Use of Nitroglycerin and Verapamil Solution by Organ Bath Technique in Preparation of Left Internal Thoracic Artery for Coronary Artery Bypass Surgery
Chandan Kumar Ray Mohapatra, Prashant Mishra, Jayant V Khandekar
Department of Cardiovascular Thoracic Surgery, LTM Medical College &Hospital, Sion, Mumbai
Introduction & Objective: The aim of this prospective study was to compare the effect of application of nitroglycerin with verapamil solution (GV) by organ bath technique with other methods of applications such as, papaverine solution by organ bath technique, topical GV solution and topical papaverine solution on the free blood flow in the left internal thoracic artery (LITA) prepared for coronary artery bypass grafting (CABG).
Methods: One hundred twenty consecutive ischemic patients posted for CABG were randomly assigned to four groups: group I (n _ 32, GV solution by organ bath technique), group II (n _ 30, papaverine solution by organ bath technique), group III (n _ 29, topical GV solution) or group IV (n_29, topical papaverine solution). In each patient, pedicled LITA was harvested; thereafter applied with the randomized different methods and solutions. The free flow from the distal cut end of the LITA was measured under controlled hemodynamic conditions after harvesting (Flow 1). Just before the anastomosis, the flows of the LITA were measured again (Flow 2). The flow rate before and after applications of solution were compared among the entire group and analyzed.
Result: The mean blood flow in the LITA was 56.2±5.0 ml/min before application of solutions. After application, the mean blood flow in group I was 102.3±7.0 ml/min (p<0.0001), in group II, it was 92.7±3.4 ml/min, and in group III, it was 88.6±2.2 ml/min) and in group IV, it was 81.4±2.1. Proportional increases in blood flow observed in group I (82.6%) >group II (65.1%) > group III (57.6) > group IV (44.8%) (p<0.0001).
Conclusions: Nitroglycerin with verapamil solution and papaverine are able to treat the spasm and increase the flow of the LITA, when they are used by organ bath technique compare to topical application. The GV solution by organ bath technique is effective and superior in compare to others.
Atrial Septal Defect Device Complications- Surgical Management - A Case Series
Santosh Kumar Dangeti
Meenakshi Mission Hospital and Research Centre
Introduction: Atrial septal defect is a common congenital cardiac anomaly. Although surgical closure has been the traditional and gold standard treatment of choice, percutaneous device closure is gaining popularity in recent times because of the very short duration of stay, cosmetic advantage and relative avoidance of morbidity associated with surgery, nevertheless they are associated with some unavoidable complications making surgeons intervention mandatory.
Material and methods: Between may 2014 to June 2016, 6 patients has been referred to our centre after percutaneous closure of atrial septal defects. Of them, 3 patients referred for device migration within 24hrs and 1 patient with device migration and Right atrium puncture producing pericardial collection and cardiac tamponade. 1 patient referred with endocarditis of device done 6 months back and 1 patient with device done 1 year back eroding the aorta producing Aorto- RA fistula.
Results: The 3 patients with device migration underwent surgery and retrieval of device and pericardial patch closure of defect and 1 patient with device migration and RA perforation underwent emergency sternotomy with device retrieval and patch closure of defect. 1 patient with endocarditis of device underwent elective surgery with device retrieval, mitral valve replacement and pericardial patch closure of the defect. 1 patient with Aorto-RA fistula underwent device removal, closure of fistula with Dacron patch and pericardial patch closure of the defect. All patients are discharged with normal convalescence.
Conclusion: Although the complications for Atrial septal defect devices are minor, some times they can be very disastrous leading to high mortality in a rapid transit of time, making surgeons intervention mandatory and emergency surgery with device retrieval and for the correction of original defect and other device related complications.
Surgical Management of Chronic Thromboembolic Pulmonary Hypertension- A Single Centre Experience.
Ashwin Uday Phadke, G. Ramasubrahmanyam, T. Vamshidhar
CARE Hospitals, Banjara Hills, Hyderabad.
Introduction: and Objectives Cardiopulmonary function in patients with chronic thromboembolic pulmonary hypertension (CTEPH) can almost be normalised by pulmonary endarterectomy, mortality of which is reported from 4-24% in various literature. The procedure involves the removal of organised and incorporated fibrous obstructive tissue from the pulmonary arteries (endarterectomy rather than embolectomy). We report our results in series of 11 patients with CTEPH that underwent surgery at our centre.
Materials and Methods: From 2011 onwards, 11 patients (9 males, 2 females) with age range 26 to 46 years underwent pulmonary endartectomy at our centre. 3 of the patients had a positive history of DVT and all were in NYHA class III or IV. All patients received an IVC filter pre-operatively. Pre-operative median Pulmonary Arterial (PA) systolic pressure was 75 mm Hg (Std. Deviation 18) and median PA mean pressure was 46 mm Hg (Std. Deviation 11). Pulmonary Vascular resistance ranged from 650-950 dynes/cm. Midline Sternotomy, cardiopulmonary bypass and deep hypothermic circulatory arrest was essential for all patients.
Results: Average total operating time was 380 minutes with mean bypass time of 190 minutes and median circulatory arrest time of 45 minutes. Post-operative PA pressures reduced significantly (systolic PA 46 mm Hg and mean PA 28.7 mm Hg). There were two early deaths (18%) (one due to sepsis and the other due to sudden fibrillation). There were no late deaths. Re-perfusion pulmonary edema developed in 1 patient ( 8.1%) which later subsided. Average ICU stay was 5 days and average hospital stay was 11 days.
Conclusions: Pulmonary endarterectomy is the gold standard for the treatment of CTEPH. However, it requires careful patient selection, surgical expertise and highly meticulous post operative care.
Hybrid Cardiac Surgery- A single Centre Experience
Swapnil Deshpande,P.K. Deshpande, S.K. Deshpande, D.V. Gupta, Jyoti Panhekar, M.K. Deshpande,Prajakta Kayarkar, V. Bisne, Prabhakar Deshpande, Anil Modak, Shrikant Kothekar, D.R. Bahekar
Dr. K.G. Deshpande Memorial Centre
Introduction: Hybrid Cardiac Surgery is a novel method of treating patients with combination of diseases and giving them complete cure in one admission itself.
Material and Methods: we present our data of 28 patients who have undergone Hybrid cardiac surgery at our centre from September 2010 till October 2016 8 patients underwent one stage OPCAB Plus Renal Artery Stenting. 1 patient underwent One Stage OPCAB Plus Bilateral Renal Artery Stenting plus Ascending aorta to Bi Femoral Bypass using Tube Graft. 1 patient underwent pulmonary thrombectomy followed by completion angiogram, 1 pulmonary artery thrombectomy plus trans Right Atrial IVC filter placement. 17 patient underwent CABG to Left sided Coronary Arteries via Left Thoracotomy plus Stenting to Right Coronary artery. all the patients were operated in Hybrid Cardiac Surgery Theatre so did not require any shifting from CathLab to Operation theatre or Vice Versa.
Results: All patient are doing well and did not require any additional hospitalisation for any of the medical issues. the Treatment given to all the patients was complete and was done in same sitting and same admission without any complication and significantly reduced the hospitalisation days, cost and morbidity of additional procedure. The Operative time was not very prolonged. also there was no significant increase in the ICU stay or any additional morbidity. There was no Mortality in any of the patients
Conclusion: Hybrid Cardiac Surgery is an Attractive, Complete and Less Expensive way of treating patients having multiple problems under one admission. The availability of Hybrid Cardiac Operation theatre reduces the pain of repeated admissions. Proper Teamwork and planning is a must for proper therapeutic result and outcome.
Septo superior vs left atrial approach in redo mitral valve surgeries
G Praveen Prabu, Saravana Krushna Raja
MMC,RGGGH,Chennai
Introduction: To analyse the surgical techniques in superior septal and left atrial approach and to evaluate the best of the two incisions for redo mitral valve replacement and record the post operative events in the study groups.
Materials and methods: Inclusion Criteria: All adult patients who underwent closed mitral commissurotomy, mitral valve repair & replacement admitted with mitral valve pathology. Exclusion Criteria: Patients who underwent mitral valve procedures along with coronary artery bypass grafting, aortic valve replacement, tricuspid valve repair or replacement. Two groups were divided with one group of patients undergo superior septal approach and the other group of patients with conventional left atriotomy incision in redo mitral valve replacement. Electrocardiographic and echocardiographic findings were compared between the study groups.
Results: In our study group females 64% and 36% were males. The major indication for redo MVR in our study groups was mitral restenosis following previous closed mitral commissurotomy (94%). The average pre bypass time in superior septal approach group was 49.6 minutes, cross clamp time was 74 minutes, total CPB time on an average was 112 minutes. where as in patients who underwent in left atriotomy was 77.8 minutes, 76 minutes, 126 minutes respectively. In our study groups, 3 patients in superior septal approach needs temporary pacemaker and 4 patients in left atriotomy needs it.
Conclusion: Our study results conveyed that superior septal approach appeared to be good alternative to conventional left atriotomy incision in redo mitral valve replacement. Pre bypass time and total cardiopulmonary bypass time were less in superior septal approach compared to the left atriotomy approach. No statistically significant increase in new rhythm disturbances and the need for temporary pacemakers among the study groups.
Coronary artery bypass grafting with Mitral Valve Replacement for Acute Severe Mitral regurgitation – Our Experience
Krishna Kishor S, Gracy
Royalcare Superspeciality Hospital
Introduction: Ischemic mitral regurgitation is a well-documented complication following myocardial infarction (MI) with increased mortality and morbidity. Following MI 50 % of patients develop mitral regurgitation (MR). Adding mitral valve surgery to coronary artery bypass grafting( CABG )has shown increased survival and better long term results.
Methods: Between 2013 and 2016, 38 patients underwent CABG + MVR of which 8( 22%) patients had acute severe MR (within 6hrs of MI) and 30 (78%) patients had recent MI (within a week) and presented with severe MR. The male to female ratio was 30: 8. Intra aortic balloon pump (IABP) was inserted preoperatively in 4 patients and 34 patients needed IABP during weaning off from cardiopulmonary bypass. Intraoperative findings revealed that 22 patients had papillary muscle rupture and 16 patients had multiple chordal rupture. None of the patients had signs of chronic MR. All patients underwent CABGwith MVR. Internal mammary artery and saphenous veins were used as conduits and grafting was done on bypass. Mitral valve was replaced using mechanical prosthesis and interrupted pledgeted sutures. The native valve was plicated preserving the chordal apparatus. All patients were discharged on 6th post op day.
Results: All patients had uneventful post-operative period with nil mortality. 37 patients are in regular follow up and 1 patient lost to follow-up over past 6 months. Follow up echocardiogram shows normal functioning mitral prosthesis with improved ventricular function by 10-15 % and no paravalvular leak or gradient across the prosthesis. All our patients reported a good quality of life.
Conclusion: CABG with MVR in acute severe MR was found to yield better outcomes in terms of mortality and morbidity. We prefer replacement over repair for negating the need of second surgery in future.
Randomized Comparative Prospective Study Of Effect Of Papaverine On LIMA Flow After Intraluminal Instillation and Topical Application
Arun Garg
Sri Jayadeva Institute of Cardiovascular Sciences and Research
Introduction &Objectives: Left internal mammary artery (LIMA) is one of the most commonly used conduits in coronary artery bypass grafting (CABG) but it has the tendency for spasm during harvesting. Papaverine has been used by many surgeons to relieve spasm and to increase the LIMA flow before grafting mostly by topical use. In this study we have compared the effects of intraluminal versus topical application of papaverine on LIMA flow.
Material & method: This was prospective randomized study of 60 patients. They were divided into two groups: group 1 (n=30; intraluminal papaverine application) and group 2 (n=30; topical papaverine application). The blood flow from the LIMA from distal cut end was measured under controlled hemodynamics, before papaverine application and 5 min after papaverine application.
Results: The mean blood flow in group 1 measured was 61.07±3.1 ml/min before papaverine application and 119.6±3.72 ml/min after papaverine intraluminal instillation (p value <0.0001). In group 2, it was 60.4±2.24 ml/min before and 72.13±2.56 ml/min after papaverine topical application. The increase in blood flow observed in group 1 was 95.84% versus 19.42% in group 2.
Conclusion: In this study we observed that rate of increase of blood flow after papaverine application was significantly higher in patients with intraluminal instillation than in patients with topical application.
Heart Transplantation outcomes after Mechanical support with Heart Ware Ventricular Assist Device: Single Centre Experience
Hassiba Smail, Pankaj Saxena, David Mc Giffin, Sylvana F Marasco
Cardiothoracic Surgery, The Alfred hospital, Melbourne, Australia
Background / Study Objective: The safety and efficacy of the Heart Ware Ventricular Assist Device (HVAD) as bridging therapy to transplant has been proved . The outcomes of heart transplant remain less described after HVAD support We report our single institutional experience with the post-operative and long-term outcome of heart transplantation after HVAD support Patients 44 patients received HVAD, 33 left ( LVAD), 9 biventricular (BiVAD), 2 right (RVAD) . 4 (10%) recovered, 2 (5%) remain on support and 29 (65%) patients underwent heart transplant . From the transplanted patient, the mean age was 46± 16 years, 20 ( 69% ) male, dilated cardiomyopathy in 23 (80%). Mean duration of support before heart transplant was 373 ± 258 days range (36-970 days)
Methods: From September 2011 to April 2016, 29(65%) patients received a heart transplant after HVAD we retrospectively evaluated the early post operative outcome after heart transplant, global survival and survival without rejection or allograft vasculopathy.
Results: Mean duration of ICU and hospital stay was 15±10 , 39± 41 days, re-explorations for bleeding 8 (27%), dialysis for kidney injury 5 (17%), primary graft failure in 10 (34%) patients, requiring ECMO support in 4 and Intra aortic balloon pump in 3. 30 days post-operative mortality was Nil. Mean duration of follow up was 1.6± 1.1 years; 2 patients suffered from humoral chronic graft rejection, no coronary allograft vasculopathy Actuarial survival after heart transplantation at 1, 2, 3 years was respectively 89% ±5%, 83% ±7%, 83% ±7%.
Conclusion:We report high rate of transplant after HVAD support with excellent early and long-term post transplant survival. These findings support the efficiency and safety of the HVAD used as single or biventricular support as bridge to transplant.
Magnetic Resonance Imaging in Follow-up after Tirone David I Procedure: Single Centre Experience
Hassiba Smail, Jean-Nicolas Dacher, François Bouchart, Fabien Doguet
Department of Thoracic and Cardiovascular Surgery, University Hospital Charles Nicolle, Rouen, France.
Background: We analysed the outcome after Tirone David I procedure and assessed the aortic valve function, the left ventricular remodelling and the size of the remaining thoracic aorta using cardiac MRI.
Methods: 121 patients underwent Tirone David I; the mean age was 55 ± 15 years. Marfan syndrome was diagnosed in 12% (n = 15), bicuspid aortic valve in 15% (n = 18) and aortic dissection in 20% (n = 26). During surgery, 30% (n = 40) had an aortic valve repair. The clinical and echocardiography follow-up involved 92 patients, followed by cardiac MRI in 65 patients for duration of 4.2 ± 2.3 years.
Results: Hospital mortality was 4.9% (n = 6). The TTE revealed an AR≥ grade II in 19% (n = 18) patients. The cardiac MRI revealed an AR ≥II in 27% (n=18), left ventricular ejection fraction <50% in 9 patients, a left ventricular mass of 72 ± 18 g/m2, no aortic dilatation or aortic dissection has occurred in the remaining thoracic aorta. Freedom from aortic valve replacement at 1, 5, and 10 years was 96% ± 1.4, 91% ±3.5, 91% ±3.5. The overall survival was 93% ±2 at 1 year, 87% ±3 at 5 years and 75% ±9 at 10 years.
Conclusions: The Tirone David I technique is a safe, reproducible procedure. Cardiac MRI could be a new tool for a homogenous follow up to assess of the aortic valve function, the left ventricular remodelling, the size of the aortic annulus and the remaining thoracic aorta.
Standardising the Pulmonary artery banding Could LAST (Left Anterior Small Thoracotomy) be the answer?
B R Jagannath, Ashish M Agrawal
STAR Hospital
Introduction & objectives: Pulmonary artery band has always been associated with high morbidity, mortality and unpredictable outcomes. Approach, parameters to consider while banding is still undefined. Trusslers formula defines only the band length for two different situations i.e. single ventricle pathway or two ventricle pathway. In an attempt to define the parameters and standardize the protocol for PA band, we conducted a retrospective analysis of all our PA bands over the last 5 years. The paper outlines our management protocol and decision making algorithms.
Materials and Method: All patients who underwent a PA band between April 2010 till Dec 2015 ( N=49) were studied retrospectively. The initial approach was towards a full median sternotomy (n = 26) but of late the trend is towards performing a small left anterior thoracotomy in the 2nd or 3rd intercostal space (n = 23). Pre marked Mersilene Tape based on Trusslers formula is used.
Results: No significant differences were seen in demography of patients but Sternotomy was associated with higher in hospital mortality (15.3 %) vs. LAST (4.3 %), lower conversion to second stage (23 %) vs. LAST (52 %), longer duration of ventilation and ICU stay. Also follow up mortality were higher in sternotomy group (18 %) vs. LAST (13 %) even though there was no significant differences in the band gradients at time of hospital discharge.
Conclusion: PA banding still has a significant mortality. Trusslers estimate still is the gold standard, but additional parameters are taken into consideration. We present our standardised protocol for PA banding in the setting of increased pulmonary blood flow, as part of preparation for either single ventricle pathway or bi-ventricular repair. We advocate the LAST as it is simple, safe, effective, easily reproducible and the re-entry in the second stage becomes easy.
Timing is crucial in surgery for endocarditis; lessons from a case series
Vasudev B Pai, Sambhram Shetty, Nikhil Nandineni, S Ganesh Kamath
Kasturba Medical College, Manipal University, Manipal
Introduction & Objectives: Despite all diagnostic and therapeutic advances, surgery for infective endocarditis, is still related to a high risk of morbidity and mortality. Patients initially managed in community hospitals with basic facilities are frequently referred to specialized centres in an already advanced stage of the disease. Appropriate antibiotic treatment according to culture sensitivity; good heart failure management; close monitoring and timely surgery is needed in these patients.
Materials & Methods: All patients who underwent surgery for endocarditis from 2013 to 2016 were studied. Their cultures, antibiotics as well as operative details are summarized.
Results: 7 patient underwent surgical treatment for infective endocarditis. Their ages ranged from 20 to 68 years (mean of 40.6) and all were males. Blood cultures were positive in all patients. All the patients were electively taken up for valve replacement. 3 patient had embolic stroke preoperatively. 5 patients underwent double valve replacement and 2 underwent aortic valve replacement. Average bypass time was 198 minutes with a cross clamp time of 116mins. Valve culture report and serology revealed 2 patients with brucellosis, 4 patients with streptococcus and 1 patient with staph aureus. Post operatively antibiotics were continued for 6-8 weeks after consultation with the infectious diseases team. Average ICU stay was 3 days and postoperative stay was 8 days. Waiting for a few days until antibiotic treatment reduced the systemic bacterial load thus helping to prevent profound refractory hypotension when cardiopulmonary bypass was instituted.
Conclusion: After appropriate diagnosis antibiotics according to culture is essential. Timing of surgery is crucial especially in patients with stroke. Three of the patients presented with strokes and were operated after appropriate intervals to achieve optimal results. Operating these patients too early could have resulted in poor postoperative recovery since they would have been unable to mobilise after surgery.
A comparative Study between Video Assisted Insertion of InterCostal Drain and conventional technique of Insertion.
Shaik Gouse Khaja Arif, Subrata Dey, Rajarshi Basu, Bhaskar Das
R.G Kar Medical College and Hospital
Introduction: Intercostal chest drain (ICD) is the commonest interventional procedure performed electively and in emergency settings for removal of collections in the pleural space. And like any invasive procedure the conventional ICD have various complications such as injury to underlying structures and inadequate drainage. A method to counter this has long been sought Objective:- To evaluate outcomes and safety of Video Assisted ICD insertion in Comparison with conventional ICD insertion.
Material & Methods: A total of 75 patients were included in the study. The Video Assisted technique was attempted in 35 (46.6%) cases, and compared with 40 (53.3%) cases of conventional technique.outcomes compared were procedure time, intra operative complications, repositioning requirement, post procedure thoracotomy requirement, mean hospital stay & achievement of complete lung expansion
Results: Technical success was obtained in 94% for the Video Assisted technique as compared to 92% of conventional technique. The procedure time for the video and the conventional techniques was approximately 25+/-15 and 15+/-10 minutes, respectively. Iatrogenic Complications occurred in 2.5% for video group versus 10% for conventional. Repositioning requirement was 6% in video group as compared to 42% in conventional group. Formal Thoracotomy Procedure requirement was 11.4% in video assisted group as compared 35% in conventional group. Mean hospital stay was 7+/-2 days in video group as compared to 18+/-4 days in conventional group. Complete lung expansion was achieved in 94% in Video group as compared to 85% in conventional group
Conclusion: Video assisted ICD is a safe and effective procedure It was sufficient to achieve complete lung expansion in 33 out of 35 cases.Mean hospital stays was also lesser. Avoidance of formal thoracotomy procedure was higher and Intra op complications were lower. It also aided in diagnosis in 3 cases.
Impact of Retrograde Autologous Priming of the Cardiopulmonary bypass circuit on post operative hemodilution and blood transfusion requirements
Remananda Krishnanand Pai, Murugan MS, Murugesan PR, Imran K, Biradar P, Ganeshan C, Mathew A
PSG Institute of Medical Sciences & Research, Coimbatore, Tamilnadu,India
Introduction: Approximately 60% of patients undergoing cardiac surgeries on cardiopulmonary bypass (CPB) require blood / products transfusion. Blood transfusion is associated with increased risk of Wound Infection, Renal Impairment, mediastinitis, and poor long term survival and coronary artery bypass graft patency. Retrograde Autologous Priming (RAP) of the CPB circuit has the potential to be part of an effective blood conservation strategy.
Materials & Methods: In a prospective, randomized single blinded study, on first time CABG patients, we compared the degree of hemodilution and transfusion requirement in patients in whom RAP was used (Group A)[60 patients] with those in whom RAP was not used (Group B) [60 patients] intraoperatively during first-time CABG. Primary end-point studied were intraoperative and postoperative haematocrit and secondary outcomes measured included total blood loss, blood products transfused, inotropic requirement, need for re-exploration, hospital stay and major outcomes / postoperative complications.
