysm carries an acceptable low operative risk and excellent long-term outcome. Though high-risk population, an early diagnosis and optimal surgical approach can prevent worsening of symptoms and consequent heart failure.

Absent right superior vena cava with left superior vena cava draining into unroofed coronary sinus with common atrium in a child with an atrioventricular septal defect.

The association of absent right superior vena cava and persistent left superior vena cava draining into unroofed coronary sinus with common atrium and the atrioventricular septal defect is an extremely rare form of the congenital cardiac disorder with only one case reported so far, hence, can be missed preoperatively if not carefully looked for. Failure to detect absent right superior vena cava beforehand may otherwise pose difficulties in carrying out invasive surgical or medical interventions.

Pulmonary valve neocuspidisation with glutaraldehyde-treated autologous pericardium-A novel technique in pulmonary valve endocarditis.

Infective endocarditis (IE) is a serious condition leading to heart failure, persistent sepsis. The management of IE involving valve is mainly excision of the infected valve and replacement with a heart valve; which are also at the risk of prosthetic valve endocarditis. Hence repair of the valve with autologous pericardium is much more physiological. We had a 20-year-old male presented with features of heart failure and high-grade fever not responding to optimum medical management. Two-dimensional echocardiogram revealed vegetation on pulmonary valve cusps with the erosion of the left and right cusps. Neo cusps with autologous pericardium offered good hemodynamics with trivial regurgitation. The patient is doing well with normal pulmonary valve function 3 months after surgery. This technique is reliable, economic, and easily reproducible.

Congenital right coronary artery aneurysm with fistula to right ventricle associated with isolated pulmonary valvular stenosis.

Congenital aneurysmal dilatation of coronary artery with coronary cameral fistula is rare in childhood. We report an even rarer association of congenital right coronary artery aneurysm and right coronary artery to right ventricle fistula with bicuspid pulmonary valve stenosis and an intact ventricular septum in a 3-year-old child.

Early thrombolysis is associated with decreased operative mortality in postinfarction ventricular septal rupture.

BACKGROUND: Post myocardial infarction ventricular septal rupture (PMI-VSR) is a dreaded mechanical complication of acute coronary syndromes. Given that surgical mortality approaches 50%, it is pragmatic that the risk factors for mortality and outcomes after surgical correction of PMI- VSR are carefully scrutinized. METHODS: We performed a single-center, retrospective cohort study of 35 patients presenting for surgical closure of post myocardial infarction ventricular septal rupture over six years. We reviewed patient characteristics, clinical, echocardiographic, angiographic and perioperative risk factors which may affect mortality after surgical repair of PMIVSR and 30 day and one year mortality rates of these patients. Univariate and multivariate logistic and cox proportional hazard regression analysis was used to identify predictors of operative and overall mortality. Long term survival was presented with Kaplan-Meier Survival Curve. RESULTS: Sixteen patients (46%) were in cardiogenic shock. Concomitant coronary artery bypass grafting (CABG) was done in 22 patients (63%) but did not influence survival. Preoperative thrombolysis was done in 12 patients (34%) out of which 10 (53%) survived Operative mortality was 46% and one-year mortality was 49%. Multivariate analysis identified preoperative thrombolysis: Hazards ratio, 0.12; 95% CI, 0.02-0.61; p value of 0.01, as significant independent predictor of survival in PMIVSR cohort. CONCLUSIONS: Preoperative thrombolysis is associated with decreased odds of operative and overall mortality after surgical repair in PMIVSR patients.

Surgical outcome in aortopulmonary window beyond the neonatal period.

OBJECTIVE: Aortopulmonary window (APW) is a rare congenital cardiac defect accounting for 0.1% to 0.2% of all congenital cardiac defects. We here present the current midterm outcome of surgical repair of APW in patients more than 3 months of age. METHODS: The retrospective study was conducted to identify all the patients more than 3 months of age at presentation who underwent surgical repair of APW between June 2010 and August 2018 at our tertiary care institute and their outcome was analyzed. RESULTS: We found 14 patients of APW operated at the age of more than 3 months over a period of 8 years. Mean age of the cohort was 2.29 ± 2.96 years ranging from 3 months to 10 years with 57.14% being males. There were 11 (78.57%) patients with isolated APW and 3 (21.43%) had associated cardiac defects including tetralogy of Fallot (n = 1), ventricular septal defect (n = 1), subaortic membrane causing subaortic stenosis (n = 1), and one had extracardiac malformations. Two patients had type I, nine had type II, and three had type III APW as per Jacobs' classification. The mean size of the defect was 14.14 ± 4.33 mm. Mean duration of mechanical ventilation was 26.91 ± 16.65 hours (range, 12.25-67 hours). There was one in-hospital mortality and no late mortality over a mean follow-up of 3.06 ± 2.19 years. None of the patients required any kind of reintervention. CONCLUSION: Good results can be obtained even on late presentation with adequate perioperative care of the patients with the reversible pulmonary hypertensive disease.

Traumatic aortic dissection pseudoaneurysm with multiple entry: Role of transesophageal echocardiography.