Results: The two groups were evenly matched in terms of patient risk profile and investigative parameters. We were able to achieve an average of 387.95ml ± 21.47ml RAP volume. This resulted in a significantly better hematocrit on bypass in RAP group at 40 minutes [Group A=24.34 vs Group B=23.90, p<0.04] and 60 minutes[[Group A=24.41 vs Group B=24.03, p<0.01]. There was no difference however in the hematocrit coming of CPB, the blood transfusion requirement or post operative outcomes.
Conclusion: Removal of asanguinous prime volume and replacing it with patients blood can be achieved safely and with good outcomes. A Rap volume of 390 ml [average] did not show any statistical improvement in outcomes compared to group of patients not having RAP. A higher threshold of RAP may be required to show statistically obvious benefits on transfusion outcomes.
Surgical Management of Femoral Artery Pseudoaneurysms: our series
Soumik Pal, Subhash Kumar Kadim, Parvez,,Mayuri S.,Vikas SR,Sathyanarayan J, Syed, Shio Priye, Durgaprasad Reddy B
Vydehi Institute of Medical Sciences and Research Centre
Introduction: Femoral artery pseudoaneurysms are a vascular complication that are increasingly occurring due to the increased number of percutaneous interventions. We report our case series of patients with femoral pseudoaneurysms.
Materials and Methods: The study was conducted from January 2007 to January 2015. The study included all the patients who developed pseudoaneurysm of the femoral artery following percutaneous interventions, which were not amenable to conservative management. There were a total of 15 patients in which 12 were male and 3 were female. All the patients were subjected to routine blood investigations, Doppler ultrasound, CT angiogram. These patients underwent surgery resection of the pseudoaneurysm and primary repair of the artery.
Results: 13 patients recovered uneventfully in the post operative period and got discharged in the first week. 2 patients developed skin necrosis and required debridement and dressing. All the patients came for follow up after 3 months and 1 year and had no complaints.
Conclusion: When conservative methods fail, open surgical repair is the gold standard in treatment of pseudoaneurysms. It is usually used as a last resort. Absolute indications for open surgical repair include shock or cardiovascular instability, greater than 100% increase in size of the pseudoaneurysm on duplex US, imminent rupture, and evidence of vascular compromise. The disadvantages associated with open repair include potential for bleeding, infection, nerve injury, and lymphatic leaks.
Surgery in Grown up Adults with Congenital Heart Diseases (GUCH) – a single centre 11 year Experience
Akhilesh Arumalla, RV Kumar, Vijay Kumar, T Rama Krishna Dev
Nizam's Institute of Medical Sciences
Outcomes data for adults undergoing congenital heart surgery are limited. The overview of our 11 years experience (2005 – 2015) with more than 924 operations of adults with CHD at our department gives a basis for contemplation and planning the special requirements needed in surgical care for this very specific group.
AIM & OBJECTIVES: To identify demographic characteristics of Adults with Congenital Heart Diseases presenting to our centre NIMS for cardiac surgery. To asses presenting Complaints, clinical presentations and to asses Surgical Complications faced and their management including postoperative immediate complications.
Material & Methods: The study subjects were consecutive GUCH patients who underwent cardiac surgery (CPB) at the age of 15 years or older at NIMS Hospital over the period from January 1, 2005 to December 31, 2015. Medical charts, anaesthetic records, and operative records were retrospectively reviewed.
Results: The median age of our 924 patients is 28.76±12.09,with nearly equal sex ratio. CPB time (90min±53) and Aortic cross clamp time(45min ±33). Most common Acyanotic Lesion is ASD( 57.9%n=535) followed by VSD( 8.23%,n=76). Most Common Cyanotic Lesion is TOF. The predominant number of patients presenting for surgery belong to 15-20 years 313(33.87%).60% of Complex Lesions,40% lesions with moderate complexity present before 20 yrs of age. 49.8% (n=460) patients are in NYHA Class1, 40.8% (n=377) are in class 2, 8.7% (n=80) are in class 3,and 0.8%(n=7) are in class 4.78 cases (8.44%) of series had previous surgeries 96.75% (n=872) had complete repair, 2.60% (n=24) had reoperations, 3.03% (n=28) had palliative surgeries. Postoperative complication rate in our study is 21.86%. The Mean ICU Stay varied from less than a week to 18days.The Mortality is 1.5% (n=14).
Conclusion: Despite the long term deleterious effects of CHD in adult patients, surgical correction can be achieved with low mortality and acceptable morbidity. Key Words: adults, heart defects, congenital,surgery outcome assessment, GUCH.
Outcome of Ischemic Mitral Regurgitation in Patient undergoing Coronary revascularization
Nitin Kumar Gupta
G. K. N. M Hospital
Aims and Objectives:Ischemic MR has been a well known complication of coronary artery disease and revascularization procedures are known to be insufficient to reduce mitral regurgitation. The aim of this study is to evaluate the patient of coronary artery disease with significant ischemic MR who are undergoing CABG, to compare clinical outcome and echocardiographic results of patients who underwent CABG with or without concomitant Mitral valve intervention.
Materials and Methods: The study was a prospective non randomised study conducted from May 2013 to June 2015. It included patients with coronary artery disease associated with ischemic MR,who underwent CABG with or without Mitral valve intervention in the form of either mitral valve repair with reduction annuloplasty ring or mitral valve replacement. They were divided into three groups: group I - CABG + MVR, group II - CABG + MV Repair, group III - CABG alone. The decision on repair or replacement was purely based on discretion of surgeons and on table TEE assessment of Mitral valve pathology. All patients were followed up during the 1 year interval.
Results: 90 patients were recruited with moderate or more ischemic MR associated with coronary artery disease , who underwent elective CABG with mitral valve intervention for the first time. The study group was divided into 3 groups, Group I had 36 patients (CABG+MVR ), group II had 43 patients (CABG+MV Repair ) and group 3 had 11 patients (CABG). The aetiology of MR was similar in all groups. There was significant reduction in mean MR grade in group 1 (1.09 ± 2.07) and group II (2.50 ± 2.43) compared to Group III (6.84 ± 3.18) .There was significant reduction in left ventricular dimensions LVID (s) and LVID (d) in group II compared with group I and group III with P value - 0.05. The mean NYHA class in preoperative period was 2.85 ± 0.93 in group I , 2.71 ± 0.92 in group II and 3.44 ± 0.71 in group III. In one year follow up NYHA class was significantly reduced to 1.21 ± 0.41 in group I, 1.17 ± 0.44 in group II, and 1.56 ± 0.76 in group III. The survival rate was highest in group II (95.3%) and group I (91.7%) compared to group I (81.8%) which favours the concomitant addressing of IMR with coronary revascularization.
Conclusion: Patients with ischemic MR who are undergoing CABG achieve superior midterm outcome with mitral valve intervention than isolated coronary revascularization. The patients who underwent CABG with concomitant MV repair have superior outcome than CABG with MV replacement.
Which variables predict mortality in mitral valve reoperations? A 20-year single surgeon experience
Daniel Almeida, Filipe Almeida, Rui M S Almeida
Assis Gurgacz University Foundation
Objectives: Mitral valve diseases are one of the most prevalent heart valve diseases in developed and nondeveloped countries. As we still have not achieved an ideal valve substitute, the great majority of patients will have their prostheses replaced once or more times, during their lifetime. The authors evaluated a consecutive series of mitral valve reoperations, performed by the same surgeon, and identify as primary objective the variables, predicting mitral valve mortality and as secondary all other variables, using multivariate analysis.
Methods: A retrospective analysis, February 1993 to January 2015, of 107 patients, undergoing mitral valve reoperation was performed. The demographics included pre-operative clinical and ecochardiografic data, trans and post-operative variables, and they were analyzed in a multivariate analysis frame, to target, which would predict hospital mortality. The patients were divided according to the logistic EuroScore into two groups (0-9,9% and 10% and above).
Results: The mean age was 48,00 ± 15,18 (8-76 years), being 71,96% females. In 70,09% biological valves were used and in the other cases the valve was replaced by a mechanical one (23,36%) or repair was performed (6,54%). Associated procedures were performed concomitantly in 9,35%, being concomitant aortic valve replacement performed in 50% and CABG in 30%. The left atrial appendage was closed in all cases were atrial fibrillation was the basic rhythm (56,07%). The mean logistic EuroScore was 8,10%. The mean length of stay in ITU was 3,00 ± 6,15 and in hospital 7,00 ± 10,43 days. The overall mortality was 14,02%, mainly on the high EuroScore group, and on those patients with more than one reoperation.
Conclusion: The statistical analysis identified age, NYHA class and pulmonary hypertension as preoperative primary predictors for mortality. The authors conclude that the reoperation can be performed safely on the technical point and the result depends on the patient pre-operative conditions.
Single Stage CABG and Peripheral Arterial Bypass for Combined Coronary and Peripheral Arterial Disease
Divya Arora, Ashok Chahal, Kuldeep Laller, Shamsher Singh Lohchab
Pt B D Sharma PGIMS Rohtak
Introduction: Peripheral arterial disease and Coronary artery disease often coexist and former is an indicator of systemic atherosclerosis. Patients undergoing surgery for PAD alone in presence of significant CAD are at high risk of perioperative major adverse events hence we adopted the strategy of single stage CABG and peripheral arterial bypass for combined disease.
Methods: From January 2014 to August 2016 36 patients all males mean age 62 ± 7 years range 45 to 73 years underwent concomitant off pump CABG and peripheral arteria bypass for combined CAD and PAD. These patients presented with severe lower limb ischemia and lower extremity CT angiography demonstrated infra renal aortoiliac disease in 9(25%) patients, isolated external iliac occlusion in 12 (33%), and superficial femoral artery occlusion in 15 (42%). Significant double vessel coronary occlusion was found in 12(33%) and triple coronary disease in 24 (67%) on coronary angiography. LV dysfunction was there in 24 (50%). There were 9(25%) diabetic patients. The strategy adopted for aortoiliac disease was single stage abdominal aortobifemoral bypass grafting first followed by off pump CABG keeping in view the need for IABP. For iliac artery disease and superficial femoral artery, the peripheral bypass was done after completion of CABG.
Results: The operative mortality observed was in 2/36 (5.5%) related to limb ischemia and renal failure. Postoperative complications observed were acute limb ischemia in 1/36 (2.7%). Renal failure 2/36 (5.5%). Two patients required IABP support and in one patient the catheter was put through the one limb of aortobifemoral femoral graft. 30/34 (88%) patients were asymptomatic at maximum follow up of 32 months range (3-32).
Conclusion: Single stage off pump CABG and peripheral artery bypass can be performed safely and obviates the major cardiovascular events in patients presenting with severe lower extremity ischemia.
Coronary Endarterectomy: It is not a Devil
Sunil Agrawal, Geevarghese Mathew,Chandrasekhar Varma,Rakhi K.R., Nikhil George,K.M.Cherian
St. Gregorios Cardiovascular Centre, Parumala, Kerala
Background: To achieve complete revascularization in patients with diffusely diseased coronary arteries, endarterectomy is the only option. There are concerns about increased risk of arrhythmias, and early graft occlusion in these patients Aim: The aim of this study is to discuss the results of our endarterectomy and the tips and protocol we follow after endarterectomy.
Material and Methods: From January 2007 –October 2016, 2107 patients underwent CABG, of which 376, patients had endarterectomies (17.8%). Isolated RCA/PDA endarterectomy was the most common (286 patients). 109 patients had multiple endarterectomies including triple endarterectomies. In all cases it was ensured that the endarterectomy is complete, with extensive arteriotomies and patch plasty if needed. In the case of RCA, attention was paid to complete endarterectomy in both PDA and PLB. Amiodarone (150mg) was electively added to the pump after endarterectomy. It was then continued as infusion for 24-48 hours before switching over to oral doses. Antiplatelets (Clopidogrel 75mg+Aspirin 75mg) was given once drainage settled (as early as 4 hours post surgery). Unfractioned heparin infusion was started once the drainage settled with the ACT maintained between 175-200.This was changed to subcutaneous heparin till the 4th POD. Warfarin was used in few patients with extensive arteriotomies and vein patch plasty in the beginning but since 2012 we stopped warfarinaltogether and continuing only with dual anti-platelets.
Results: We had 3 hospital deaths. All three patients had severe LV dysfunction prior to surgery. The incidence of post op arrhythmias was low. The incidence of AF was 10%. Life threatening arrhythmias were not observed in any patient. There were no peri-operative infarctions. We do the TMT routinely at 3 months and 12 months after the surgery in all the patients. So far only 2 patients needed repeat interventions due to recurrence of angina.
Outcome analysis after surgical management of ventricular septal defect complicating acute myocardial infarction in a tertiary referral Government Hospital
Kallol Dasbaksi, Plaban Mukherjee, Suranjan Haldar, Mohammad Zahid Hossain, Tinni Mitra
Department of CTVS, Medical College, Kolkata, 88, College Street, Kolkata-700073
Introduction: Although the present incidence of Post myocardial infarction ventricular septal defect ( PI-VSD) is .20%, the outcome of PI-VSD remains poor even in the era of reperfusion therapy. We reviewed our experience with surgical repair of 6 cases of PI-VSD during the last 3 years and analyzed outcomes with an objective to identify prognostic factors.
Methods: From March 2014 to April 2016, data from 6 consecutive patients of PI VSD who underwent surgical repair at our institute were retrospectively reviewed. Referral was after echocardiographic diagnosis of post MI VSD from Cardiology Department. 4 Patients had coronary angiography (CAG) done after the diagnosis of Myocardial infarction (MI) and before the VSD developed. Whereas no CAG was done in 2 patients. Out of the 6, 4 patients could be stabilised with conservative management (3 anterior VSD,1 posterior VSD) but 2 patients being in refractory “shock” needed emergency surgery (1 anterior and 1 posterior VSD). The 4 patients who could be stabilised were operated upon 14 to 18 days later. Out of the 6 patients 4 had anterior VSD and 2 had posterior VSD. All were repaired with bovine pericardium using cardiopulmonary bypass under moderate hypothermia. In all the 4 patents, who had CAG, the obstructed coronary arteries were bypassed.
Results: There were two deaths, one each from emergency surgery group and one from the conservatively managed with delayed surgery group. Post operative analysis revealed that the survivors had higher preoperative left ventricular ejection fractions (LVEF) compared to those who died (40 ± 3.7% vs. 25 ± 2.4%, respectively;). Failure of improvement of hemodynamic status to resuscitative measures including IABP and consequent earlier surgical intervention, the extent of MI including right ventricular infarction, have been found to be associated with poor prognosis in our study. We did not find any relation of the length of total period of cardioplegic arrest toward mortality.
Conclusion: Inadequate response to resuscitative measures and need for emergency surgery are predictors of increased mortality. Low LVEF and extent of myocardial damage also determine final outcome.
Acute kidney injury after OPCAB surgery: incidence and outcomes.
Swadesh Ranjan Sarker, Siddhartta Shankar Howlader, Shahriar Moinuddin, Sabrina Sharmeen Husain, Md. Kamrul Hasan
National Institute of Cardiovascular Diseases, Dhaka, Bangladesh.
Background: Acute kidney injury (AKI) is a common complication after coronary artery bypass grafting (CABG), and is associated with adverse outcomes. Still, the incidence and outcomes of AKI vary according to its definition. Our monocentric study comparatively investigates the yield of RIFLE definition, which is based on the elevation of serum creatinine levels (SCr) or the reduction of urine output (UO), taking into account only one or both criteria.
Methods: All adult patients undergoing OPCAB between January 2014 and May 2015 were included. Clinical, biological and surgical features were recorded. Baseline serum creatinine was determined as its value on day 7 before surgery. Post-operative AKI was diagnosed and scored based upon the highest serum creatinine and/or the lowest urine output.
Results: 121 patients (Male/Female ratio, 2.3; median age, 53y) were included, with 56 (46.3 %) developing postoperative AKI. Elevated serum creatinine (AKISCr) and oliguria (AKIUO) was observed in 9.2 % and 37.1 %, respectively. AKI patients had a significantly higher BMI and baseline SCr. In comparison to AKIUO, AKISCr mostly occurred in patients with co-morbidities, and was associated with an increased mortality at 1-year post surgery.
Conclusions: The use of standard RIFLE definition of AKI in 121 patients undergoing OPCAB surgery resulted in an incidence reaching 46 %. Still, significant discrepancies were found between AKISCr and AKIUO regarding the incidence and outcomes. In line with previous reports, our data questions the utility of urine output as a criterion for AKI diagnosis and management after cardiac surgery.
Impact of Renal Insufficiency on In-hospital Outcomes after Off-pump Coronary Artery Bypass Surgery
Sonjoy Biswas, Syed Al-Nahian
United Hospital Limited, Dhaka, Bangladesh
Introduction and Objectives: Chronic kidney disease (CKD) is a predictor of increased morbidity and mortality in patients undergoing off-pump coronary artery bypass surgery (OPCAB). To evaluate the characteristics and predictors of increased morbidity and mortality in the CKD population submitted to OPCAB. To compare in-hospital outcomes between patients with and without CKD, and with and without development of acute kidney injury (AKI).
Materials and Methods: A prospective analysis of all isolated OPCAB performed at United Hospital Limited from January, 2015 to October, 2016. CKD was considered when e-GFR < 90 ml/min/1.73m2. Clinical characteristics, mortality and post-operative complications were evaluated according to renal function and stages of CKD.
Results: Out of 1463 patients, 169 (11.6%) had CKD. This population was older, presented greater prevalence of hypertension, left ventricular dysfunction, prior stroke, peripheral vascular disease and triple vessel disease, hence, higher EuroSCORE. In-hospital outcomes revealed greater incidence of stroke (4.4% vs 1.6%), atrial fibrillation (12% vs 6%), low cardiac output syndrome (12% vs 7.2%), longer stay in intensive care unit (4.84 vs 2.83 days), and greater mortality (8.4% vs 2.4%). Female gender, smoking, diabetes and peripheral vascular disease were associated with higher in-hospital post-operative complications and mortality within the CKD group. Patients who did not develop post-operative AKI presented 2.4% mortality; non-dialytic AKI: 16.7%; dialytic AKI: 33.3% mortality. Mortality was directly related to the stages of CKD.
Conclusions: CKD patients submitted to OPCAB represent a high risk population, with increased incidence of complications and mortality. Post-operative AKI is a strong in-hospital mortality predictor.
Study between ring anuloplasty and suture annuloplasty in Tricuspid valve diseases
Menander M, Uday Jadhav, D V Kulkarni, Kamlesh Jain
Seth G. S. Medical College and KEM Hospital
Objective: Tricuspid regurgitation (TR) may be primary or secondary to left sided heart diseases. Residual tricuspid regurgitation is seen after both ring and suture annuloplasty. A study was conducted in to validate the long term benefits of tricuspid ring annuloplasty over suture annuloplasty (TVA).
Materials and methods: 80 patients undergoing mitral valve replacement (MVR) with TVA were studied. Of these patients 50 patients underwent MVR with ring annuloplasty and 30 underwent MVR with DeVegas annuloplasty. Criteria studied were ionotropic support required, length of decongestive treatment, reduction in pulmonary hypertension. Echocardiography was done pre operatively and post operatively at 24 hours, 7 days, 1 month and at 1 year to determine PASP (pulmonary artery systolic pressure), Grade of Tricuspid regurgitation, TAPSE (Tricuspid Annular Plane Systolic Excursion) and tricuspid annular dimension.
Results: Ionotropic support, decongestive treatment and reduction in pulmonary hypertension were comparable in both groups at 1 month. 82% of patients of ring annuloplasty group had reduction in PASP at 1 month compared to 56% in DeVegas annuloplasty group. Grade of regurgitation improved from moderately severe TR to mild TR in 86 in ring annuloplasty group compared to 53% in DeVegas annuloplasty group at one year. 68% of patients of ring annuloplasty had improvement in TAPSE at one year compared to 46% of patients in DeVegas annuloplasty group. Mean tricuspid annulus showed reduction from pre op annulus size of 37.72 to 27.5 in ring annuloplasty group to 37.9 to 32.13 in DeVegas annuloplasty group.
Conclusion: Tricuspid ring annuloplasty is a durable repair compared to suture annuloplasty for secondary tricuspid regurgitation in the long run. Though DeVegas annuloplasty is comparable to Ring annuloplasty in the immediate post operative period, tricuspid regurgitation worsens over time. Aggressive management of secondary tricuspid regurgitation with ring annuloplasty could decrease the occurrence of late tricuspid regurgitation following mitral valve surgery.
IMMEDIATE AND MID TERM RESULTS AFTER CABG WITH MITRAL VALVE REPAIR IN PATIENTS WITH ISCHAEMIC MITRAL REGURGITATION
Vinitha V Nair, TK Jayakumar
Government Medical College , Kottayam, Kerala
Background: Ischemic mitral regurgitation (MR) result from left ventricular remodelling in ischemic heart disease despite structurally normal valves. The presence of ischemic MR itself is associated with excess mortality. Patients with moderate or severe regurgitation require concurrent mitral valve intervention as repair or replacement.
Material and methods: 34 patients with ischemic regurgitation underwent coronary artery bypass grafting with mitral valve repair at our centre over a period of 3 years (2013-2015). M: F was 25:9 with a mean age of 56 years (range 41-73 years). 17 patients had moderate and 17 had severe regurgitation. The left ventricular function was normal in 16, dysfunction mild in 7, moderate in 9 and severe in 2. All patients underwent revascularisation and annuloplasty with rigid ring. Additional procedures were required in 3 patients (P3 neochordae, quadrangular resection PML and PML cleft closure ).
Results:There were no in-hospital deaths. The mean hospital stay was 6.8 days (range 4-15 days). At discharge, 17 patients had no mitral regurgitation, 14 had trivial to mild regurgitation and 3 had moderate mitral regurgitation. 4 patients expired during follow up at 2,2,10 and 21 months respectively. 3 of them had severe mitral regurgitation preoperatively. Follow up was complete for 28 patients (2 were lost to follow up). The minimum follow up was 6 months. (Median: 18 months, range: 6-38 months). 2 patients progressed from mild to low moderate regurgitation during follow up at the end of 36 and 23 months respectively. 2 patients with moderate regurgitation had low moderate regurgitation at 12 and 8 months follow up. All the other patients maintained good mitral valve competence during follow up.
Conclusion: Mitral valve repair along with revascularisation in ischemic mitral regurgitation has good midterm results and the patients remained good valve competence.
Difference in pain, mobilization and incentive spirometry compliance between extra-pleural and open internal mammary artery harvesting in off-pump coronary artery bypass (OPCABG) patients
Neeraj Aravind Kamat, Neeraj Kamat, Shruti Sonar, John Thomas, Sandeep Sinha,UpendraBhalerao, Ashish Gaur, Satish Jawali, Anvay Mulay
Fortis Hospital, Mulund, Mumbai
Introduction: Pleurotomy during IMA harvesting impairs respiratory function during the postoperative period. Hikmet iyem et al found that preservation of pleural integrity during IMA harvesting decreases postoperative bleeding, pleural effusion and atelectasis. Many studies reported that pleural effusion, atelectasis, blood loss, the need for secondary thoracotomy, pain and intercostal neuralgia are far less encountered who did not receive IMAs. Hence the aim of the study was to compare the patients capacity to do incentive spirometry, pain and mobilisation status postoperatively in extrapleural versus open IMA harvesting methods.
Materials and Methods: It’s a single centre, single surgeon, retrospective observational study. It includes patients operated for off pump coronary artery bypass surgery by either extra-pleural (closed) or open technique of harvesting IMA at Fortis hospital from September 2015-February 2016. A total of 145 patients undergone OPCABG out of which 60 patients were done with open technique of harvesting IMA and the remaining 85 patients had closed or extrapleural harvesting of IMA.
Results: The demographic characteristics in terms of age and gender and preoperative variables were comparable in both groups. Results were grouped in 3 categories 1. Incentive Spirometry Open and closed pleurotomy patients were subjected to incentive spirometry exercise preoperatively and postoperatively and it was observed that the closed pleurotomy patients were able to do spirometry better as compared to patients with open pleurotomy as compared to their respective preoperative spirometry levels. Closed pleurotomy patients were able to generate an excess of 360ml on spirometer on an average as compared to patients with open pleurotomy who were able to generate only 225ml in excess of their preoperative spirometric values 2. Pain scale There was no significant difference in pain in both groups. 3. Mobilisation &discharge Patients with closed pleurotomy were mobilised earlier i.e. 4 days as compared to 6 days in patients with open pleura and hence patients with closed pleura were discharged two days prior as compared to patients with open pleura. 4. only 1 patient of open pleurotomy required re-intervention for postoperative pleural effusion as compared to 3 patients with closed pleurotomy. 5. IMA was injured in 2 patients with closed pleurotomy as compared to only 1 injury in patients with open pleurotomy.
Conclusions: Definitely the advantages of leaving the pleura intact while harvesting the IMA in the postoperative recovery far outweigh but utmost care needs to be taken to avoid injuring the IMA and a very low threshold for opening the pleura need to be kept if any doubt of injuring the IMA.
Our experience with Prosthetic valve Sparing Aortic Root Replacement
A Mohammed Idhrees, VVBashi, Mukesh, Niranjan, Aju Jacob
Institute of Cardiac and Advanced Aortic Disorders (ICAAD), SIMS Hospital, Chennai, India -600 026
Objective: Reoperation on the aortic root is challenging because of high hospital morbidity and mortality. In prosthesis valve sparing aortic root replacement the well-functioning prosthetic aortic valve is preserved during reoperation. This is done to avoid passing sutures through the weakened aortic annulus if the initial prosthesis is removed. The aim of the present study was to assess short- and mid-term outcomes of patients who underwent such procedures.
Methods: Between June 2002 and March 2014, twenty-one patients underwent re-operative prosthesis valve sparing aortic root operations (mean age: 51.24 + 10.30 years; male: 85.71%). Nineteen of the preserved aortic prosthesis were mechanical valves. The mean time from previous aortic surgery was 10.86 + 5.67 years. Eleven patients (52.38%) patients presented with type A aortic dissection, 38.09% (n=8) had ascending aortic aneurysm and one patient had rupture of sinus of valsalva and yet another had a LCA aneurysm.
Results: Isolated prosthesis valve sparing aortic root replacement was performed in 13 patients while it was associated with aortic arch repair in 8 patients. The mean cardiopulmonary bypass time was 227.86 +/- 51.09 minutes and aortic cross clamp time was 159.86 + 26.09 min. 71.43% (n=15) had aortopathy including Marfans syndrome and bicuspid aortic valve. We had one in-hospital mortality. All the patients were followed up for a minimum of 2 years and maximum of 12 years. There were 2 late deaths due to non-cardiac cause [Road traffic accident (after 1 yr.) / Liver carcinoma (after 2 yrs.)].
Conclusion: Our favourable short- and mid-term results indicate that the prosthesis-sparing operation is a valid treatment option in re-operative aortic root procedures. In selected patients bioprosthetic valve sparing is also a viable option. This can be done with acceptable morbidity and mortality.
Hybrid Aortic Arch Replacement: Outcome analysis
A Mohammed Idhrees, VVBashi, Mukesh, A B Gopalamurugan, Aju Jacob
Institute of Cardiac and Advanced Aortic Disorders (ICAAD), SIMS Hospital, Chennai, India -600 026
Purpose: Hybrid aortic arch replacement is emerging as a safe treatment alternative for arch aneurysms. We assessed our experience with all the types of arch hybrid procedures.
Method: From 2007 to May 2016 we have performed 112 endovascular aortic repairs (EVAR), of which 53 underwent hybrid aortic arch repair. The hybrid repair entailed aortic arch vessel debranching and concomitant/delayed antegrade ± retrograde EVAR stent grafting of the arch. For Type I and II hybrid procedures, debranching of the arch vessels were done without circulatory arrest and EVAR was performed on the following day. In Type III hybrid procedures, antegrade EVAR of the thoracic aorta and arch reconstruction with four-branch Gelweave™ Plexus graft was performed in single stage.
Results: Of the 53 patients, 15 patients had Type I repair, 32 had Type II repair, and 6 had Type III repair. Mean age was 57.25 years with male constituting 79.24% (n=42). Aortic dissection was the primary pathology in 54.71% (n=27) patients followed by aneurysm in 43.39 % (n=23) patient. Marfans syndrome was present in 30.18% patients (n=16). Redo-sternotomy was performed in 7 patients (13.20%). Incidence of stroke was 5.66% (n=3) and there was no patients with renal dysfunction requiring hemodialysis. There was one retrograde aortic dissection in type I group. There were two endoleaks, both in type I patients. Mean length of hospital stay was 13.2 + 9 days. 30 days in-hospital mortality was 5.66% (2 in type I and 1 in type II). The data is presented in table 1. Considering our own experience, recently we perform more of type II hybrid than type I hybrid.
Conclusion: Hybrid aortic arch replacement can be performed with low incidence of stroke and renal dysfunction. Type II hybrid is better than type I hybrid in our experience in spite of the non-availability of frozen elephant.
Management of coarctation of aorta with ascending aortic aneurysm.
Shiv Kumar Choudhary, Amol Bhoje, Shivaparasad M B, Sachin Talwar, Parag Gharde, Manoj Sahu, Lissy Pavulose, Sanjeev Kumar, Lokender Kumar, Velayoudam Devagourou, Balram Airan
All India Institute of Medical Sciences, New Delhi
Introduction: Coarctation of aorta with ascending aortic aneurysm (AAA) is a rare entity. The ideal approach in such patients is still uncertain. Debate exists not only on the lesion to be corrected first but also on the timing of surgery. Surgery can be one staged or two staged. Hybrid techniques have also influenced the decision-making. We review our experience of 15 years for this complex entity.
Methods and materials: A single surgical team managed 17 patients with coarctation and AAA between 2001 and 2016. The coarctation morphology decided the management strategy. In 12 patients, coarctation was managed first using endovascular techniques (n=7), interposition graft (n=4), and left subclavian-aortic bypass (n=1). Five patients underwent single stage correction at the time of AAA management: patch aortoplasty using a ‘T’ sternotomy in two, and ventral aorta repair in three. Various procedures for AAA included Bentall’s in 15, aortic root remodeling in one, and Wheat procedure in another.
Results:All patients survived operation. One patient, who underwent concomitant Bentall’s and patch aortoplasty, required tracheostomy and prolonged ventilation. Median ICU stay was 3 days. Follow-up raged from 1 to 12 years. One patient required balloon dilatation for recoarctation. Another patient developed type B aortic dissection and is being followed. Twelve patients continued to receive anti-hypertensive therapy.
Conclusion: This disease combination can be managed with one or two staged procedure. However hybrid procedure has minimized surgical risk. The selection of procedure should be based on proper case selection, surgeons experience and institutional protocols.
Study of Circle of Willis in Indian population
Shiv Kumar Choudhary, Sumit Agasti, Arun V, Pradeep R, Sachin Talwar, Manoj Sahu, Parag Gharde, Velayoudam Devagourou, Balram Airan
All India Institute of Medical Sciences, New Delhi
Introduction: During aortic arch or carotid interventions, completeness of Circle of Willis (COW) is an important determinant of cerebral protection strategy. Studies performed in different ethnic groups report different patency rates of COW. We performed this pilot study aim is to assess the anatomy and variations of COW in Indian population by means of magnetic resonance angiography (MRA).
Patients and methods: MRA data from 200 consecutive patients without abnormalities of the main feeding vessels of the COW were analyzed. Age ranged from 21 years to 72 years. 130 were males. Most common indications for MRA were cerebrovascular accident (55.0%), AV malformations (10%), visual loss (8.0%) and transient ischemic attacks (4.0%).
Results: 62 patients (31.0%) had incomplete COW and males and females were equally affected. Out of these, only one patient had a truly incomplete COW as both the ipsilateral anterior communicating and posterior communicating arteries were absent. 38 patients had deficient posterior COW (25 on the right side, 12 on the left side and one patient had both the posterior communicating arteries absent). 24 patients had deficient anterior COW (15 on the right and 9 on the left side).
Conclusion: The COW was anatomically incomplete in 31% cases in a randomly chosen set of patients for whom MRA was performed for a variety of reasons including cerebro-vascular lesions. Further studies involving a larger cohort of patients need to be planned before these results can be extrapolated to the general Indian population. Also, the functional significance of these anatomically deficient COW needs to be investigated.
Aortic Valve Replacement (AVR) with Zero Patient Prosthesis Mismatch (PPM): An integrated approach
Shiv Kumar Choudhary, Amol Bhoje, Anupam Das, Parag Gharde, Manoj Sahu, Lissy Pavulose, Rajesh Yadav, Sachin Talwar, Velayoudam Devagourou, Milind Hote, Balram Airan
All India Institute of Medical Sciences, New Delhi
Introduction:PPM has been associated with higher early and late mortality after aortic valve replacement. Prosthetic valve Indexed Effective Orifice Area (EOAI) < 0.85cm2/m2 has been considered significant PPM. We review our strategy to prevent PPM in patients undergoing AVR with either a mechanical valve or bioprosthesis.
Patients and method: A single surgical team performed 634 isolated AVR over the period of 15 years from January 2001. Age ranged from 6 years to 82 years, and 482 were males. Body surface area (BSA) ranged from 0.93 m2 to 2.34 m2. Aortic stenosis was the predominant lesion in 386 patients. Choice of mechanical valve or bioprosthesis depended upon age, comorbidities, expected survival, life style, and socio-economic factors. An integrated approach was used in selection of prosthesis and technique of insertion to achieve prosthetic valve EOAI > 0.85cm2/m2. If it was not possible to insert the desired prosthesis in the native annulus, posterior root enlargement was performed.
Results: All patients survived the operation. It was possible to insert a valve prosthesis with EOAI > 0.85cm2/m2 in all patients. Only 28 (4.4%) patients required aortic root enlargement. In pediatric patients, irrespective of BSA, minimum EOA > 1.4cm2 was ensured to accommodate future growth. Intra-operative trans-esophageal echocardiography was performed in later half of experience in 267 patients. Mean transvalvular aortic gradients ranged from 4 to 26 mm Hg. Two patients had significant paravalvular leak and needed re-intervention. There was no operative mortality and 16 patients required re-operation for excess mediastinal drainage.
Conclusion: With careful selection of prosthesis and insertion technique, it is possible to achieve zero PPM in patients undergoing AVR. Aortic root enlargement is required infrequently in <5% patients.
Acute Type A Dissection complicated by Stroke: Optimum Strategy ?
Shiv Kumar Choudhary, Amol Bhoje, Anupam Das, Parag Gharde, Manoj Sahu, Manjumol Biju, Sudha Lama, Rajesh Yadav, Sachin Talwar, Velayoudam Devagourou, Balram Airan
All India Institute of Medical Sciences, New Delhi
Introduction: Management of acute type A aortic dissection (AAAD) complicated by stroke remains controversial. The urgency of immediate repair is tempered by the concern about cerebral reperfusion and hemorrhagic conversion. The purpose of this study was to analyze our results with AAAD complicated by new onset stroke.
Patients and Methods: During the period of 15 years (2001-2016), a single surgical team managed 7 patients of AAAD complicated with stroke. Patients presented after 6 hours to 120 hours of chest pain. Six patients presented with left hemiplegia/hemiparesis with innominate artery with or without right common carotid artery (CCA) involvement. One patient presented in coma (intubated, on mechanical ventilation) with innominate and left CCA involvement. Six patients were operated on urgent basis using different cannulation strategies. One patient with massive infarct and significant midline shift but without aortic regurgitation or tamponade, underwent decompression craniotomy first. This patient was closely followed and dissection repair was performed after 3 months.
Results: There was no episode of hemorrhagic conversion of the infarct. Among patients who were operated early, the patient with coma deteriorated and expired on 5th day. She had extensive bilateral infarcts and no salvage neurosurgical procedure was attempted. In two patients, neurological status deteriorated in post-operative period and required decompression craniotomy. One patient who presented at 6 hours, recovered completely. Other two patients who presented late showed slight neurological improvement only. The patient operated late showed marked neurological improvement. Follow-up raged from 3 months to 12 years. All, except one, are able to lead an independent life.
Conclusion: Stroke in AAAD is not a contra-indication for dissection repair. A close coordination with neurologist and neurosurgeons is required to achieve optimum results.
Renal cell carcinoma (RCC) with intracardiac extension: Radical excision under moderate hypothermia
Shiv Kumar Choudhary, Amlesh Seth, Amol Bhoje, Parag Gharde, Manoj Sahu, Lissy Pavulose, Parul, Rajesh Yadav, Sachin Talwar, Velayoudam Devagourou, Balram Airan
All India Institute of Medical Sciences, New Delhi
Introduction: RCC, rarely, can grow till right atrium (RA) via renal vein and inferior vena cava (IVC). We have developed a technique of radical nephrectomy and intracardiac thrombus removal under cardiopulmonary bypass (CPB) and moderate hypothermia.
Patients and Methods: 32 patients with RCC without metastatic disease but with tumor thrombus extending in the supra-hepatic IVC or right atrium were operated upon between Jan 2001 and July 2016. Mean age was 50.2 years (range 14-72 years), male: female ratio was 24:8, and 27 tumors were located in right kidney. All patients were operated via midline sterno-laprotomy. CPB was established after radical nephrectomy with aortic, superior vena cava, and infra-renal IVC cannulation. Under moderate hypothermia, cardioplegic arrest, and with supraceliac abdominal aortic occlusion, suprarenal vena cava and right atrium was opened and tumor thrombus was removed.
Results: There were three early deaths (excessive bleeding and its attendant complications in two, and post-operative renal failure in one). Additional complications included wound infection in 3, pleural effusion needing inter-costal drainage in 2 and acute psychosis in one patient. Lower body ischemia time ranged from 15 to 24 minutes. Cardiac arrest time ranged 21 to 26 minutes, and CPB time ranged from 38 to 64. Transfusion requirements ranged from 2 to 14 units (median 4). Median ventilation time was 10 hours (6-21 hours) and average ICU stay was 3.2 days. Mean follow-up was 38.4 months (range 2-78 months). Median survival in operative survivors was 62 months.
Conclusion: Aggressive surgical management in patients of renal tumor with intracardiac thrombus provides good long-term prognosis with acceptable mortality and morbidity.
Trans-aortic mitral valve repair for functional MR in patients undergoing aortic root / valve procedure: A feasibility study
Shiv Kumar Choudhary, Atul Abraham, Amol Bhoje, Parag Gharde, Manoj Sahu, Mary Thomas, Ligimol Liju, Parul, Yogesh Solanki, Sachin Talwar, Balram Airan
All India Institute of Medical Sciences, New Delhi
Introduction:There are no clear guidelines for management of functional mitral regurgitation (MR) in patients undergoing aortic valve interventions. The risks of additional mitral intervention often outweighs the benefits of abolition of MR. Trans-aortic edge-to-edge mitral repair emerges as a quick and technically simple procedure in this setting. The present study evaluates feasibility, safety, and efficacy of this procedure.
Patients and Method: Between Jan 2012 and Nov 2016, sixteen patients ( age 24-76 years) underwent trans-aortic edge-to-edge mitral valve repair for moderate/severe functional MR. All patients were primarily operated for severe aortic regurgitation ± aortic root lesions. LVIDes ranged from 35 to 69 mm, LVIDed ranged from 54 to 85 mm, and ejection fraction ranged from 20 to 60%. MR was 2+ in 8, 3+ in 6, and 4+ in two. Primary surgical procedure included Bentall’s ± hemiarch replacement in 10, aortic valve replacement in 5, and non-coronary sinus replacement with aortic valve repair in one.
Results: Intra-operative TEE showed diminished severity of MR in all. There was trivial or no MR in 13, mild (1+) in two, and moderate (2+) in one. There were no gradients across mitral valve in 9, less than 4 mm Hg in 6, and 9 mm Hg in one. There was no operative mortality. Follow-up ranged from 2 weeks to 54 months. Follow-up echocardiography showed trivial or no MR in 12, mild in 2, and moderate in two. None of the patients had significant mitral stenosis. LVEDed ranged from 42 to 74 mm, and LVIDes ranged from 28 to 64mm. Ejection fraction also improved mildly (22-65%).
Conclusion:Trans-aortic edge-to-edge mitral valve repair is a safe and effective technique to abolish functional MR. However, its impact on overall survival needs to be studied.
Analysis of the Extent of Degenerative changes in Intra-pericardial Aorta of patients with Bicuspid Aortic Valve (BAV)
Shiv Kumar Choudhary, Pradeep R, Ruma Ray, Sudheer Kumar Arava, Parag Gharde, Manoj Sahu, Sudha Lama, Manjumol Biju, Palleti Rajshekar, Balram Airan
All India Institute of Medical Sciences, New Delhi
Objectives: To study the extent of degenerative changes in intra-pericardial aorta of patients with BAV presenting with aortic valvular lesion.
Methods: Patients with BAV, who were undergoing aortic valve intervention with or without ascending aortic replacement, from January 2010 till March 2016 were included. Biopsies taken from aortic sinus, mid ascending aorta and distal ascending aorta, were analyzed for degenerative histopathologic changes using modified Schlatmann and Becker criteria and a composite histopathological examination (HPE) score was calculated. Preoperatively, patients were evaluated clinically, echocardiographically, and by computerised tomographic angiogram.
Results:112 (94 male) patients were included. The mean age was 39.3± 15.6 years (range11-78 years). Aortic stenosis was the predominant lesion in 64 (57%) patients. The mean diameter of the aorta was 39.5 ± 10.06mm (range 23-108mm) at sinus level, 45.1 ± 11.49mm (range 18-85mm) at mid ascending aortic level and 36.3 ± 6.93mm (range 22-60mm) at distal ascending aortic level. The mean total HPE composite score was 6.25 at aortic sinus level, 5.75 at mid ascending aortic level and 4.75 at distal ascending aortic level. There were significant degenerative changes even with aortic diameter less than 4.5cm at all the three levels. Statistically significant correlation between aortic diameter and histopathologic degenerative changes was present at all three levels: aortic sinus (R= 0.3, p = 0.001),mid ascending aorta (R= 0.26, p =0.009) and distal ascending aorta (R= 0.23, p = 0.01).
Conclusion: There is significant correlation between the severity of degenerative histopathologic changes and the ascending aortic diameter at all levels. Maximum correlation was found at the aortic sinus level. The degenerative changes were not only present in the dilated segments of aorta; significant changes were also present in non-dilated segments throughout the ascending aorta.
A Study on Efficacy of Video Assisted Thoracoscopic Surgery ( VATS) Biopsy as a Diagnostic tool
Ashith Shetty, KR Balasubramoniam, Praveen K Varma
Amrita Institute of Medical Science, Kochi
Introduction: Numerous medical conditions remain diagnostic dilemmas even after extensive investigative modalities. Video Assisted Thoracoscopic Surgery ( VATS ) biopsy offers an minimally invasive surgical option to attain a definitive histopathological diagnosis with minimal morbidity and no mortality. In our study we report a series of patients with various thoracic pathologies who were evaluated and not yielded final histopathological diagnosis.
Materials and Methods: Our study consisted of 30 patients with clinically and radiologically apparent thoracic pathology who were undiagnosed despite investigations like PET scan, CT, bronchoscopic or EBUS guided biopsy who then underwent VATS biopsy for a definitive histopathological diagnosis. They were assessed based on variables like age, sex, histopathological diagnosis, length of hospital stay, complications,pain scale and diagnostic efficacy. VATS biopsy was performed under General anaesthesia with Double lumen endotracheal tube.
Results: Our surgical cohort (n=30) consisted of 17 male and 13 female patients. Mean age was 47.37 years. VATS Biopsy included lung biopsy in 11 patients, lymph node biopsy in 11, mediastinal mass biopsy in 5, lung and lymph node biopsy in 2, lung and pleural biopsy in 1. Mean length of hospital stay was 4.8 days. Definitive histopathological diagnosis was obtained in all 30 patients (100%). Mean pain scale was 3.2 out of 10. Only complication was persistent air leak for > 7 days which was present in 2 patients (6.6%). No mortality reported.
Conclusion: VATS Biopsy is a new weapon in the physicians armamentarium which promises a high rate of diagnostic efficacy with minimal morbidity and no mortality to the patient. It should be considered as the safe and reliable investigative modality of choice for thoracic mass lesions and medical conditions presenting with mediastinal lymphadenopathy.