Traumatic aortic dissection following sudden deceleration injury requires urgent treatment as it may result in formation of aneurysm that may expand or rupture leading to catastrophe. Confirmation of diagnosis of aortic dissection often requires contrast-enhanced computed tomography (CECT) or magnetic resonance imaging, which is time-consuming. Often, there is a significant time lag between the CECT chest and surgical intervention. Progression of aortic dissections may be missed on CECT chest, which would be done in the initial hours after injury. Transesophageal echocardiography (TEE) is equally efficient for the diagnosis of aortic dissection. It may also provide additional information that can be very useful for the management. We report the case of a descending thoracic aortic dissection where TEE plays a crucial role during the surgical management of the patient.

A novel surgical technique of repair of posterior wall laceration of thoracic trachea during transhiatal esophagectomy.

Tracheal injury is a rare, dreaded and potentially fatal complication of transhiatal esophagectomy (THE). The close proximity of major airway to esophagus makes it vulnerable to iatrogenic laceration during mediastinal manipulations. Over a period of five years, three patients with injury to membranous trachea during THE, were managed through the cervical incision. There was laceration of membranous trachea ranging from 3.5 to 5 cm in length with minimal loss of tracheal tissue. One of the lacerations was extending up to the right bronchus. All the patients were successfully managed through the cervical incision. The operative repair of trachea lasted for 45-60 min. One patient developed permanent left recurrent laryngeal nerve injury and another had postoperative bronchopneumonia. There was no mortality. Trans-cervical approach is an effective way of repairing thoracic membranous tracheal laceration during THE without any significant increase in the morbidity.

Major airway injury during esophagectomy: experience at a tertiary care center.

BACKGROUND: Tracheal laceration is a rare but life-threatening complication of esophagectomy. It is seen both with transhiatal and transthoracic esophagectomy. METHODS: Three hundred eighty-two esophagectomies were performed from 1998 to 2008. The medical records of five patients with laceration of trachea during esophagectomy managed at a tertiary care center were reviewed retrospectively. RESULTS: There were three males and two females with age range 18-62 years. The overall incidence of tracheal laceration was 1.31%. Four lacerations (1.30%) occurred during transhiatal and one (1.35%) during transthoracic resection of esophagus. Tracheal laceration was detected intraoperatively in all. Laceration was long (>3 cm) in three patients and short (<2 cm) in two. Patients with long laceration required direct suturing, while those with short laceration could be managed with gastric reinforcement. No patient required additional thoracotomy to access the lesion. Two patients had pneumonia, one had recurrent nerve palsy, while another developed anastomotic disruption. No patient died. CONCLUSION: Laceration of trachea is a potentially morbid complication of esophagectomy. Management should be individualized based on the extent and type of laceration. The surgical strategy depends upon the index procedure. The present series describes successful management of patients with tracheal injury associated with esophagectomy.

Surgical removal of entrapped and broken percutaneous transluminal coronary angioplasty balloon catheter.

OBJECTIVES: The percutaneous coronary artery angioplasty is routinely being used worldwide for the management of short and discrete coronary artery stenosis. The purpose of this report is to address the potentially lethal complication among the variety of surgical problems in conjunction with this procedure. The case also illustrates the potential pitfalls in the management of CAD. METHODS: A 60-year-old man had a broken and retained percutaneous transluminal coronary angioplasty (PTCA) balloon catheter entrapped in the left anterior descending artery and portion of it was lying in the ascending aorta. The patient underwent retrieval of this catheter through the standard coronary arteriotomy for coronary anastomosis without aortotomy on cardiopulmonary bypass. RESULTS: It was found that the PTCA balloon catheter was entrapped in the entire LAD and portion of it was lying in the ascending aorta, which could be delivered through the standard coronary arteriotomy for coronary anastomosis, thus avoiding the aortotomy. CONCLUSIONS: PTCA balloon catheter entrapped in the entire LAD and portion of it lying in ascending aorta could be delivered through the standard coronary arteriotomy for coronary anastomosis, thus avoiding the aortotomy.

A possible role of HSP70 in mediating cardioprotection in patients undergoing CABG.

Heat shock protein 70 (HSP70) has been reported to be involved in myocardial self-preservation system. This study shows direct evidence of the effect of HSP70 on lymphocytes during ischemia and reperfusion in CABG (coronary artery bypass graft) surgery. Lymphocytes were separated from the blood obtained from 10 patients undergoing CABG at different time intervals. (i) Baseline samples (drawn before onset of bypass), (ii) ischemic samples (30 min after cross-clamp) and (iii) reperfusion samples (10 min after the cross clamp removal) were incubated with recombinant HSP70 and the cells were harvested after 36 h. The effect of HSP70 was monitored by measuring second messengers such as intracellular calcium, protein kinase C (PKC) and inositol triphosphate (IP3). In addition CD69 expression was also measured. The results showed a significant decrease in intracellular calcium and CD69 expression in ischemia and further in reperfusion samples as compared to their respective untriggered controls. PKC and IP3 levels however remained unaffected. The protective effect of HSP70 during ischemia and reperfusion could thus be attributed to decreasing intracellular calcium and CD69 expression. This study could therefore provide a mechanism of cardioprotection afforded by HSP70.