Immediate and early cardiovascular functional alterations after off-pump and on-pump coronary artery bypass grafting: A comparative analytical study
Sayar Kumar Munshi, Pares Bandyopadhyay, Krishnendu Chakrabarti
Nilratan Sircar Medical College and Hospital (NRSMCH), Kolkata, West Bengal
Introduction & Objectives: The purpose of the study is to evaluate and compare the effect of off-pump and on-pump coronary artery bypass grafting (CABG) on the cardiovascular functioning in the immediate and early post-operative period and to compare it with the preoperative status.
Materials & Methods: The study population included a total of 106 patients who were operated for CABG from January 2015 to June 2016. The patients with age <40 or >80 years, with ejection fraction <30%, with serum creatinine level >2 mg/dl or patients undergoing redo operation were eliminated from the study. Among the total number of patients studied, 75 patients were operated for off-pump CABG and rest were operated under cardiopulmonary bypass. Hemodynamic parameters including heart-rate, cardiac output, cardiac index, stroke volume, systemic vascular resistance index and left ventricular stroke work index were measured before surgery as well as 1, 4 and 20 hours after surgery. Troponin-T and creatine kinase-MB were also measured in blood sample at the same interval.
Results: There was no significant difference in age, sex, ejection fraction and number of grafts between the groups. Cardiac output, cardiac index, stroke volume and left ventricular stroke work index were higher after 1 and 4 hours of surgery in off-pump group than on-pump group. Systemic vascular resistance index was lower after 1 hour of surgery in off-pump patients. Troponin-T and creatine kinase-MB were significantly lower in off-pump group after 1 and 4 hours of surgery than on-pump group.
Conclusions: Immediately after surgery there is better cardiovascular function and less release of markers of myocardial damage after off-pump CABG compared to the on-pump CABG group. Time-dependent increase of hemodynamic parameters were also significantly higher in off-pump group than on-pump patients in this period. At 20 hours almost all differences were eliminated.
Aortic Valve cuspal replacement with glutaraldehyde treated autologous pericardium
Vikas Kumar Keshri, Aandrei J Jha
The Mission Hospital, Durgapur, (WB), India.
Background: Severe aortic valve pathology at young age presents the surgeon with options such as replacement of the valve with a mechanical prosthesis or a pulmonary autograft. Both these options have certain limitations. We present a third option of aortic valve repair by cuspal replacement with glutaraldehyde treated autologous pericardium.
Materials and methods: From January 2013 to Dec 2015, 25 patients (14 female, 11 male) underwent aortic valve repair. The mean age was 8 yrs (range, 7-20 yrs). 20 patients were in NYHA class III & IV and 5 in class II but with dilated ventricles. 12 patients had definite history of rheumatic fever, the others were also presumed to be of rheumatic origin. At surgery the diseased cusps were excised and neo aortic cusps were fashioned from glutaraldehyde treated autologous pericardium and stitched onto the true annulus. All three cusps were replaced in 22 patients, two cusps in 1 patient and only one cusp in 2 patients. Warfarin was prescribed for 6 months to maintain INR of 1.5 to 2.0. Patients were followed up with serial echocardiogram at one, six and twelve months.
Results: Intraoperative TEE showed no aortic stenosis (AS) or regurgitation (AR) in 18 patients and trivial to mild AR in 7 patients. Mean peak systolic gradient (PSG) across aortic valve was 12 mm Hg (range, 8-20 mm Hg). There was no in-hospital mortality. Two patients were lost to follow up. Mean follow up was 12 months (range, 3-20 months). 74% patients were in NYHA class I, 22% in class II. Increase in PSG was noted in 3 patients with mean PSG of 26 mm Hg. 4 patients had low moderate AR (mean vena contracta 0.4).
Conclusion: Aortic valve cuspal replacement with glutaraldehyde treated autologous pericardium is a viable alternative to aortic valve replacement in younger patients.
Mitral valve repair in children and young patients with rheumatic heart disease - A series of 270 cases from rural eastern India
Aandrei J Jha, Vikas Kumar Keshri
The Mission Hospital, Durgapur, (WB), India.
Background: Mitral valve (MV) repair has always been the preferred choice over MV replacement as it gives the patient a better lifestyle and is more physiological. However the operation in rheumatic heart disease (RHD) has its challenges.
Materials and Methods: From January 2012 and Dec 2015, 270 patients (116 male, 154 female) underwent MV repair. Mean age at presentation was 12 yrs (range, 5-25 yrs). 88 % of the patients presented in NYHA class III & IV and 12% in class II. Underlying aetiology was RHD in 98% patients and infective endocarditis in 2%. 21% patients had pure mitral regurgitation (MR), 24% had pure mitral stenosis (MS) and 55% had mixed lesions. Reparative methods used were ring annuloplasty 89 %, sub-valvular release and fenestration 90% , PML augmentation 21% , commisurotomy 75%, cuspal thinning 35%, chordal shortening 20%, AML augmentation 10% , quadrangular resection 15%, chordal transfer 10%, neo-chordae construction 2%. Patients were followed up with serial echocardiogram at one, six and twelve months.
Results: Intraoperative TEE showed no MR in 62%, trivial to mild MR in 35%, low moderate MR in 3% patients. The gradient across the MV following repair was 3-7 mm Hg. 30 days mortality was 2%. Out of the 5 deaths two were secondary to complications of infective endocarditis, one due to refractory heart failure and two due to sepsis. Mean follow up was 14 months (range, 3-30 months). 68% patients were in NYHA class I, 28% were in class II and 3% patients had class III and IV symptoms. 6 patients required repeat surgical intervention of which one was successfully repaired with chordal transfer and other 5 required MV replacements.
Conclusion: With the concern of poor patient compliance in rural population mitral valve repair is practical, feasible and reproducible with acceptable results.
Carotid Aneurysm after stenting: a dreadful situation & its management
Asit Baran Adhikary, Saha H, Ranjan R, Bhandari S, Saha SK, Adhikary N, Adhikary S
Bangabandhu Sheikh Mujib Medical University (BSMMU)
Introduction: Carotid artery dissection followed by aneurysm formation is a rare but important complication of Carotid stenting. In this study 7 patients with carotid Aneurysm after stenting were treated surgically.
Materials and Methods: The study period was from January 2014 to September 2016. A total of 7 consecutive patients were selected for surgical management. All these 7 patients were suffered from huge swelling & severe pain over neck, vertigo, headache, signs of facial palsy such as deviation of angle of mouth, unable to close the affected side’s eyelid, slurred speech etc. All patient developed this aneurysm within the period of 6 months of carotid stenting. Carotid angiogram was done routinely to confirm the diagnosis and to see the extent of the lesion. Surgical procedure: Under GA neck was opened. Both end of aneurysm was identified, heparinized and then after 5 minutes’ vascular clamps were applied. Aneurysmal sac was opened and occluded stent with atheroma was removed. Then a 5-mm interposition PTFE graft was anastomosed end to end with 6-0 prolene. In all the 7 cases, proximal anastomosis was done in common carotid artery out of which in right side 2 distal anastomoses were in internal carotid artery & 2 just before the bifurcation, in left sided case distal anastomosis were in common carotid artery just before the bifurcation. All Patients were discharged from hospital on 5th POD.
Results: Post-operatively all the pre-operative symptoms were improved. Carotid duplex was done on 4th POD & after 3 months in every patient which showed excellent flow through graft. No Major complication or death was recorder during the follow-up period.
Conclusion: Surgical correction of carotid aneurysm after stenting is a safe and effective modality of treatment but prompt decision and meticulous dissection with proper stitching is needed for good result.
Total anomalous systemic venous drainage – Management and Outcome in Six Patients.
Chinna swamy Reddy
Narayana Institute of Cardiac Sciences
Introduction: Total anomalous systemic venous return is a very rare anomaly, where superior venous cava, inferior vena cava and coronary sinus drain its left atrium. This condition requires the presence of a left – to – right shunt for survival. Atrial septal defect, patent ductus arteriosus or ventricular septal defect to allow the systemic venous return to reach the pulmonary circulation.
Methods: Six patients were operated between November 2012 to August 2016. Diagnosis was made by echo / CT angio / MRI / Cath studies. The youngest patient was 5years and oldest was 18 years. Four were females and two was male, five patients underwent re-routing of TASVC to right atrium with small 4mm fenestration in the intra atrial baffle and one patient had BD Glenn shunt.
Results: There was no in hospital mortality. All patients recovered well except for the need for increased duration of inotrophic support. One oldest patient had supraventricular tachycardia and treated with antiarrythmic drugs and same patient was readmitted a year later for complete heart block requiring permanent pacemaker implantation. Mean follow up of 28months. All patient were in NYHA class I except one patient who had BDG who was in NYHA class II symptoms. Echo evaluation showed good biventricular function with good RV size. Patient with Ebstein anomaly had moderate TR and small RV cavity.
Conclusion: Total anomalous systemic venous drainage is a infrequent condition and can exist in multiple different forms. Although it remains an uncommon form of cyanotic CHD is should he considered in the differential diagnosis of hypoxemia. Total anomalous systemic venous drainage has been reported in all age ranges from neonates to adults, Review of literature revealed a total of approximately twenty supported cases with diagnosis attained from a combination of contrast Echo cardiography and angiography. Surgical interventions is guided by associated cardiac morphology. In the presence of isolated Total anomalous systemic venous drainage atrial septation with appropriate routing of veins orifice. In the presence of associated extreme ventricular imbalance, a univentricular pathway may need to the resorted to.
ROSS Procedure- Our Experience
Cinnaswamy Reddy
Narayana Institute Of Cardiac Sciences
Introduction: ROSS procedure has become established as on appropriate method for aortic valve replacement in children and young adults. In 1967, Donald ROSS developed native pulmonary valve autograft for aortic valve replacement in turn replacing the pulmonary valve with a homograft. Pulmonary autograft uses live tissue from the patient’s own pulmonary valve. This means the valve grows as the patient grows and can function indefinitely. More over patient do not need permanent anticoagulation. Pulmonary autograft permits central seminal flow and improves hemodynamics performance so that previous dilation and ventricular hypertrophy recede in most patients.
Methods: Over 5 years period from June 2011 to August 2016, 24 patients underwent the ROSS procedure. The medium age was 12.2 years (1-22years) of which 15were males and 9 were females. The main indications were: Aortic regurgitation in 13 patients; aortic stenosis in 7 patients and mixed aortic valve disease in 4 patients. Fourteen patients had previously undergone balloon dilatation of aortic valve.
Results: There have been no deaths reported in this series. Over a median follow up period of 28 months there have been no re-operations for repair of autograft leak. All patients were in NYHA functional class I except two patients were in NYHA class II. One of the patient had severe neo aortic regurgitation with moderate MR who underwent MV Repair and AVR( St Judes Bi leaflet prosthetic valve). The other patient had severe obstruction of homograft in pulmonary position due to dense calcification requiring re-operation.
Conclusion: The ROSS procedure is a complex aortic valve replacement used with great success in patients with congenital and acquired etiologies. Among possible complications found at follow up was autograft in sufficiency and progressive homograft stenosis. Young children can be expected to out grow their homograft. Re-operation to replace the pulmonary homograft is a relatively un complicated procedure and can be accomplished with low mortality. Despite the increased technical complexity, the ROSS procedure can be performed safely in both paediatric and adult population with satisfactory mid term results of the ROSS procedure.
30 day Readmission Post Cardiac Surgery
Vinay Malhotra, OP Yadava, Vikas Ahlawat, Anirban Kundu, Amita Yadav, Vinod Sharma
National Heart Institute
Objective: To identify causes of readmission post cardiac surgery and its impact on outcomes.
Methods: A retrospective analysis of 30 day readmission over the last 5 years.
Results: 50 out of 2653 patients were readmitted within 1 month of discharge (1.8%) (off pump coronary artery bypass grafting-40/1852-2.15% ; valvular-8/525-1.52%; congenital- 2/276-0.72%). The presenting complaints (cardiac -23/50; non cardiac 27/50) were breathing difficulty (34%), sternal wound related complications (24%), gastroenteritis (14%) and chest pain (12%). In these patients the average hospital stay during the first hospitalisation was 9 days (range 6-22) compared to 6 days in regular patients. The average hospital stay during readmission phase was 6.5 days (range 1-36) with 60% readmitted within first week. Out of 12 patients who were readmitted with sternal wound related complications, 7 patients presented within first week with 3 requiring omentoplasty (42.8%) as against 3 out of 5 requiring omentoplasty (60%) who presented after 1 week of discharge. This suggests early presentation requires less invasive procedures for management. Among 17 patients readmitted for breathing difficulty, 9 were admitted in first week. Pleural effusion was detected in 3 of them (33.3%) and their mean hospital stay was 2.5 days. Compared to this, 8 patients were readmitted more than 1 week after discharge. Pleural effusion was detected in 3 (37.5%) and 2 patients (25%) diagnosed as tamponade. The average stay was 4.5 days. Overall 5 patients (10%) had rhythm abnormalities with atrial fibrillation among 4 of them. There was no mortality reported during readmission phase at our institute.
Conclusion: Cardiopulmonary bypass does not increase readmission rate. Prolonged first hospitalisation predisposes to readmission. Early readmission with prompt intervention leads to better prognosis.
Changing trends in reoperative coronary artery bypass grafting: a 18 year study
Sudhanshu Singh, Lokeswara Rao Sajja , Gopichand Mannam, Satyendranath Paturi
Star Hopsitals, Road No.10, Banjara Hills, Hyderabad- 500034
Introduction & Objectives: Currently a fewer patients undergo re-operative coronary artery bypass grafting (CABG) for recurrent coronary artery disease (CAD). The present study was proposed to analyze the prevalence of redo CABG and prior percutaneous coronary interventions (PCI) in patients with recurrent CAD and the early outcomes of redo CABG.
Patients & Methods: Data on demographics, preoperative risk factors and early postoperative outcomes were collected from the institutional database for 222 consecutive patients undergoing redo CABG from January 1998 through July 2016. Patients were divided into two groups based on the period of performance of redo CABG. Group 1: January 1998 through December 2004 (n=114) and group 2: January 2005 through July 2016 (n= 108). Redo CABG was performed using on-pump technique in 163 patients (group 1:107 patients and group 2:56 patients) and off-technique in 59 patients (group 1:7 patients and group 2: 52 patients). We have analyzed the trends and early outcomes of redo CABG.
Results: Prevalence of redo CABG decreased from 4.6% in group 1 to 1.24% in group 2 (P= 0.000). A significant increase in the prevalence of PCI prior to redo CABG was observed (10.5% in group 1 to 33.3% in group 2 p= 0.000). Internal thoracic artery graft used was more in group 1 than in group 2 (71.9% vs 53.35% p=0.035). The number of patients with advanced age, left ventricular dysfunction and renal insufficiency were higher in group 2. There is no statistically significant difference in the hospital mortality between the two groups (6 patients vs 2 patients p= 0.281 ).
Conclusions: There is a declining trend in the number of patients undergoing redo coronary artery bypass graft surgery. In spite of high incidence of co-morbidities in the latter part of the study (group 2) no increase in the operative mortality was observed.
Obstruction of Mechanical heart valve prostheses: Our experience
Nikhil Pachpande
National Heart Institute
Introduction: Prosthetic valve obstruction (PVO) is a life-threatening complication. We reviewed our experience regarding incidence, risk factors and treatment strategies of this complication.
Methods: The data of 14 patients who presented with PVO was analysed retrospectively from Oct 2010- Oct 2016.
Results: Of these 6 were operated in our institute and 8 at other centres. Mitral valve was obstructed in 9 and 5 involved Aortic valve. The mean time interval from implantation to obstruction was 118 months (MV-90, AV-152). Onset of symptoms was acute in 50% (n-7; MV-6, AV-1), sub-acute in 35% (n-5; MV-3, AV-2) and chronic in 14% (n-2; MV-1, AV-1). The most frequent presentation was severe CHF in 42% (n-6), 14% had oliguria (n-2) and 14% had multiorgan failure (n-2). On presentation, PT-INR was <2.5 in 84% (n-12). All had mechanical disc type prosthesis. 92% had bileaflet prosthesis (n-13; MV-8, AV-5) and 7% single leaflet (AV-1). On ECHO, single leaflet obstruction was found in 42% (MV-5, AV-1) and bileaflet in 58% (MV-4, AV-4). Pannus formation was seen in 4, 1 diagnosed preoperatively (operated) and 3 intraoperatively. In MV, Chordal preservation was done in 44% at primary surgery (Partial AML and full PML-22%, basal Chordae-22%). Before thrombolysis, peak Transvalvular gradient ranged from 22-58 mm Hg for MV and 70-108 for AV, which decreased to 6-32 and 48-77 mm Hg respectively. Reoperation was done in 28% (MV-3, AV-1). Mean ICU stay was 4.14 days while total hospital stay was 6.5 days. Total in-hospital mortality was 21% (n-3). 2 died due to multiorgan failure and 1 sudden death presumably due to total obstruction of AV.
Conclusion: Inadequate anticoagulation is the most important factor for pathogenesis of prosthetic valve PVO. They respond well to thrombolysis. Obstruction due to pannus requires reoperation.
Minimal invasive approach for intracardiac repair of Tetralogy of fallot
Chirag Doshi, Manish Hinduja, Vivek Wadhawa
U N Mehta Institute of Cardiology and Research Centre
Introduction and Objective: Median sternotomy has been the standard approach for intracardiac repair of patients with tetralogy of fallot. In the era of minimal invasive surgery, left anterior thoracotomy was assessed as an alternative approach for the same procedure.
Materials and Methods: From January 2014 to October 2016, 26 patients with tetralogy of fallot underwent intracardiac repair via a short incision left anterior thoracotomy and minimal invasive cannulation. 16 patients were children and 10 were adult. The average age was 7.4 +/- 2.8 years (2 - 32 years). The average weight was 18.6 +/- 4.6 kg(10 - 67 kg). Patients were selected based on their favourable surgical anatomy and patients with associated cardiac lesions were excluded. Skin incisions were as long as 5 cm. Intraoperative and post operative parameters were studied.
Results: Mean CPB time was 88 min (70-134 min). 10 patients were extubated within 2 hours of surgery. Cosmetic results were very good. There was one mortality due to intractable ventricular arrhythmia. Post operative hemodynamics, need for inotropic support, drain output and ICU stay were similar to patients routinely operated via median sternotomy.
Conclusion: Intracardiac repair for tetralogy of fallot through left anterior thoracotomy is a safe, effective and cosmetically better alternative to same surgery via median sternotomy.
Influence of Diabetes Mellitus in women undergoing CABG
Shylesh Kunnanattil, Sweta R, Madhu Sankar N, Kulasekharan M, Cherian KM
Frontier Life Line Hospital, Chennai
Background: Female gender has been considered as a risk factor for CABG. This single centre study aim at evaluating the influence of diabetes mellitus as a peri-operative risk factor in women undergoing CABG.
Material and Methods: Retrospective study including all women patients undergoing CABG during the period January 2014 to December 2015. The patients were divided two groups. 78 patients were diabetic (Group I) and 82 patients were non diabetic (Group II). The parameters analysed include presence of risk factors like hypertension, renal disease, no of vessels affected, previous PTCA, Ejection Fraction, presence of RWMA, menopausal status, use of LIMA, re-exploration, units of blood transfused, use of IABP, mean ICU stay, mean hospital stay, post operative renal dysfunction, post operative cerebrovascular event and hospital mortality. Patients with previous cardiac surgery or concomitant cardiac procedure have been excluded from the study. Patients with critical preoperative state, has been excluded. The outcome in diabetic group was compared to non diabetic group.
Result: A total of 160 patients fulfilling the inclusion criteria of this study underwent isolated CABG during the study period. Mean age was 58.77 +/- 7.8 years (Range 41-81 years). 13 patients had previous PTCA. 2 patients died in the hospital (1 in each group). There was no late mortality. The incidence of post operative renal dysfunction is marginally higher in Diabetic patients.
Conclusion: Diabetic women undergoing CABG in the modern era have similar outcomes compared to non diabetic women in the study group.
Total arterial multivessel MIDCAB
Manish Hinduja, Chirag Doshi, Vivek Wadhawa
U N Mehta Institute of Cardiology and Research Centre
Objective: In current era of cardiac surgery, minimal invasive coronary artery bypass (MIDCAB) plays an important and challenging role. Also MIDCAB with bilateral internal thoracic conduits or total arterial grafts is the best option for patients with coronary artery disease who are high risk for sternotomy. We evaluated 108 such selected patients who underwent minimally invasive multivessel total arterial off pump anaortic CABG through left anterolateral thoracotomy.
Material &Methods: The procedure was performed using 4-8 cm left anterolateral thoracotomy incision. LIMA harvested in every patient, RIMA or radial artery used as second conduit. LIMA RIMA Y, or LIMA -RADIAL Y was made to accomplish multivessel total arterial bypass grafting. All intraoperative (hemodynamics and requirement of inotropic support, perioperative blood transfusion ) and post-operative data (bleeding, wound infection, pain score, ICU stay, duration of mechanical ventilation, arrhythmias, perioperative MI, pleural effusion, need for IABP support, and post operative patient satisfaction index) were collected and evaluated. Post-operative graft patency was checked in every patient by CT coronary angiography before discharge.
Results: Multivessel total arterial CABG was accomplished in all selected individuals. There was no mortality or wound infection. Re-exploration was done in one patient for bleeding. In two patients saphenous vein was used to graft LAD and LIMA used to graft diagonal as LIMA length was not adequate to graft distal LAD. In one individual conversion to sternotomy and CPB was required due to unstable hemodynamics. Muscle healing of anterolateral thoracotomy was faster as compared to bone healing of conventional sternotomy incision.
Conclusion: With conventional immobilization techniques and instruments multivessel, total arterial MIDCAB can be accomplished safely in selected individuals. RIMA can be harvested in long standing diabetic patients with no concern for sternal wound healing. Muscle healing of anterolateral thoracotomy is faster as compared to bone healing of conventional sternotomy and patients are back to normal life earlier.
Aortic dissection repair – good results are possible with attention to detail- a case series
Vasudev B Pai, Nikhil Nandineni, S Ganesh Kamath
Kasturba Medical College, Manipal University, Manipal
Introduction & Objectives: Type A dissection repair still carries a high mortality even in the best of centres. Recommendations for emergency repair have been described with deep hypothermia and circulatory arrest if needed. We describe our series and the lessons we have learnt from them.
Materials & Methods: All patients who underwent surgery for type A dissection repair from 2013 to 2016 were studied. Their operative details and postoperative course are summarised.
Results: 7 patients underwent surgical treatment for aortic dissection. Their ages ranged from 35 to 68 years and 4 were females and 3 were males. All the patients were taken up for emergency dissection repair. 2 patients underwent aortic root replacement and 2 underwent aortic valve replacement with interposition grafting of the aorta and 3 patients needed only aortic interposition grafting. Average bypass time was 328 minutes with a cross clamp time of 192 mins. 2 patients did not need circulatory arrest and the average circulatory arrest time for the 5 patients was 46 minutes. All the patients had Teflon sandwich patch repair of the aorta. One patient had previous heart surgery of mitral valve repair a few years back; one patient had a recent PCI and one patient was detected with side biting clamp injury during beating heart surgery. All the patients were hypertensive. Average ICU stay was 7 days and postoperative stay was 17 days. One patient developed a stroke postoperatively and one developed non dialysis dependant renal failure postoperatively.
Conclusion: Repair for aortic dissection has high mortality as the surgery is long and demanding on very poor quality tissues. Attention to detail during the operation and good postoperative care are crucial to achieving good results.
Successful Submitral Left Ventricular Aneurysm Repair – A Case Series
Ashish Rayate, G Ramasubrahmanyam, G Nagasaina Rao, CR VijayaMohan, Himani Shrivastava, Togiti Sushanth, T Vamshidhar
CARE Hospitals, Banjara Hills, Hyderabad
Introduction &Objectives: Submitral aneurysm is a rare cardiac pathology seen mainly in African population, with less incidence in Indian population. Etiology can be congenital defect in fibrous annulus of posterior mitral leaflet and/or inflammatory conditions like tubercular pericarditis, takayasu arteritis etc. Here we present a case series of five patients who underwent Submitral aneurysm repair with mitral valve replacement with excellent results.
Materials & Methods: From April 2007 to September 2016, we treated 5 patients (3 males, 2 females) of Submitral left ventricular aneurysm, whose mean age was 34 years. One patient had moderate mitral regurgitation, 4 patients had severe mitral regurgitation. Three patients had aneurysms with multiple necks; two of them had extension of aneurysm into left atrium. Posterior annulus of mitral valve was found to be distorted in all the patients. Diagnosis was made by echocardiography. Coronary angiography was normal for all the patients. In all cases, aneurysm was excised and mouth of the sac closed with treated autologous pericardial patch. Mitral valve was replaced with mechanical valve in all the patients. Regular follow-up was done with periodic echocardiography evaluation.
Results: Hospital stay for all the patients was uneventful with no early or late mortality. All the patients were discharged in a stable condition. There was no residual MR or residual aneurysmal sac for any patient on follow-up evaluation.
Conclusions: Submitral aneurysm is a rare condition. Offering an aneurysm repair along with Mitral Valve Replacement is a good strategy in case of distorted annulus for long term benefits as the predisposing etiologies can lead to recurrence. Understanding the relations of aneurysm, identification of additional aneurysm necks, adequate closure of aneurysm and addressing the mitral regurgitation is the key to successful surgical repair.
Post MI VSD-Early Surgery is the key
A Kapoor, O P Yadava, A Kundu, V Ahlawat, A Yadav, A Prakash, V Sharma
National Heart Institute
Objective: Institutional experience of post MI VSD repair with or without CABG (2010-2016).
Methods: Retrospective analysis of clinical data was done. 16 patients including 5 females were analysed. Mean age was 67.06 years. 10 patients presented with anterior & 6 with posterior VSD. 12 patients were in cardiogenic shock. Intraaortic balloon pump was inserted in 12 patients preoperatively. 7 patients were diabetic, 8 patients had prior history of coronary artery disease, 5 were hypertensive, 6 were smokers, 2 were thrombolysed. Coronary angiography was done in all patients, of which 8 had SVD, 5 DVD and 3 TVD. 8 underwent concomitant CABG (2 diagonal, 2 distal RCA, 2 PDA, 2 LAD). Operative approach was median sternotomy, bicaval cannulation, cold blood cardioplegia, VSD closure with Dacron patch using pledgetted prolene sutures & ventriculotomy closure with 3-0 prolene over Teflon strips. 1 patient underwent LV aneurysmectomy.
Results: 2 patients died in hospital both of which had anterior VSD. Of these 1 patient underwent concomitant CABG. There were no intraoperative deaths. 4 patients had residual shunt. Mean ACC time with CABG was 86.75 minutes and without CABG, 64.37 minutes. Mean ICU and hospital stay was 7 and 15 days, respectively. IABP was removed after average of 48 hours. Early era and late era mean period between MI & VSD detection was 5.2 days and 4.9 days; & from VSD detection to surgery, 45.6 hours and 19.5 hours, respectively. Postoperatively 1 patient who underwent CABG had renal failure and sepsis. 1 patient died of coagulopathy on POD zero, another succumbed to ventricular arrhythmias on POD 9.
Conclusion: In the current era, viewing abysmal result of medical management patient to be taken early for surgery including posterior VSD.
Size of Patent Ductus Arteriosus - A determining factor for the modality of surgical treatment
Menander M, Uday Jadhav, D V Kulkarni, Kamlesh Jain
Seth G S Medical College and KEM Hospital
Objective: Patent Ductus Arteriosus (PDA) is one of the commonest acyanotic congenital heart disease. Surgical closure is done when medical management fails. Simple ligation of PDA has been shown to have high recurrence rate. Operative technique either direct ligation or modified division and suturing technique was based on the size of PDA at pulmonary end. A study was conducted to assess the type of surgical technique to be followed.
Materials and methods: 30 cases of PDA were studied from 2012 – 2015. All patients were operated with limited thoracotomy. Of which, 10 were taken for division and suturing and 20 underwent ligation. Size of PDA at pulmonary artery end was the determinant in deciding the type of technique. 5 or more than 5 mm was considered for division and suturing. Less than 5 mm was considered for ligation. 40% of the patients were females. The ages ranged from 12 days to 14 months with youngest weighing 650 grams.
Results: There were no immediate or late postoperative deaths. There were no intra-operative or post-operative complications. The mean hospital stay was 3 days. Repeat ECHO after 3 months did not show recanalization in either group.
Conclusion: Surgical closure of PDA is a safe and effective technique. Division and suturing of PDA can be done safely for PDA more than 5 mm. However, larger, long follow up and a multi centric study is required to set up a definitive guideline.
Midterm outcomes of superior septal approach for mitral valve repair/replacement
Bharath Kumar M, Ejaz Ahmed Sheriff, Rajan S, Sivakumar Pandian, Karthik Raman, Sumit Rawal, Anjit Prakash, Arun Singh, Swaminathan, Naga Sai Lakshmi
The Madras Medical Mission Hospital
Introduction and Objectives: Good exposure of the mitral apparatus is mandatory for mitral valve (MV) procedure. The aim of our study was to evaluate outcomes and complications if any associated with this approach.
Materials and Methods: Between January 2011 and Decemeber 2015 , 34 patients (22 male, 12 female) underwent MV procedure through superior septal approach. Nine patients underwent MV replacement, 2 patients underwent MV repair, 8 patients underwent double valve replacement, 15 patients underwent MVR and tricuspid valve repair. Eleven among these 34 patients underwent redo procedure. The total follow up period was 32.25±2.18 patient-years. The data was collected retrospectively from the hospital data base.
Results:Post operative complications were re-operation for bleeding 2.94%, renal failure 5.88%, deep sternal wound infection 2.94%. Four patients (11.6%) needed prolonged ventilation (≥48 hours). Three among 20 patients (15%) who were in sinus rhythm preoperatively developed new onset arrhythmia. One patient (2.94%) had ventricular tachycardia (VT), 2 Patients(5.88%) had atrial fibrillation (AF). The in hospital mortality was 20.58%. One patient (2.94%) died of VT and 2 patients (5.88%) died of low cardiac output. At the end of follow up 2 patients (5.88%) had AF. One patient (2.94%) had severe valvular leak.
Conclusion: The superior septal approach provides good exposure to MV and subvalvular apparatus. From the limited follow up period definitive conclusions could not be drawn on the long term outcomes of this approach. However this approach appears to have no significant effect on post heart rhythm and associated complications.
Warm perfusion: A Novel mode of myocardial preservation in Atrial Septal Defects. Prospective study
Syed Wahid, G N Lone, Shadab Nabi, Farooq A Ganie, Nadim Kawoosa, A M Dar
Departmental/Institutional Affiliation: CardioVascular and Thoracic Surgery, Sher-i- Kashmir Institute of Medical Sciences (SKIMS),Srinagar-190 011, Kashmir (India).
Objective: the primary aim of this study was to evaluate the effect of continuous antegrade perfusion on an empty beating heart with normothermic blood to avid myocardial ischemia and the detrimental effects of cardioplegic arrest on the myocardium.
Patients and methods: From September 2011 to November 2016, 25 patients underwent ASD repair on beating heart with continuous antegrade normothermic blood perfusion with aortic cross clamp on. Another group of 25 patients were subjected to ASD repair on arrested heart. Patients’ age and size of defect were similar in both the groups. Preoperative diagnosis was established by 2D echo and colour Doppler study. The normothermic perfusion was kept at 4-5 ml/kg-BW/min in the beating heart group. CPK –MB and Troponin –I were done after 6 hours in all the patients.
Results: The mean aortic cross clamp time in the beating heart and arrested heart group were 20.72±7.08 and 30.56±5.83 minutes respectively. The mean bypass time in the beating heart and arrested heart group were 32.80±7.48 and 47.12±6.28 minutes respectively. There were no differences in blood products transfused. ICU and hospital stay were significantly less in beating heart group. There was no hospital mortality in either group. There was no statistically significant difference in CPK-MB and Troponin –I levels between the 2 groups. No major complications were observed during hospital stay. Post operative echocardiography showed normal LV function and no residual shunt in either group. The ejection fraction and the incidence of postoperative arrhythmias were similar in both groups.
Conclusion: Beating heart surgery using normothermic blood is a safe and effective technique for the closure of ostium secundum ASD which is substantiated by clinical and biochemical assessment.
Surgical Management of Embolized Cardiac Devices as an Emergency: Experience at SKIMS, Srinagar, Kashmir.
Nadeem--ul- Nazeer Kawoosa, G N Lone, A M Dar, A G Ahangar, Farooq A Ganie, Syed Wahid
Departmental/Institutional Affiliation: CardioVascular and Thoracic Surgery, Sher-i- Kashmir Institute of Medical Sciences (SKIMS),Srinagar-190 011, Kashmir (India).
Background: We analyzed our experience with emergent surgical management of displaced/impacted cardiac devices after failure during attempts to occlude the defects by transcatheter route during childhood or thereafter.
Methods: 5 of 185 patients who underwent device closure of congenital heart defects during the period from November, 2000 to Oct 2016 were shifted to OR for surgical management and operated under cardiopulmonary bypass/standby cardiopulmonary bypass. Their diagnosis, selection for device closure and surgical management techniques are discussed. Results: 2 of 5 patients had failed device closure of patent ductus arteriosus whose device had embolized to left pulmonary artery. Both had successful retrieval without cardiopulmonary bypass through left thoracotomy. 2 patients who had undergone device closure for atrial septal defect, had device impacted in right ventricular apex and right ventricular outflow tract respectively. Both of them were successfully managed by surgical removal through right atrial approach on beating heart cardiopulmonary bypass. 5th patient who was a 30 years old male patient was presumed to have a muscular ventricular septal defect. An attempt was made to close the defect by the Amplaz device but it embolized to left pulmonary artery. He was proved to have a RSOV into right ventricular outflow tract and a large subpulmonic ventricular defect. Device had embolized to left pulmonary artery which had crated dissection of the artery. Device was successfully removed on cardiopulmonary bypass with arrested heart. VSD and RSOV were repaired by double patch technique through combined transpulmonary-transaortic and transatrial approach. Dissected left pulmonary artery was repaired. No mortality was observed during the study.
Conclusions: Inspite of many advantages with nonsurgical closure of congenital cardiac defects, embolization of devices continues to remain the major challenge for an interventionist.
Single Stage Minimally Invasive Approach of Lower Partial Sternotomy (MILPS) for Abdomino-Thoracic Hydatidosis: Single Surgeon Experience
Haroon Rashid, G N Lone, Muzaffar Ali Khan, Farooq Ah Ganie, Mohsin Mushtaq, Syed Wahid
Departmental/Institutional Affiliation: CardioVascular and Thoracic Surgery, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Srinagar-190 011, Kashmir (India)
Background: Systemic hydatid cystic disease although rarely encountered, requires multi staged approach and poses a challenge to a surgeon in terms of accessibility. The objective of the study was to find a feasible alternative approach to conventional multi staged approach.
Methods: 27 of 62 patients with abdominothoracic hydatid disease selected out of 484 patients with pulmonary hydatid disease were subjected to single-staged lower ministernotomy. Primary diagnostic tools were chest radiography, ultrasonography, computer tomography and serology. Preferable mode of management of hydatid cysts was enucleation with deroofing, with no or partial capitonnage without any intracavitory drainage.
Results: 62 of 484 (12.80%) patients had concurrent hepatic and pulmonary hydatid cysts. 27of 62 patients were selected for lower ministernotomy. Male: female ratio was 1: 1 and mean age was 25.10. Mean operative time was 85 minutes. Air leak was the commonest postoperative complication and cause of morbidity (22.2%). No patient had significant biliary leakage. Mean hospital stay was 7.4 days. Post-operative recovery was prompt. 1 of 27 patients died (3.7%) due to late onset, sudden and unexplained hemothorax. Overall results were encouraging.
Conclusion: This approach is expeditious, economical, convenient, minimally invasive; less painful and cosmetically appealing. This approach although requiring a learning curve, can be an excellent alternative to staged modalities if applied to properly selected patients.
Role of trans hiatal oesophagectomy in carcinoma oesophagus-A retrospective pilot study
Nadeem-ul- Nazeer, G N Lone, M A Bhat, A M Dar, Shyam Singh, A G Ahangar, Farooq A Ganie, Zubair Ashraf, Syed Wahid, Asrar Qadri, Mohsin Mushtaq, Mohd Amin, Feroz Ahmad, Haroon Rashid
Sher i Kashmir Institute of Medical Sciences, Srinagar.
Background: Patients with histopathology proved oesophageal carcinoma were studied retrospectively to determine the role of trans-hiatal oesophagastrectomy and overall profile of the patients.
Methods: 1432 patients documented to have esophageal carcinoma underwent transhiatal oeosphagectomy by a team approach with or without neoadjuvant chemotherapy with cervical oesophagogastrostomy after detailed workup and preparative measures.
Results: A total of 1432 patients underwent transthoracic esophagectomy. The duration of symptoms were less than three months. Around 56% patients had carcinoma of the middle-third of the thoracic esophagus,42% patients had carcinoma of lower-third of the thoracic oesophagus while 2% had upper thoracic lesions. Most of our patients had squamous cell carcinoma (59 %) followed by adenocarcinoma (38%). Average blood loss in the series was 650 mls. Perioperative and postoperative morbidity was studied. The median follow-up was 4.3 years. Estimated 3-year disease free survival (DFS) was 30.25 %, whereas the 3-year overall survival (OS) was 40.25%. Also, the estimated 5-year DFS rates was 20.65%, whereas the 5-year OS rate was 28.45%.
Conclusion: Trans-hiatal oesophagectomy is a procedure suitable for patients with carcinoma of the oesophagus and affords a surgical option at an "acceptable price" among carefully selected patients with carcinoma of the oesophagus.
Risk categorisation for surgical repair of double aortic arch – data from a 10-year cohort
Arun Beeman
Great Ormond Street Children Hospital, London
Introduction: Persistence of aero digestive symptoms after surgical repair of double aortic arch (DAA) is not uncommon. This retrospective study aims to identify risk factors associated with persistence of symptoms in children undergoing surgical repair of double aortic arch.
Methods: Retrospective study in a single institution between 2005 and 2015. All children who had surgery for true vascular ring due to DAA was included. The factors analysed were symptoms, age at onset of symptoms, diagnostic investigations, associated anomalies, age and weight at surgery, surgical technique and symptoms at follow-up, patency and dominance of the arches, anterior angle subtended at the level of compression and position of descending aorta in relation to the airway. Data was analysed by t-test and anova.
Results: 55 children underwent repair of DAA, with a median age of 8 months (0-201) and weight of 8.2 kilos . Right aortic arch was predominantly dominant. The left arch was atretic distally in 37 children and 6 children had associated aberrant subclavian artery. Airway symptoms were predominant in 51 children while 15 children had oesophageal symptoms. After surgery symptoms persisted beyond three months in 31children. Persistence of oesophageal symptoms was longer than the respiratory symptoms (14 months vs. 12 months, p=0.3). Univariate analysis showed that the arch angle between 45 and 60 was significantly associated with persistence of symptoms. On multivariate analysis, early symptomatic relief was seen in male sex, presentation at a younger age symptoms sans oesophageal compression, absence of chromosomal abnormality and presence of right sided proximal descending thoracic aorta.
Conclusion: In surgical repair of DAA, the branching pattern and arch angulation of the DAA plays an important role in predicting the persistence of symptoms after repair.
Outcomes Of Right Ventricular Outflow Tract (RVOT) Reconstruction Using Handsewn Valved Conduits
R Jaiganesh, Mubeena, Roy Varghese, Rajan Sethurathnam
The Madras Medical Mission, Chennai
Aim: To study the outcomes of RVOT reconstruction using hand sewn bovine pericardial/PTFE (polytetra fluoroethylene) valved conduits in our institution for a period of 2years Background: The ideal choice for a valved conduit has yet to be found. Although homograft conduits remain the popular choice, certain disadvantages such as lack of availability, requirement of sterilisation and preservation and late complications due to degenerative processes and calcifications- have led us to search for other alternatives.
Methods: Between 2015-2016,a total of 18 children underwent RV-PA conduit using hand sewn conduits. The data was collected from medical records department and analysed for variables like age, sex, diagnosis, preop echo details, etc. The intraoperative details with any complications in the immediate and late postoperative course are documented. These patients were followed up in the 3rd month after surgery and yearly once thereafter.
Results: All the surgical procedures are successful with no mortality. The mean age group was 45.9months with 61%(n=11) males. The most common diagnosis which required a RV-PA conduit is tetralogy of fallot with pulmonary atresia -55%(n=10),followed by cTGA,truncus arteriosus, DORV+PS, TOF with absent pulmonary valve. In all the patients the conduits were made from bovine pericardium on table according to the body surface area. The valves that were sewn in the conduits were bovine pericardium in 13(72.22%) patients and PTFE in 5(27.77%) patients. The postoperative course was smooth with no interventions. There is no conduit gradient/regurgitation in the postop and followup echo.
Conclusion: Hand sewn conduits offer good results as with homografts. The early outcomes after surgery were satisfactory. Long term followup needed in future for the betterment of its use.
Age related outcome variability after complete atrio-ventricular septal defect repair in small children
Arun Beeman
Great Ormond Street Children Hospital, London
Introduction: While the surgical techniques around repair of complete atrio-ventricular septal defect is standardised, the risks of reoperation or residual regurgitation in relation to timing of surgery is not well profiled. The present study aims to assess specific age and weight related variable outcomes following complete atrio-ventricular septal defect repair.
Methods: Retrospective analysis of 202 children after repair of complete AVSD repair between 2006 and 2015. Follow up data were available for 178 children. End points evaluated include death, presence of at least moderate left or right AV valve regurgitation or reoperation for any residual lesions.
Results: 25 events were noted in 178 children who had complete follow up data. Repair at age less than 3 months had hazard ratio of 3.1 for any events, and risk of reoperation of 10% at 1 year post-repair. Similarly, repair at weight of less than 4 kg had higher risk for any events including death or reoperation at 1 year post-repair (12% higher risk for any events; p = 0.004) including 20% higher cumulative risk for death on actuarial estimate in 10 years.
Conclusions: While the repair of complete AVSD is standardised now, there remains a higher risk for reoperation and cumulative risk for death when operated in small children. This warrants a revised strategy in these small children including consideration towards staged repair, who present very early in life with heart failure.
Evolution of mitral regurgitation in post aortic valve replacement patients
Vijayanand Palanisamy, Karthik Raman, Bharath Kumar, Sumith Rawal, Swaminathan, Arunsingh, Vijay Madhan, Mithun, Sunil, Teja, Shilpa Shree, Naga Sailaskshmi, Vasanthi, Ajit Cherian, Sivakumar Pandiyan, Suresh Kumar
Madras Medical Mission
Objectives: Frequently aortic stenosis (AS) is encountered with mitral regurgitation (MR) either due to primary pathology affecting mitral valve or secondary to AS. Aim of the study is to analyze the evolution of MR in patients undergoing aortic valve replacement (AVR) for calcific AS and to identify the factors which influences the regression/persistence/progression of MR after AVR.
Methodology: From January 2011 to June 2015, 387 patients underwent AVR alone, among which 38 patients were found to have calcific AS as primary lesion, with associated grade2+ MR, constitutes the study population. 27 patients were associated with grade2+ Aortic regurgitation. Out of 38 patients, 32 patient’s preoperative and postoperative echo and clinical parameters were analyzed for mean follow up of 18.4 months.
Result: Among 32 patients, 27 patients MR regressed to mild grade, 4 patients had persistence of moderate MR, 1 patient had worsening of MR [mean Jet area prep Vs postop -> 5.37Vs2.55, 8.09Vs4.5, 5.57Vs6.73 respectively]. All patient’s functional status improved irrespective of presence of MR. 13 patients with severe left ventricular dysfunction improved drastically among which only one patient had persistence of MR. All patients were in sinus rhythm in preop and during followup. None of them had failure admission/reoperation/late mortality. One patient had PPM whom MR worsened. Among 5 patients with minor chordal rupture to AML, 2patients had persistence of MR.
Conclusion: Not all MR to be addressed at the time of AVR. In our study, presence of PPM& minor chordal rupture have negative effect and sinus rhythm& preoperative poor ejection fraction have positive effect on evolution of MR. In our study, Pulmonary artery pressure, Left atrial size, Left ventricular dimensions doesn’t showed any correlation with persistence/worsening of MR as seen in literature. Depends upon the echo parameters and clinical assessments, patient should be individualised.
A TALE OF HUNDRED CYSTS”’.- A Retrospective analysis of Hundred consecutive cases of pulmonary Hydatid cysts -
Deepak Narayanan A, Roy Gnanamuthu
Christian Medical College Vellore
Aim and objectives: To study the modes of presentation and management of hundred consecutive cases of pulmonary hydatid cysts.
Material and methods: 100 cases of pulmonary hydatid cysts were evaluated pre and post operatively, 56 males and 44 females with a mean age of 34.2 yrs. Age and sex distribution, modes of presentation pre operative investigations, type of surgical procedure performed, post operative complications, post operative length of hospital stay and post operative follow up of all patients were analyzed.
Results: Out of the hundred cases analyzed 56 were females and 44 were males. The most common symptom was recurrent cough (44%) followed by cough with hemoptysis (24%). 83% of patients presented with pulmonary hydatidosis. 16% presented with lung and liver involvement. Lt lower lobe was involved in 33% of disease followed by Rt lower lobe (28%).hydatid cyst excision was done for 50% of cases followed by excision and capittonage in 30% of cases. The mean duration of hospitalisation was 7.2 days. Complications occurred in 15% of patients and prolonged airleak (9%) being the commonest..Patients were followed up for 6 months and recurrence was detected in 2 patients.
Conclusion: Surgery is the main stay in the management of pulmonary hydatid cysts. Lung preserving surgeries should be the preferred approach in all patients.Radical surgeries should be reserved for cases where irreversible lung damage has occurred. Close follow up of patients should be done to diagnose recurrences.
Mediastinitis: incidence, prognosis of early versus late presentation
S Sehrawat, OP Yadava, V Ahlawat, A Kundu, A Yadav, A Prakash, V Sharma
National Heart Institute
Objective: To compare incidence and prognosis of mediastinitis at early and late presentation post cardiac surgery.
Methods: A retrospective observational study of National Heart Institute, New Delhi of patients who developed mediastinitis post surgery from October 2010 to October 2016.
Results: In a cohort of 2653 surgeries (1852 CABG, 525 valvular, 279 congenital), 19 patients (0.7%) developed mediastinitis. Total number of mediastinitis cases were 20 (1 was operated at another hospital). 12 cases (60%) presented early (<15 days post surgery), 8 cases (40%) presented late (after >15 days). Among those presenting early, in 38.5%, culture was sterile and Klebsiella was predominantly isolated in 33%. 6 cases (50%) required omentoplasty, 5 cases (41.7%) required only debridement. Average hospital stay in this group was 19 days. In the late group, Pseudomonas was the predominant organism (37.5%) and 5 cases (62.5%) required either omentoplasty or PM flap closure. Average hospital stay in this group was 41 days.
Conclusions: The incidence of mediastinitis is low (0.7%). Morbidity was lower in patients presenting early. Most common organism responsible for mediastinitis in early group was Klebsiella and Pseudomonas in late group.
Video-assisted thoracoscopic surgery of sliding hiatus hernia- a single Institute experience
Sayar Munshi, Binay K Sarkar
Nil Ratan Sircar Medical college
Introduction and Objectives: Sliding hiatus hernia is associated with laxity of the phrenoesophageal membrane and the cardia of the stomach herniates. Sliding hiatus hernia is diagnosed by barium swallow radiography, endoscopy, or manometry. The gastroesophageal junction becomes incompetent and esophageal acid clearance is compromised in patients with hiatal hernia, which facilitates the development of GERD (gastro-esophageal reflux disease). Majority of these patients with hiatus hernia present with GERD. Because GERD may lead to several complications, Surgery should be considered in patients with refractory symptoms and in patients with complications, such as recurrent bleeding, ulcerations or strictures. We have performed video-assisted thoracoscopic fundoplication in nine patients with symptomatic hiatus hernia which has been described here.
Materials and Methods: From March, 2015 to September, 2016 a total of 9 patients were operated in the department of Cardiovascular and Thoracic Surgery, NRS Medical College & Hospital, Kolkata, West Bengal, India.
Results: We had a total of nine patients (male-3, female-6; age range 28 – 63 years). Video-assisted thoracoscopic fundoplication was done in all cases through 3-4 port technique. Port size ranged from 5mm to 7cm. Hernia size was moderate (2-5cm). Duration of Surgery was from 90-120minutes. All these cases had smooth postoperative recovery. Feeding could be started within 48 hours. All these remained free of symptoms till last follow-up with definite improvement in quality of life.
Conclusion: Thoracoscopic technique using 3-4 ports and 10mm camera was found to be effective and reproducible with minimum morbidity. All patients had significant improvements of symptoms. No recurrence noted till 18 months follow-up (maximum). Long term study is required to see the effectiveness of the procedure in the long run.
Paediatric Heart Transplantation – Our Experience of 33 cases
Anitha Chandrasekhar, Ganapathy Subramaniam, SK Chowdhury, KG Suresh Rao, KR Balakrishnan
Fortis Malar Hospital
Introduction: Paediatric heart transplantation has been established as a lifesaving procedure for children with end stage heart failure either due to cardiomyopathy or congenital heart disease refractory to medical and surgical therapy. We report our experience of 33 cardiac transplantations in children < 18 years.
Methods: We retrospectively analyzed the data of 33 paediatric patients who underwent orthotopic heart transplantation from March 2014 to November 2016. The preoperative, intra-operative and postoperative variables, survival and follow-up data were studied.
Results: Age ranged from 1.4 years to 18 years with a mean age of 10.4 years. There were 12 patients in the age group of 0-10 years and 21 in the 11-18 years age group. The etiology for heart failure was cardiomyopathy in 88% of the patients (n=29) and 4 had congenital heart diseases (12%). A right heart hemodynamic study was done in all patients. The mean pulmonary vascular resistance was 2.7 wood units. 1 patient had IABP, 1 had ECMO support and 2 patients were on temporary LVAD support (CENTRIMAG pump) preoperatively as bridge-to-HTx. 16 patients were on ambulatory Milrinone therapy preoperatively for stabilisation. Donor to recipient body weight ratio was 1.59 ± 0.9 (range 0.67 to 4.42). Bicaval anastomosis was the procedure of choice. Nitric oxide therapy was used in all patients during weaning off cardiopulmonary bypass to prevent right heart failure of the graft. Operative mortality was 4 out of 33 (12%). There were 2 late deaths due to acute events. One year Event free survival is 93.1%. All of the 27 surviving patients are asymptomatic and having a good quality of life.
Conclusion: Heart transplantation is a feasible option for terminally ill paediatric patients. Meticulous pre-operative stabilisation, optimal donor selection, diligent surgical planning and technique, careful postoperative monitoring and rigorous surveillance for infection and rejection are keys to successful outcome.
Improvement in Clinical Outcomes After Treatment of the Vascular Conduit in Coronary Artery Bypass Grafting Surgery
Niket Arora, Sivakumar Pandian, Suresh Kumar, Femy Abraham, Gomathy Jeeva, S Rajan
The Madras Medical Mission
Introduction and objectives: Although arterial grafts are the preferred conduit for CABG surgery, the most widely used conduit is the Saphenous Vein Graft (SVG). However, SVG patency rates remain unacceptably low, impairing clinical outcomes. We investigated a recently approved intraoperative SVG treatment (DuraGraft) and its effects on clinical outcomes in CABG patients.
Materials and methods: Between 4/9/2013 and 31/10/2015, a total of 338pts (age: 47-72) were randomized and underwent CABG with at least one SVG. SVGs were treated with DuraGraft in 122pts (treatment-group) or bathed in autologous heparinized blood in 139pts (control-group) undergoing CABG. Clinical outcomes up to 18±8 months were assessed with particular regards to repeatrevascularization (RR), myocardial-infarction (MI), death, and a composite of all these major adverse cardiac-events (MACE).
Results: The average size of the SVG in treatment group was 4.20 ± 0.5 mm and was 4.3±0.5 mm in the control group. A total of 674 SVGs (291 in the treatment group and 383 in the control group) were included with an average of 2.39 SVGs (treatment) and 2.76 SVGs (control) per CABG. One patient experienced an MI in the treated SVG group which was managed with IABP support. There were no in hospital mortality in either groups. Variable DuraGraft Autologous Blood p=Value n=122 (%) n=139 (%) MI 1 (0.8%) 8 (5.8%) 0.0001* RR 0 (0.0%) 1 (0.7%) 0.0023* Death 0 (0.0%) 0 (0.0%) NS MACE 1 (0.8%) 9 (6.5%) 0.0001*
Conclusion: This study demonstrates that DuraGraft treatment of the vascular conduit during the CABG procedure improves clinical outcomes in CABG patients with regards to perioperative MI, RR and MACE.
A Double Trans Atrial Trans Pulmonary Approach Helps To Preserve Pulmonary Valve Better In Tetralogy Of Fallot
Sudheer Gandrakota, Pooja Shetty, CS Hiremath, Krishna Manohar
Sri Sathya Sai Institute of Higher Medical Sciences , Whitefield, Bangalore
Background: Tetralogy of Fallot (TOF) correction involves various surgical techniques to minimise right ventricular outflow tract (RVOT) enlargement to preserve function of the pulmonary valve and post operative right ventricular dysfunction.
Methods: The retrospective study was conducted in the Department of Cardiothoracic and Vascular Surgery, at Sri Sathya Sai Institute of Higher Medical Sciences, during the period from February 2014 to February 2016 on 141 cases who underwent TOF corrections at a median age of 2 yrs. 126 (89.36 %) patients had perimembranous VSD and 15( 10.63 %) had Doubly Committed VSD. Out of 126 PM VSD cases, 108 ( 85.71 %) had Pulmonary valve preserved and 18(14.28 %) needed Transannular patch (TAP). Out of 15 cases of TOF with Doubly Committed VSD 7 ( 46.6 %) cases had Pulmonary valve preservation and 8(53.33%) cases needed transannular patch.
Results:Post operative ECHO assessment in pulmonary valve preserved cases had nil or mild pulmonary regurgitation. RVOT gradients were less than 20 in 32 ( 22.69 % ) of cases , between 20-40 in 63 (44.68 %) cases and above 40 in 13( 9.21 % ) cases with a maximum gradient of 60.1 (0.7 %)case had small residual shunt and 1(0.7 %) case had moderate shunt. We had 9(6.38 %) mortalities. Follow up evaluation was done to a maximum of 2 years. Re- operation was done in 2 ( 1.41 %) cases. Conclusions: Being aggressive and going in with an open mind in preserving native pulmonary valve in Tetralogy of Fallot repair results in early recovery, avoids free pulmonary regurgitation, prevents right ventricular dilatation or dysfunction and later the need for pulmonary valve replacement.
Pushing boundaries for organ acceptance in paediatric heart and lung transplantation
Arun Beeman, Nagarajan Muthialu
Great Ormond Street Children Hospital, London
Introduction: With the imbalance between donation rates and potential recipients increasing, heart transplant programs increasingly have to use non-ideal organs from so-called “marginal donors”. There has been a welcome increase in overall solid organ donation rates in the UK over the last decade. However, this is largely due to the use of donors after circulatory death (DCD) and older and heavier donors and donors for the smallest recipients remain rare. Other techniques, such as sophisticated analysis of organs prior to retrieval, 2 are being attempted, but only the use of ABO-mismatched transplants has yet to make an impact on numbers of pediatric heart transplants.
Methods: Retrospective analysis of children who underwent heart and lung transplants, where organ acceptance would deviate from conventional acceptance criteria: these include exceeding weight or height for heart or lungs, ABO mismatch transplants for heart (n = 4), heart from donor with ALCAPA (n = 1), DCD donor for lungs and possibly for heart (n = 3 for lungs), suboptimal function for both heart and lungs, and presence of non-metastasizing brain tumours.
Results: The immediate postoperative course of these children is comparable to those, whose organs satisfied the existing donor criteria for acceptance. There was no unusually high need for extra-corporeal support. The early survival is similar.
Conclusion: Widening of donor pool increases the possibility of transplant, thereby reducing waiting list mortality and morbidity. While extended criteria in general is attractive in small numbers, more work needs to be done to ensure organ function is better preserved in this group so also the long term survival. Role of ex-vivo perfusion and DCD donors need to be evaluated in a wider scale for paediatric population.
Rejection after heart transplantation: role of 77 consecutive endomyocardial biopsies in an active heart transplant centre
C Manoras Mathew, Jose Chacko Periappuram, Bhaskar Ranganathan, Kochu Krishnan
LISIE Heart Institute, Cochin
Introduction & Objectives: Heart transplantation is the best treatment for end stage heart failure. Endomyocardial biopsy (EMB) is a gold standard test for transplant rejection. The objective is to discuss our experience of rejection surveillance with EMB.
Materials & Methods: A retrospective analysis of patients who underwent orthotopic heart transplant between 2013 and 2016 was done. EMB’s were done on 1st week, 1st month, 3rd month, 6th month, 1st year, 18th month and 2nd year post transplant. All biopsies were done through the right internal jugular vein. Rejection was graded as per the ISHLT nomenclature (0R- no rejection, 1R- mild rejection, 2R- moderate rejection, 3R- severe rejection and AMR- antibody mediated rejection). The standard immunosuppression included Tacrolimus, Mycophenolate and prednisolone.
Results and Discussion: A total of 19 heart transplants were done. We had three early mortalities (30 day). One year mortality was five. A total of 77 EMB’s were done. 79.2 %( 61) of biopsies did not show any rejection (0R). Mild rejection 1R and moderate rejection 2R were seen in 9 %( 7 each) of these biopsies. Severe rejection (3R) and Antibody mediated rejection (AMR1) was seen only once. ECHO (Echocardiography) was done while patients were admitted for EMB. Patients who had mild to severe forms of rejection did not have any symptoms nor did their ECHO show any major change. This shows the ineffectiveness of ECHO as a surveillance tool. Steroids showed good response in case of rejection. Everolimus was started for one patient who had 3R. Rituximab was given to the patient who had AMR1.
Conclusions: EMB is invasive but quite safe. ECHO is an inferior tool for rejection detection. Steroids have shown exceptional benefit. Change of immunosuppressants may be required. Our experience confirms EMB as an important early marker for surveillance.
Our experience with Reoperations on the aortic root and ascending aorta following previous cardiac surgery
KMukesh, VVBashi, Mohammed Idhrees, Aju Jacob
Institute for Cardiac and Advanced Aortic Disorders (ICAAD),SIMS Hospital,Chennai
Background: First time operations on the aortic root and ascending aorta are performed with relatively low morbidity and mortality. However there is increased risk in reoperations. In this study we reviewed our experience with aortic reoperations over a period of 20 years with the intent of analysing our techniques, perfusion strategies and results.
Methods:From March 1996 through April 2016,118 patients underwent reoperations on the aortic root and ascending aorta following previous cardiac surgery (mean age 42 yrs, male 62%).The previous operations were aortic valve replacement (38),coronary artery bypass grafting(32),mitral valve replacement (20),aortic root replacement(10),ascending aortic replacement(6),and other procedures(12). The reoperations performed were aortic valve replacement(59), aortic root replacement(38) and graft replacement of the ascending aorta(21). Concomitant procedures included arch replacement, coronary artery bypass grafting, mitral valve replacement and tricuspid valve repair. Follow up period ranged from a minimum of 6 months to maximum of 19 years.
Results: The mean cardiopulmonary bypass time was 205 mins (range-180 to 264 mins) and the mean myocardial ischemic time was 132 mins. Proximal arch/ascending aortic cannulation was preferred in most cases except in cases of dissection where axillary artery/femoral artery was the preferred site. Custodiol cardioplegia was used in patients requiring aortic root replacement and with concomitant arch procedures. Selective antegrade cerebral perfusion was used in cases requiring distal anastomosis under circulatory arrest. Two patients expired in immediate postoperative period owing to low cardiac output. Three patients required reexploration for postoperative haemorrhage. One patient had cerebrovascular accident. Two patients developed renal dysfunction postoperatively not requiring dialysis. None of the patients required prolonged ventilator support. There was no deep sternal wound infection. On follow up, two patients required reoperation for disease progression (tricuspid regurgitation in rheumatic disease and arch dissection in Marfan’s syndrome )
Conclusion: Reoperations on the aortic root and ascending aorta can be performed safely with low operative risk if meticulous attention to myocardial protection, cerebral protection and surgical technique is followed.
Can Endarterectomy be useful in peripheral arterial occlusive disease with critical limb ischemia?
Bhuban Mukherjee, Binay K Sarkar
Nil Ratan Sircar Medical college
Introduction and Objectives: Importance of thromboendarterectomy (TEA) had declined with the advent of bypass techniques and availability of prosthetic grafts, in patients with Peripheral arterial occlusive disease (PAOD). Many of these patients with advanced and complex arterial occlusive disease with critical lower limb ischemia required endarterectomy of the tibiopopliteal segment and of the distal landing zone of the prosthetic graft on the diseased arterial segment for optimal revascularization and relief of symptoms. We describe a series of eleven patients with advanced peripheral arterial occlusive disease with ulcerating gangrene of the lower limb where endarterectomy was done along with prosthetic bypass grafting (anatomic or extra-anatomic).
Materials and Methods: From January,2013 to November, 2016 a total of 11 patients with advanced peripheral arterial occlusive disease with ulcerating gangrene of the lower limb were operated in the department of Cardiovascular and Thoracic Surgery, NRS Medical College & Hospital, Kolkata, West Bengal, India.
Results: We had a total of eleven male patients (age range 48 – 65 years). Of these 11 patients, 9 patients had femoral and tibiopopliteal disease and two patients had aorto-iliac disease in addition. All patients required endarterectomy of the tibiopopliteal segment or femoral segment. Three patients had extra-anatomic bypass and one patient needed venous patch plasty of lower popliteal artery after endarterectomy. All these cases had smooth postoperative recovery with considerable improvement of symptoms.
Conclusion: The effectiveness of TEA is found to be effective in the symptomatic improvement and salvage of the limb by improving inflow to distal vessels considering the lower costs, when the indications and the accuracy of surgical technique are respected. It aided in prosthetic grafting and improved revascularization in of limb-threatening ischemia and in multilevel complex arterial obstructive disease.
Redo cardiac surgery outcomes: single centre experience
Sujeeth Suvarna, Maria Hayes, Alexandru Cornea, Delia Clune, Edel Costigan, Niamh Dunne, Kristo Papa, Laura Viola
Blackrock Clinic
Introduction and objective: Redo cardiac surgeries are associated with an increased risk of postoperative morbidity and mortality. These cohorts of patients in the present era are becoming more complex due to multiple co-morbidities. The aim of our study was to analyse our experience concerning the immediate post-operative outcomes in this sub-group of redo patients.
Methods: Between January 2012 and June 2016 a total of 1,980 patients underwent cardiac surgery at Blackrock Clinic, 80 (4.04%) of whom had redo surgery. Data analysed included peri-operative, intra-operative and post-operative details.
Results: The mean age was 67.88(SD9.22) years; 57 (71%) were male, 23 (29%) were female. Eighty out off 1,980 patients underwent redo surgery (CABG: n= 35/80, VALVE: n= 31/80, CABG + VALVE: n= 7/80, OTHER: n=7/80). The mean logistic EuroSCORE was15.61 (SD13.10), mean ITU length of stay 6.86 (SD12.60) Reoperation for tamponade 10% (n=8/80) Postoperative renal dialysis 11% (n=9/80) Stroke 2% (n=2/80) In hospital survival at time of discharge 89% (n=71/80) Mortality: 11% (n=9/80) CABG: 11 %( n=4/35), VALVE: 9.67% (n=3/31), CABG +VALVE: 28.57%) n=2/7, OTHER: 0 %. Out of these deaths Emergency: 0%, Urgent: 55 %( n=5/9), Elective: 44 %( n=4/9).
Conclusion: Our single centre small volume analysis suggest that redo surgery do present an increased risk of morbidity and mortality than first-time surgery patients. These sub-groups of patients can present new challenges especially when co-morbities exist.
Effectiveness of Sildenafil in Pulmonary Hypertension secondary to Mitral valve disease
Tinni Mitra, Kallol Dasbaksi,Plaban Mukherjee, Suranjan Haldar, Mohammad Zahid Hossain
Department of CTVS, Medical College, Kolkata, 88, College Street, Kolkata-700073
Introduction: Cardiac surgery in patients with mitral valvular disease with severe pulmonary arterial hypertension ( PAH ) is often complicated with right ventricular (RV) failure with an adverse consequence on its prognosis. This necessitates pre and perioperative strategy to reduce PAH and RV dysfunction by inducing relaxation in pulmonary arterial vasculature. The final messenger for vascular smooth muscle relaxation, Cyclic guanosine monophosphate (cGMP), is metabolized by phosphodiesterase ( PDE). Among the various PDE, PDE5 is the predominant type in the normal pulmonary vasculature that may be upregulated after CPB. The inhibition of PDE5 is therefore a logical step to increase the bioavailability of cGMP and support endogenous vasodilation in patient with PAH. PDE5 is selectively inhibited by sildenafil, vardenafil, and tadalafil and less selectively by zaprinast and dipyridamole. A prospective randomized double blind study was performed at our institution on the effect of sildenafil in secondary pulmonary artery hypertension due to mitral valvular disease.
Materials and Methods: Fourteen patients with mitral valvular disease with moderate to severe tricuspid regurgitation, diagnosed by trans thoracic echocardiography (Echo), undergoing mitral valve replacement (MVR) with or without tricuspid valve repair, were enrolled for study between September 2014 to July 2016. Those patients with concomitant significant aortic valve (AV) disease requiring AV replacement were excluded. Patients with pulmonary artery systolic pressure ( PASP) more than 50mm Hg at rest were selected from OPD. Patients in group S (sildenafil) were administered oral sildenafil tablets 25 mg three times a day in preoperative period and placebo tablets in C (control group ) in the same fashion for 2 weeks and Echo repeated. After induction of anaesthesia pulmonary artery catheter was inserted and PASP was calculated after ½ hour after induction. Postoperatively, patients were monitored by Echo after 1 week, 1 month and at 3 months.
Results and Analyses: In this study, PASP was significantly lower (P < 0.0001) after induction of anaesthesia, after weaning from CPB, and in immediate postoperative period in S as compared with C group. In group S, patients required less inotropes than C. Two mortalities was recorded in the study, one each from each.
Conclusion: Because of predominant selective activity of sildenafil in management of pulmonary hypertension and improvement of RV function without compromising the systemic blood pressure, the use of this drug in patients undergoing mitral valve surgery should be considered in preoperative period.
Preoperative assessment of myocardial viability for decision making before CABG in patients with LV dysfunction
Ravi Shivdasani, Gopal Murugesan, Vijit K Cherian
MIOT Hospitals
Introduction and objective: Left ventricular function is a major predictor of outcome in patients with coronary artery disease. Acute ischemia, stunning and hibernation are among the reversible forms of myocardial dysfunction. Assessment of myocardial viability and ischemia continues to be an important issue in patients with ischemic cardiomyopathy. In patients following myocardial infarction, evaluation of eligibility for revascularization mandates accurate assessment of myocardial viability. Different diagnostic methods are currently performed are FDG-PET, SPECT and CMR. Evidence of myocardial viability usually relies on the demonstration of uptake of various metabolic tracers, such as thallium or fludeoxyglucose by dysfunctional myocardium or by the demonstration of contractile reserve in a dysfunctional region.
Material and methods: 217 patients with ischemic cardiomyopathy were retrospectively studied for their preoperative assessment with myocardial viability imaging to differentiate among dysfunctional myocardial segments.
Results: 160 patients underwent Rest thallium, 35 patients underwent FDG-PET and 22 patients had CMR. All the patients had preoperative viability imaging workup and that greatly aided in decision making for surgical revascularisation. CABG, SPECT, PET and CMR are generally considered the optimal modalities by which viability can be assessed and are excellent predictors of myocardial viability.
Conclusions: In patients with ischemic cardiomyopathy, benefit from revascularisation with defined viability can be assessed by these methods. Accurate preoperative viability imaging in these patients helps in decision making and results in a significant reduction of peri-operative morbidity and mortality after CABG. However CMR being best, it is not preferred option because of cost, duration of imaging, requirement to lie flat and other patient factors.
Mid term results in Valve sparing aortic root replacement surgeries at a tertiary care centre in a second tier city
Kunal Krishna, Jayakumar TK, Ratish Radhakrishnan
Government Medical College, Kottayam,Kerala
Introduction & objectives: Valve sparing aortic root replacement provides an attractive alternative to aortic root replacement in patients with aortic root abnormalities even in the emergency setting of an acute type A aortic dissection.
Materials & Methods: From 2014 to 2016 we at our centre have performed 12 valve sparing aortic root surgeries which include 11 David Procedure & 1 Yacoub procedure for patients with various ascending aortic & aortic root disease. 50% of patients (n = 12) were in age group of 40 – 50 yrs while 2 patients were > 55 yrs of age & 3 were <30 yrs . 3 were females & others malesv . 50% of these patients were operated for dissecting ascending aortic aneurysm & one was a case of Takayasu’s aorto-arteritis. Additional procedures were done in 2 patient. Leaflet prolapse was corrected by plication in 2 cases. Mean follow up was 3 years.
Results: Except for 2 patients which could be followed up only over phone rest were under regular follow up personally Mortality has been ZERO till now including 30 days / late mortality. No episode of neurologic/other systemic complication post-operatively .All patients were discharged within 5 days. 1 case of late onset moderate AR while others had no significant / trivial AR. No incidence of re-operation/conversion to bentall procedure. The quality of life is improved markedly with most of the patients having no work limitation. Patients are only On antiplatelets resulting in zero incidence of anticoagulant induced bleeding manifestations.
Conclusion: The Valve sparing procedure certainly provides a challenging option to treat selected young patients with AI in the presence of AAD. However, current data suggest that it is safe and feasible even in emergency cases. Long-term valve-related events are rare and aortic valve function remains stable forobjectives.
Heart transplant (Light at the end of the tunnel) – Our experience
Pravir Sinha, Pawan K Singh, Ratna Malhotra, Madhav Shinde, Asish Asija, Rahul Kumar,Sanjoy Majhi, Adrash Koppula,Kewal Krishan
Max Super speciality hospital, Saket,New Delhi
Background:Heart failure is one amongst the leading cause of death in India and across the globe. Reliable estimates of heart failure are lacking in India because of absence of surveillanceprogramme to track incidence, prevalence, outcomes and key cause of heart failure. Nevertheless the number of death due to heart failure in India is magnanimous. Despite advancement in medical and surgical treatment of circulatory failure like left ventricular assist device, “Heart Transplantation” still remains the gold standard.
Methods: We reviewed our experience with four patients who required heart transplant primarily due to dilated cardiomyopathy. Variables analysed included renal, neurological and respiratory dysfunction, arrthymias, length of hospital stay and mortality.
Results: The age range for these patients were between 20 years – 56 years Among which (3- Males & 1 – Female) None of the patients were reintubated & mean intubation period was 18 hours All four patients were discharged to home. ( In hospital mortality – 0 % ) Mean hospital stay was 18 days (Shortest stay – 12 Days & Longest stay – 34 days) All the patients received immunosuppression with steroids, mycophenolate (cell Cept) & tacrolimus. None of the patients developed acute rejection One patient developed respiratory complication in the form of pneumonic consolidation in right middle lobe requiring frequent bronchoscopic suctioning and incidentally had prolonged hospital stay. One patient (25%) developed SVT requiring medical cordioversion & none developed any significant ventricular arrthymias. There were no renal or neurological complications in any of these patients.
Conclusions: Heart transplantation still remains a gold standard for treatment of end stage dilated cardiomyopathy. As a result of improved immunosuppression and advancement in medical management, there is a significant improvement in functional capacity and quality of life in all such patients with significantly reduced complications.
Mid term experience of adult ECMO in India
Kewal krishan, Pravir Sinha, Chintan Mehta, Tania Mehta, Saurabh Pandey, Arvind, Ravi K Singh,Raj kumar, Rajesh Chand, Rajneesh Malhotra
Max Super speciality hospital, Saket,New Delhi
Background: Mid term experience of adult ECMO in India Objective Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for critically ill patients with reversible cardio-respiratory pathology and those who have probability of death around 80% despite maximal conventional treatment. The positive results of the recent trials have stimulated our interest to use ECMO for life treating conditions due to cardiorespiratory failure. Here we describe our experience at a tertiary care centre in India.
Methods: We established an adult ECMO program for cardio-respiratory support in April 2013. In the last 3.5 years, we supported forty five patients on ECMO and it was only considered once the conventional therapy deemed failing. A retrospective analysis of our patient data was performed to collect information regarding patient demographics, indication for ECMO, type of ECMO and outcomes.
Results: A total of forty five patients received ECMO between April 2013 to October 2016. The mean age was 36.4 yr (range 18 - 57years), 29 Male:16 Female. Out of 45 patients 7 were veno arterial (VA) and 38 were veno venous (VV) ECMO. In VA ECMO the first patient had intractable arrhythmias and second had acute viral myocarditis leading to refractory cardiogenic shock, one was post cardiotomy and one was myocardial depression post sepsis. Out of 38 patients of VV ECMO, 17 had viral pneumonia, six bacterial pneumonia and three with fulminant fungal infection leading to ARDS, one had pulmonary haemorrhage due to wegener’s granulomatosis and 11 were swine flu related ARDS. ECMO was instituted by peripheral cannulation in all patients. Average support time was 13 days (range 2 to 44 days). 28 patients were successfully separated from ECMO and 27 survived to hospital discharge. Four patients had major complications including pump failure and bleeding, Oxygenator failure and air in the circuit. One underwent lobectomy for multiple bronchopleural fistulae in right lung.
Conclusion: ECMO is salvage therapy in patients with life treating refractory circulatory shock or severe ARDS. This therapy has the potential to save lives if applied in time and in appropriate clinical settings.
Predictors of outcome following aortic valve repair for aortic regurgitation complicating ventricular septal defect – A retrospective study
Mahendranath S Prasad
Sri Chitra Tirunal Institute for Medical Sciences and Technology
objective: To identify the factors that can predict a durable repair for AR complicating VSD on long term follow up.
Methods: A single institute retrospective observational study with the study period was between January 2010 and December 2015. The type of repair was based on the mechanism of AR dictated by the preoperative transthoracic ECHO findings, validated with intraoperative TEE. All patients were followed up in their 1st month, 6th month & first year following surgery with transthoracic ECHO for assessing presence and the severity of AR. Disease recurrence and treatment failure (reoperation) were the end points.
Results:RECURRENCE •21.4% (n = 3) who had undergone NCC plication, 9.1% (n=1) who had undergone RCC plication and 33.3% (n = 1) of the patients who had undergone central plication had AR recurrence during follow up. None of the patients who had undergone Trussler repair, Yacoub repair and pericardial patch repair of the NCC had AR recurrence during follow up. • 8.3 % (n = 1) of the patients with subcommisural annuloplasty had AR recurrence during the follow up period. The difference between the two groups was statistically insignificant (p = 1.000). REOPERATION • Four percent (n =2) of the patients had aortic valve replacement with mechanical prosthesis during immediate postoperative period. • Two percent (n=1) of the patients had reoperation for surgical site infection
Conclusion: • The overall recurrence rate in the study is 8% and reoperation rate is 4%. • The sex of the patient, valve anatomy, preoperative severity of AR and addition of annuloplasty to aortic valve do not significantly affect the durability of aortic valve repair. • Further, the effect of age at operation, body mass index, body surface area, the type of aortic valve repair technique and additional surgical procedures on the durability of aortic valve repair couldn’t be established owing to small sample size.
Comparison of predictive validity of EuroSCORE II and Society of Thoracic Surgeons [STS] score for clinical outcome in patients undergoing open heart surgery, a prospective observational study
Mohammed Abiduddin Arif, Ramesh Chandra Mishra, Amaresh Rao Malempati
Nizam's Institute of Medical Sciences, Hyderabad
Introduction: Preoperative risk scores are an essential tool for risk assessment, cost benefit analysis, and the study of therapy trends. Majority of the studies conducted on predictive validity deal with mortality as the outcome. Even though morbidity can have huge negative impact on hospital stay, cost of treatment and quality of life, studies focusing on morbidity as primary outcome are scarce. Objective To compare the predictive ability of European System for Cardiac Operative Risk Evaluation [EuroSCORE] II and the Society of Thoracic Surgeons [STS] for clinical outcome in patients after cardiac surgery.
Materials & Methods: The study was a prospective observational study conducted in a tertiary care teaching hospital. A total of 50 subjects undergoing open heart surgery for various etiologies were recruited consecutively. For each subject EuroSCORE II and STS score were calculated on admission. Occurrence of any major morbidity was considered as final outcome. Predictive validity of both the scores was assessed by receiver operating curve (ROC) analysis. IBM SPSS version 22 was used for analysis.
Results: Out of the total 50 subjects, elective and emergency were done in 84% and 16% respectively. Single procedure was done in 74% and two and three procedures were done in 22% and 4% of participants respectively. The proportion of subjects with uneventful outcome was 88% and 12% had eventful outcome ( major morbidity) in study population The area under the ROC curve to predict the outcome for EuroSCORE II was 0.765 (0.61 to 0.91, p value 0.037) and for STS score it was 0.697 (0.535 to 0.859, p value 0.121) was observed for STS score respectively.
Conclusion: EuroSCORE II score had better predictive validity compared to STS score in predicting morbidity in patients undergoing open heart surgery.
Assessment of Coronary stenosis by Computational Fluid dynamic study
Sanjeev Dasrao Muskawad, Shailendra Sharma, James Thomas, Rushikesh Shinde
Indian Institute of Technology Bombay
Introduction & Objectives: Assessment of coronary stenosis is important exercise for clinical management and planning an appropriate intervention. Currently available imaging modalities such as coronary CT angiography can reveal detailed geometric aspects of the coronary obstruction. The available computing power facilitates building of CAD geometry as well as computation fluid dynamic (CFD ) analysis. This study illustrates the building of CAD ( computer aided geometry) model and flow analysis for the range of physiological boundary conditions.
Materials & Methods: The CAD geometric models are built with the variables such as length of stenosis, cross sectional area of obstruction, eccentricity etc. The clinical data from angiography is also idealised to build the CAD model. The CAD geometry is imported into ANSYS-Fluent a commercial CFD software. Refined meshing is done for the 3-D fluid volume to achieve grid independence and convergence. The study is done for the physiological range of inlet flow velocities and outlet pressures.
Results: The pressure loss across the stenotic lesion ( reduction in cross sectional area) is due to frictional (Poiseuille) losses as well as due to convective acceleration with flow separation at the exit of of the lesion. The effect of stenosis is visualised by plotting the curve between the volumetric flows and pressure loss across the stenosis.
Conclusions: The Computation fluid dynamic study provides accurate assessment of stenosis. It also helps in estimation of Fractional Flow Reserve which is important parameter.
Primary airway tumours in children
Arun Beeman, Nagarajan Muthialu
Great Ormond Street Children Hospital, London
Background: Primary airway tumours are rare in children. Aims and objectives: To analyse the characteristics of primary airway tumours in children managed in our tertiary paediatric airway centre.
Methods: Retrospective data collection of all children with primary airway tumours who were managed in our tertiary paediatric airway centre over the last 10 years. Data collection included age at diagnosis, sex, symptoms, investigations, surgery, histology, complications and outcome.
Results: 11 children (male = 7, female = 4) with the mean age of 4.5 years were reviewed. Frequent symptoms were cough (n = 9), dyspnoea (n = 4) and weight loss (n = 3). Workup included Computerised Tomography (CT scan) and bronchoscopy. Location of tumours were left paratracheal (n = 1), Right main bronchus (n = 2), left main bronchus (n = 4), Right bronchus intermedius (n = 2), carina (n = 1) and distal (n = 1). Surgery included right pneumonectomy (n = 2), sleeve resection of bronchus (n = 6), sleeve lobectomy (n = 1) and excision (n = 2). Histological diagnosis were inflammatory myofibroblastic tumour (IMFT, n = 9) and mucoepidermoid carcinoma (n = 2). Mean follow up was 4 years with no death. One child with IMFT (ALK-positive) continues to receive chemotherapy (crizotinib) and needed bio-degradable tracheal stent for recurrent stenosis. One child had insertion of tissue expander in hemithorax.
Conclusions: Airway tumours are uncommon in children, and need extensive work up including contrast enhanced CT scan. While majority of them can be amenable to local excision, these tumours can, at times, follow a protracted clinical course.
Predictors of Mortality & Morbidity in patients with severely depressed LV functions: A Single centre observational study
Pravir Sinha, Sachin Chatterjee, Soumaya Deep, Sanjeev Malhotra,S K Sinha, Rajneesh Malhotra, Kewal Krishan
Max Super speciality hospital, Saket,New Delhi
Introduction: Patients with symptomatic multi vessel coronary artery disease and severely depressed LV function (EF< 0.30) have significantly higher mortality & morbidity than patients with moderate EF. In this subset, CABG is associated with higher postoperative morbidity & mortality compared to patients with normal left ventricular function.
Aim and Objectives: Analyse the Predictors of immediate, short, mid and long term events occurring after revascularization in patients with CAD with severe LV dysfunction (EF <35%). Effect of revascularisation on functional status, symptomatology (angina class) and LV systolic function.
Material and Method: Total 114 subjects recruited for the study & followed up at 3, 6 and 12 months. All deaths and re admission events also recorded and analysed Data analysed using student’s t-test or Mann Whitney U test as appropriate. Categorical data analysed using chi-square analysis or fisher’s exact test. Multiple logistic regression to analyse the risk of predictor variables.
Results: Cigarette smoking, renal failure, cerebrovascular disease, peripheral vascular disease, mean NYHA score and arrhythmia were more frequent in the patients with severe left ventricular dysfunction. Significant difference in No.of diseased vessels, emergency CABG, Cardiac arrest, heart block, thirty-day mortality rate, length of stay in ICU & hospital after surgery were also higher in the ventricular dysfunction group. Multivariate logistic regression analysis showed the NYHA score, postoperative prolonged ventilation, prolonged ICU stay and postoperative renal failure were related to the 30-day mortality rate. Prolonged LOS in hospital was related to the female gender & postoperative AF.
Conclusion: Although left ventricular dysfunction is itself an important strong risk factor in patients undergoing CABG, the early outcome of CABG in patients with LV dysfunction is acceptable and the management of this factor will help to reduce the mortality and total length of stay in hospital with the help of a regular follow-up.
Results of minimally invasive Aortic Valve replacement in Octogenarians.
Sobaran Sharma, Yasir Ahmed, Joseph George, Umair Aslam, Prakash Nanjaiah, Pankaj Kumar
Morriston Hospital Swansea, United Kingdom
Background: Aortic valve stenosis is the most common acquired valve lesion among octogenarians in the western societies. Octogenarians are the fastest growing population in the UK, currently 2.5 million growing to 5 million by 2030.
Background:Minimally-invasive aortic-valve replacement (mini-AVR) via J-sternotomy has been shown to reduce surgical morbidity. Mini-AVR aims to reduce trauma, post-operative pain, blood loss, ventilation time, leading to faster recovery and better aesthetic outcomes. Little data is available on the outcomes of min-AVR in the very elderly population (octogenarians). Aims/Objectives We assessed the clinical outcomes of the min-AVR in all octogenarians undertaken at our centre.
Methods: A single consultant surgeon and his team routinely undertook the minimally-invasive approach via J-sternotomy for all isolated first-time aortic valve replacements. Operative records and clinical outcomes of all patients who had undergone min-AVR in our centre between 2006 and 2016 were retrieved from the national cardiac surgery database. Patient demographics, pre-morbid status, operative details and outcomes were evaluated.
Results: 223 mini-AVRs were undertaken between 2006 and July 2016, out of which 55 patients were aged 80 YEARS or above. Patient demographics were as follows: mean age 83.8 years (range 80-91, SD 2.93), female gender 63.4%, diabetes mellitus 9.8%, pulmonary disease 22.0%, LV function: <30% in 7.3%, 30-50% in 17.1% and >50% in 75.6%, logistic euroSCORE 13.3 (interquartile range 8.44-14.7, SD 9.04). Overall in-hospital and 30-days mortality, stroke, re-exploration rate & conversion to full sternotomy were all 0%, renal failure requiring dialysis 1.8% (1/55), permanent pacemaker 1.8% (1/55)
Discussions/Conclusion: Despite high logistic EuroSCOREs, we have shown excellent results in octogenarians by this approach. In this era of transcatheter aortic-valve implantation, mini-AVR adds to the armamentarium of the surgical team.
Bidirectional Glenn Shunt Without Cardiopulmonary Bypass Our Initial Experience
Jaswinder Singh, Rajiv Nair, Amit Pushkarna, SK Jha, Anurag Garg
Military Hospital (CTC), Pune
Objectives: There is an increasing trend to perform the bidirectional superior cavopulmonary (Glenn) anastomosis without cardiopulmonary bypass at our Centre during last one year. we present our results of off-pump bidirectional Glenn operation [BDG] done a venoatrial shunt to decompress superior vena cava during clamping.
Methods: A retrospective study was conducted in patients with functional single ventricle anomalies who underwent bidirectional Glenn anastomosis. A total of 11 patients underwent BDG during this period. All patients underwent a complete neurological examination both preoperatively as well as postoperatively.
Results: A total of 11 patients underwent BDG during the study period for single ventricle palliation. Two patients were excluded from the study as BDG was performed on cardiopulmonary bypass in these patients. In one case indication for going on CPB was restrictive PFO and in second case there was RPA origin stenosis which was corrected before BDG. The mean follow-up was 11 months. The mean internal venous pressure on clamping the superior vena cava was 20±4.4 mmHg. All patients were extubated on table. The mean intensive care unit stay was 3.6±1.08. There were no major neurological complications apart from treatable convulsions in one case.
Conclusions: Off-pump bidirectional Glenn operation without cardiopulmonary bypass is a safe, simple and more economic procedure.
Institutional experience of Coronary Artery Bypass Grafting in Severe Left Ventricular Dysfunction
Col G S Nagi, Lt Col RS Sohal
MH CTC- Pune
Backgroung: Despite the ominous prognosis of advanced ischemic cardiomyopathy, coronary artery bypass grafting in this setting remains controversial because of concerns over operative risk and lack of functional or survival benefit.
Aim: This study evaluates our experience with coronary artery bypass grafting in patients with severe left ventricular dysfunction.
Methods: We retrospectively analysed our data base. Out of 3490 coronary revascularization surgeries, over a period of 27 years, 1511 patients were those with left ventricular dysfunction. Out of these 663 patients were with severe LV dysfunction that is ejection fraction < 30%(414 men, 249 women, aged 50 to 75 years). The ejection fraction ranged from 22% to 30%.Preoperatively, 86% of patients had angina, 52% had congestive heart failure and 30% manifested significant ventricular arrhythmia. The internal mammary artery was used in 82% of grafts to the left anterior descending coronary artery. The intra aortic balloon pump was prophylactically placed preoperatively in 37% of patients with almost 83% requiring IABP support to come off CPB. 63 of these cases were done on an emergency basis.
Results: The average crude hospital mortality rate was 8.67%. The mortality rate was 6.3% (4 of 63) in patients undergoing emergency surgery. Canadian Cardiovascular Society angina class improved postoperatively by 1.9 categories and New York Heart Association congestive heart failure class by I category. Left ventricular ejection fraction improved from 24.6% preoperatively to 33.2% postoperatively (36% increase) (p < 0.001). At 1 and 3 years, respectively, all-cause survival was 87% and 80%
Conclusions: In patients with coronary artery disease and advanced ventricular dysfunction coronary artery bypass grafting can be performed relatively safely with good medium-term survival. The use of coronary artery bypass grafting is encouraged for this group of patients and may provide a viable alternative to transplantation in selected patients.
Surgical plication of symptomatic giant left atrium- controversy unfolded
Chintan Mehta, Rajneesh Malhotra, Kewal Krishan, Adarsh Koppula
Devki Devi Heart and Vascular Institue Max Hospital Saket, New Delhi
Background:Giant left atrium as defined by Kawazoea et al is Left atrium > 65 mm with or without compressive symptoms. With an incidence of 0.3% it commonly occurs in patients with chronic rheumatic mitral valve regurgitation and has a significant impact on postoperative course, complications and outcomes. Surgical placation of symptomatic giant left atrium is still a controversy.
Materials and methods: Retrospective comparative observational study in all patients with symptomatic giant left atrium with chronic mitral valve regurgitation referred for surgery at max hospital saket between 2011 to 2016. 50 patients were enrolled in the study with 20 patients (40%) who underwent mitral valve intervention and surgical placation and 30 patients (60%) who underwent mitral valve intervention alone. The primary endpoint was reduction in inhospital 30 day mortality and secondary end points being reduction in post operative complications –respiratory complications , low cardiac output, incidence of atrial fibrillation. Surgical placation of the respective segment done as per presentation and description by kawazoea.
Results: Inhospital 30 day mortality occurred in 1 patient (5%)with surgical plication as compared to 3 patients (6%) in patients who underwent mitral valve intervention alone (p<0.05). Post operative elimination of symptoms occurred in 15 patients (75%) in patients who underwent surgical placation as compared to 10 patients (33.33%) who underwent mitral valve intervention alone. After surgical placation 10% patients had low cardiac output, 20% had mechanical ventilation >48hours, 75% had restoration of normal sinus rhythm in first 48 hours as compared to patients who underwent mitral valve intervention alone had 20% incidence of low cardiac output, 30% patients had mechanical ventilation for > 48 hours, 60% patient had restoration of normal sinus rhythm in first 48 hours.
Conclusion: Surgical placation of respective compressing segments in symptomatic giant left atrium as described by kawazoea significantly reduces post operative morbidity.
Prospective analysis of tricuspid regurgitation in patients undergoing mitral valve replacement
Muthukumar S, SundarRamanathan, Chandrasekar Padmanaban, Muralidharan Srinivasan
G Kuppuswamy Naidu Memorial Hospital (GKNM) Coimbatore,Tamilnadu,India.
Aims and Objectives: The aim of this study is to evaluate the progression of TR in patient with mitral valve disease and moderate or more tricuspid regurgitation undergoing Mitral valve replacement alone. To compare clinical outcome and echocardiographic results.
Materials and Methods: The study was a prospective non randomised study conducted from March 2011 to April 2013. It included the patients with moderate or more tricuspid regurgitation associated with mitral valve disease ( Mitral stenosis or mitral regurgitation), who underwent elective mitral valve replacement (MVR). They were divided into two groups: group1 who underwent MVR alone, and group2 who underwent MVR and tricuspid valve repair All patients are followedup at 6month,1 and 2 year interval.
Results: 74 patients recruited moderate or more TR associated with MR, who underwent elective MVR. In group 1, 45 patients underwent MVR alone, and group 2-29 patient underwent MVR and tricuspid valve repair .The mean NYHA class in preoperative period was 2.71±0.59 in group1and2 .57±0.57 in group2. In 2year followup NYHA in group2 was significantly reduced to 1.04±0.62 (P.001) which supports in favour of concomitant TV repair After two years follow up the is significant reduction in mean TR grade in group2 (1.11±0.497) compared to Group2(3.03±0.68 ).Though therewere worsening of TR in group 1,but not statistically significant (P-0.19). There is significant reduction in Right ventricular dimensions RVID (s) and RVID (d )in group2 compared with group1 with (P-0.001).
Conclusion:Tricuspid annuloplasty is an easy and safe procedure and it is in case of moderate or more functional (>2+) to achieve better midterm outcome.
Pulmonary hypertension- post surgical correction of total anomalous pulmonary venous connection
Shreyas S Runwal, Seetharam Bhat, Girish Gowda
Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore
Introduction and Objective: Total anomalous pulmonary venous connection (TAPVC) is a very uncommon cyanotic anomaly comprising 1% of all congenital heart diseases. Since pulmonary veins drain into the systemic venous circulation, TAPVC is incompatible with life unless a communication between the right and left sides of the heart exists; usually via a patent foramen ovale or atrial septal defect. As the right to left shunt is usually small, right heart dilatation and failure ensues owing to a volume overload. Stenosis and obstruction of varying degree at the junction of the anomalous trunk with the vena cava leads to severe pulmonary hypertension which further worsens right heart failure. Without surgery most infants die by 12 months of age. However, post-operative mortality is also high owing to increased pulmonary vascular resistance and inadequate repair due to obscure anatomy. The purpose of this study was to study the pulmonary artery (PA pressures) in post operative and during follow up.
Methodology:We have undergone a retrospective study of 60 TAPVC cases operated at our centre in last 3 years; of which 26 cases of supracardiac TAPVC, 25 cases of cardiac type and 6 cases of mixed TAPVC and 3 cases of infracardiac TAPVC correction. We have studied the PA pressures on 1 and 2 year post surgeries on 2D ECHO and compared it to PA pressures of immediate post operative PA pressures.
Result: 23 cases had persistent high PA pressure than immediate post Operative PA pressures.
Conclusion: In view of persistent increased pulmonary vascular bed resistance, there is possibility of persistent pulmonary hypertension even after surgical correction of TAPVC.
A study of difference in left ventricular function in patients with and without false tendon undergoing mitral valve replacement
Dinesh D, Rakesh, Prasanna Simha
Sri Jayadeva Institute of Cardiovascular Sciences and Research
Background:Left ventricular false tendon are discrete, fibromuscular stucture of varying length and thickness that traverses from septum to free wall or from free wall or between papillary muscle not related to mitral valve apparatus.
Aim and Objective: Our aim is to study the difference in left ventricular function in patients with and without false tendon undergoing mitral valve replacement.
Methods: It is an observational and prospective study. 29 patients were included who underwent elective mitral valve replacement. Of these 14 had false tendon and 15 patients had no false tendon. Patients were followed upto 6 months. We compared systolic left ventricular internal diameter (LVIDs), diastolic left ventricular internal diameter (LVIDd), end systolic volume (ESV), end diastolic volume (EDV), interventricular septal thickness and Fractional shortening preoperative, immediate postoperative, 1st,3rd and 6th month postoperatively.
Results: Patients with false tendon has less left ventricular size when compared with patients who do not have false tendon at immediate post operative period, 3rd and 6th month.[LVIDD- immediate post operative period-4.33±0.43 vs 4.90±0.44(p-0.001), 3rd month-4.23±0.48 vs 4.86±0.34(p-0.001), 6th month 4.28±0.44 vs 5.30±0.71(p-0.014); LVIDS- immediate post operative period-3.08±0.51 vs 3.59±0.46(p-0.009), 3rd month 2.94±0.48 vs 3.54±0.39(p-0.001), 6th month 2.95±0.43 vs 3.85±0.64(p-0.020)]. But there is no statistical significance in fractional shortening between these two groups at preoperative, immediate postoperative period, 3rd and 6th month. [Pre-operative period-30.72±4.76 vs 28.99±3.95(p-0.297), immediate postop period-28.76±5.38 vs 27.03±4.08(p-0.337) 3rd month 30.14±5.03 vs 28.76±3.54 (p-0.150), 6th month 29.96±4.94 vs 26.50±3.82(p-0.366)]. There is no difference between two groups in EDV, ESV and IVS
Conclusion: Eventhough LV sizes are less in patients with false tendon group, there is no difference in LV function between these two groups. KEYWORDS: false tendon, LV function, mitral valve replacement.
Mid Term Result of Mitral valve Repair in Rheumatic Heart Disease
Ashok Kumar Chahal, Divya Arora , Kuldeep Lallar, Shamsher Singh Lohchab
Pt. B D Sharma Post Graduate Institute of Medical Sciences Rohtak, Haryana
Objective:Mitral valve repair is challenging one in rheumatic heart disease due to complexity of lesions. The appropriateness of valve repair for patients with rheumatic heart disease, even when repair appears to be technically feasible, remains controversial. We present the mid term result of mitral valve repair in rheumatic etiology.
Methods: A retrospective analysis of patients operated for mitral valve repair from 2007 till 2015 was done to determine the valve related outcomes, survival, functional status, residual lesions, freedom from reoperation, infective endocarditis, and need for valve related redo surgery.
Results: The Mitral valve repair was done in 238 patients. The male:female ration was 103:135. The mean age was 30 ± 11 yrs. Mitral stenosis was present in 42.4%, Mitral regurgitation was present in 22.7% and 34.9% patients were having mixed lesions. The mean follow up was 81± 43 months. The follow up was 90.75%. The early and late mortality was 4.62% and 2.91 %. The readmission rate was 9.71%. The thrombo-embolic and bleeding complications were present in 1.94% patients. Significant mitral stenosis and regurgitation was present in 6.25% of patients. The rate of redo procedure was 4.12%.
Conclusion: The mid term results of mitral valve repair in rheumatic etiology are excellent with freedom from anticoagulant related complications.
To study the outcome of Double versus single valve replacement for Rheumatic heart disease
Dasari Kalyani Rama, Abha Chandra, D Rajasekhar, Vanajakshamma, Alok Samantaray
Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh
Introduction: Surgery for combined mitral and aortic valve disease has been associated with high operative mortality. 10 years survival rate has been better for AVR (72.1%), than DVR (62.3% ) or MVR (54.4%). Clinical presentation vary for regurgitant and stenotic lesions. This study was designed to access the outcome and follow-up results of Double versus single valve replacement for Rheumatic heart disease. Aims & objectives To assess the preoperative clinical, hemodynamic risk factors and surgical predictors for long-term survival after valve surgery.
Material & methods: This prospective study was conducted between April 2015 and October 2016. There were total 86 patients who underwent MVR [n=42], AVR [ n=20] and DVR [ n=24] under conventional cardio pulmonary bypass. Clinical and haemodynamic parameters were studied pre op, at discharge & SD Variables±at 3 months follow up.
Results: were expressed in mean DVR (n= 24) AVR (n= 20) MVR (n= 42) Age 0.8±38.5 0.6±48.5 0.5 Sex M:F±37 15/9 12/8 12/30 Pre OP NYHA 3 3 3 Post OP NYHA 1.1+0.10 1.2 + 0.06 1.3+ 0.08 NSR/AF 14/10 16/4 10/32 CT ratio (Preop/postop) 64.3/62.3 67.3/62.3 68.6/61.5 Pre OP LAD 3.02±54.6 57.6+3.01 2 Post OP LAD±65.4 3.1±51.7 4.1±52.4 1 Pre OP LVESD±63.3 2.8±51.4 2.01 Post op LVESD±3.1 52.1 ±52 2.74±51.0 2.1±51 0.4 Pre OP LVEDD±51 3.2±32.4 4.0±32.5 3.6 Post OP LVEDD±32 1.1±31 1.3±31 2.1 There was improvement in NYHA class±31 &LVEF.The cardiac dimensions LAD, LVESD, LVEDD,LVESD decreased and gradients across valve lowered. The hospital mortality was 2% (1/86)
Conclusion: DVR In patients with rheumatic heart disease should be considered whenever indicated as it has comparable in-hospital mortality and better late survival than isolated aortic or mitral valve replacement. The Left ventricular dimensions should be taken into account to determine the time of the surgery.
Role of assessment of Sub Mitral density in grading severity of mitral stenosis
TSudheendra,Rakesh Naik, Prasanna Simha
Sri Jayadeva Institute of Cardiovascular sciences, Bangalore
Introduction:Mitral valve involvement in rheumatic heart disease is the commonest cause of mitral stenosis. The assessment of severity of mitral stenosis is done pre operatively with echo using parameters like mitral valve anatomy, planimetry, mitral valve flow and PA pressures. This study compares the sub mitral density with standard assessment tools like Wilkins score and Tendolkar grading and to determine whether sub mitral density can be used as a parameter to assess the severity of mitral valve disease. Sub mitral density is calculated using 2D echo in short axis view and measuring the sub mitral area. Wilkins score is estimated pre operatively using echo while Tendolkar grading is intra operative grading of severity of disease. AIM: To determine the feasibility to use the sub mitral density as a tool in pre operative assessment of severity of mitral valve stenosis.
Methods: Study was done with pre operative assessment of 35 patients in Sri Jayadeva institute of Cardiovascular sciences ageing from 20 to 60yrs age. All patients were evaluated pre operatively with echo for Wilkins score and Sub mitral density assessment. Intra operative assessment done using Tendolkar grading. Sub mitral density was compared with Wilkins score and Tendolkar grading. Statistical analysis done using ANOVA and fischer test.
Results: The present study shows that severity of mitral stenosis using sub mitral density does not correlate well with the assessment using Wilkins score or Tendolkar’s grading. Comparison of sub mitral density with Tendolkar grading done with ANOVA test and p value was 0.868. On comparison with Wilkins the p value 0.213, using fischer extract test, again not significant. Statistical analysis does not show significant p value comparing both Wilkins and Tendolkar grading.
Conclusions: sub mitral density cannot be used as a reliable tool for assessment of severity of mitral valve stenosis.
Aortopulmonary Window: Our Series
Subhash Kumar Kadim, Parvez, Vikas SR, Mayuri S, Soumik Pal, Sathyanarayan J,Syed Mudassar, Shio Priye, Durgaprasad Reddy B
Vydehi Institute of Medical Sciences and Research Centre
Introduction and Objectives: Aortopulmonary window is a rare congenital heart defect resulting from abnormal separation of the truncus arteriosus into aorta and pulmonary artery. An AP window is found in 0.2% of patients with congenital heart disease. We have conducted a study of cases of aortopulmonary window at our institution.
Materials and Methods: We performed a retrospective study of patients with an aortopulmonary window at our institute from June 2006 to June 2015. A total of 13 patients were included in the study from 6 months to 10 years. 8 patients were males (62%) and 5 patients were females (38%). All the patients were subjected to routine blood investigations, chest x-ray, transthoracic echocardiography, and cardiac catheterisation. All the patients had a proximal type of AP window. All patients underwent AP window repair under cardiopulmonary bypass and general anaesthesia. Closure was done with a PTFE patch after exposing the defect through the ascending aorta.
Results: Post operatively all patients recovered well. Two patients developed lower respiratory tract infection in the post operative period, which was treated with antibiotics. All patients were followed up at 3 months with routine transthoracic echocardiography.
Conclusion: Aortopulmonary window is a rare cardiac malformation, which if left untreated will cause irreversible pulmonary vascular disease. But, timely diagnosis and prompt surgical intervention will give a new lease of life.
Complete AV Canal Defect Repair: Our Experience
Parvez Ahamed, Subhash Kumar Kadim, Vikas SR, Mayuri S, Soumik Pal, Sathyanarayan J, Syed Mudassar, Shio Priye, Durgaprasad Reddy B
Vydehi Institute of Medical Sciences and Research Centre
Introduction and Objectives: Atrioventricular septal defects constitute 4% of all congenital cardiac malformations. Patients with complete atrioventricular septal defect rarely survive for decades without surgical treatment. We have conducted a study to evaluate the results of complete AV canal defect patients who have undergone complete repair.
Materials andMethods: We performed a retrospective study over a period of 8 years in our institute from January 2007 to January 2015, which included all he patients with complete AV canal defects who have undergone total repair. A total of 19 patients were included in the study whose age ranged from 4 months to 18 years of age. 11 patients were males (58%) and 8 were females (42%). All patients were subjected to routine blood investigations, chest x-ray, transthoracic echocardiogram, and cardiac catheterisation. All patients were operated under general anaesthesia under cardiopulmonary bypass. Surgical repair of AV canal defect was completed by double patch technique. 2 patients who had pulmonary stenosis underwent pulmonary valvotomy and reconstruction of RVOT with an autologous pericardial patch. 3 patients required mitral valve replacement.
Results: 17 patients survived surgery. One patient had died in the post op period due to severe pulmonary hypertension. Two patients developed lower respiratory tract infection in the post-operative period, which was treated with antibiotics. The rest of the patients have had an uneventful post op period. The patients have come for follow up at 3 months and 1 year and had no complaints.
Conclusion: Complete AV canal defect is a relatively uncommon congenital heart disease, which may be associated with other associated cardiac malformations such as TOF. Surgical repair is curative and overall mortality is generally low. Patients at extremes of low weight and age and severe pulmonary hypertension have worse outcomes.
Ventricular Septal Defects with Near systemic Pulmonary Pressures - Our experience
Elavarasan C, B Kasinathan, GK Jaikaran, Haroon Shakir
Institute of Child Health, Egmore
Introduction: Ventricular septal defects (VSD) with severe pulmonary hypertension (PHT) patients are the difficult ones to intervene. They carry increased risk of perioperative morbidity and mortality especially when the pulmonary pressures are near systemic. We share our experience of 20 cases of VSD with near systemic pulmonary pressures managed by double flap patch closure and use of pulmonary vasodilators.
Methodology: 20 children having VSD with severe PHT those with near systemic pulmonary pressures (aorto-pulmonary pressure difference < 10mm hg) were included in the study. All children were treated pre-operatively with oral sildenafil. Intraoperatively, we administered half the dose of phenoxybenzamine directly into main pulmonary artery just before cross-clamping. We closed the VSD in all cases by double flap patch closure technique using goretex patch. All children were weaned off bypass with the use of phenoxybenzamine, milrinone, adrenaline and dopamine infusion and continued post-operatively. All children were electively ventilated for 24-72 hours. Elective tracheostomy was done if unable to wean after 72 hours. Children were also started on oral sildenafil and bosentan as needed.
Results: Of the twenty children, seven were in the age group 1-5 years and thirteen were in the age group 6-10 years. Average duration of ventilation was 114 hours. 11 children needed tracheostomy. Average duration of ICU stay was 7-8 days. Complications encountered were PHT crisis, RV failure, Heart block and Reintubation. Mortality was encountered in 2 cases the cause being RV failure and septicemia. All remaining 18 children remained stable during follow up. Shunt across the flap valve disappeared in 16 children by 6 months. PHT regressed to mild/moderate levels in 15 children by 1 year duration.
Conclusion: Ventricular septal defects with severe PHT children can be effectively managed by double flap patch closure surgical technique with judicious use of pulmonary vasodilators.
The role of preoperative cardiac catheterisation in predicting outcomes of surgery for shunt- associated PAH
Pooja Shetty, Prayaag Kini, C S Hiremath, Krishna
SSIHMS, Whitefield, Bengaluru
Objective: This study was conducted to determine the efficacy of cath study for determination of operability in shunt lesions and to analyse whether an improvement in pulmonary saturation alone, a fall in pulmonary artery mean or diastolic pressure or a combination of the two was better in prognosticating postoperative outcomes especially post-operative PAH and need for continuing milrinone longer in the post-op period.
Methods: 100 (M=62, F=38) patients who had PAH due to associated shunt lesions were serially studied between Jan 1, 2013 to Jan 1, 2016. 62 patients received a three-months course of sildenafil and then cathetrised. All 100 patients underwent a preoperative cath study and pulmonary artery systolic and end-diastolic pressures, pulmonary and systemic saturation, pulmonary wedge pressures, systemic saturation, were measured and the same parameters after administration of 100% oxygen for 10 minutes.
Results: Average age of the patients was 12.8+/-1.28 years. Of the 100 patients who underwent cath, (ASD=20, VSD =43, PDA=20, AVCD=8, APW =4,TAPVC=4, Lutembacher=1), longer ICU stay( mean 5.5+/- 2.2 days) and ventilation, and need for continuing milrinone( more than three days) was seen in 34 patients. Follow-up data was available in 91 patients. Multivariate regression analysis and Pearsons rank linear correlation co-efficients were calculated for each of the hemodynamic parameters in correlation with the immediate post-op residual PAH and PAH at third month follow-up.
Good inverse co-relation of postop and residual PAH was seen with degree in fall in PA end diastolic pressure (r=0.72 ). The strongest correlation was seen with combination of both fall in PAEDP and improvement in pulmonary artery saturations (r=0.77), indicating best outcomes and least post-op and residual PAH.
Conclusion: The study inferred that a combination of both fall in PAEDP and improvement in pulmonary artery saturation with oxygen administration during preoperative cath may be a better prognosticator of post-operative outcomes in patients with shunt-associated PAH, than a fall in the PA mean alone or a fall in PVR alone, or improvement in PA saturations alone which amounts to lesser post-operative residual PAH and shorter ICU ventilator need with lesser need for continuing milrinone for postoperative residual PAH.
Bidirectional Glenn on Cardiopulmonary Bypass: A comparison of Three Techniques
Sachin Talwar, ManikalaVinod Kumar,Ashima Nehra, Poonam Malhotra Kapoor,Neeti Makhija,Vishnubhatla Sreenivas, Shiv KumaryChoudhary,Balram Airan
Departments of Cardiothoracic and Vascular Surgery, Clinical Neuropsychology, Cardiac Anaesthesiology& Biostatistics, All India Institute of Medical Sciences,New Delhi, India
Objective: To analyze the intraoperative and early results of the bidirectional Glenn (BDG) procedure performed on cardiopulmonary bypass (CPB) using three different techniques.
Methods: Between September 2013 and June 2015, 75 consecutive patients (Meanage 42.2±34.4 months) undergoing BDG wererandomly assigned to either Technique I: Open anastomosis or Technique II: SVC (superiorvenacava) cannulation orTechnique III: intermittent SVC clamping. We monitored the cerebral NIRS (near infrared spectrophotometry), SVC (superior vena cava) pressure, CPB time, ICU (intensive care unit )stay, and neurocognitive function.
Results:Patients in technique III had abnormal lower NIRS values during the procedure (57 ±7.4) compared to technique I and II (64 ±7.5 and 61 ±8.0, p=0.01). Postoperative SVC pressure in technique III was higher than other two groups (17.6 ±3.7 mmHg v/s 14.2 ±3.5 mmHg and 15.3 ±2.0 mmHg in technique I and II respectively, p=0.0008). CPB time was highest in technique II (44 ±18 min) compared to technique I and III (29 ±14 min & 38 ±16 min, p=0.006) respectively. ICU stay was longer in technique III (30 ±15 hours) compared to the other two techniques (22 ±8.5 hours and 27 ±8.3 hours in techniques I and II respectively, p=0.04). No patient experienced significant neurocognitive dysfunction.
Conclusion: All techniques of BDG provided acceptable results. The open technique was faster and its use in smaller children merits consideration. The technique of intermittent clamping should be used as a last resort.
Polytetrafluoroethylene patch versus autologous pericardial patch for right Ventricular outflow tract reconstruction
Sachin Talwar, IntekhabAlam, PalletiRajasekhar, Sivasubramanian Ramakrishnan, Shiv Kumar Choudhary, BalramAiran
Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi – 110029, India
Objective:Patients of TOF with pulmonary annular hypoplasia, reconstruction of right ventricular outflow tract (RVOT) often requiresa trans annular patch (TAP). The present study aims to compare the outcomes of TOF repair usingPolytetrafluoroethylene (PTFE) patch versus autologous glutaraldehyde fixed pericardial patchRVOT reconstruction.
Materials and methods: 103 consecutive patients undergoing TOF repair in whom TAP was required were randomized into two groups: Group I (pericardial patch), Group II (PTFE patch). Postoperative outcomes in terms of postoperative heart rhythm, duration of mechanical ventilation, mediastinal and pleural drainage, length of stay in intensive care unit (ICU) and hospitalmortality were assessed. A separate team of cardiologists independently evaluated pre and postoperative gradients across the RVOT, degree of pulmonary insufficiency, right ventricular systolic function.
Results:There were no significant differences between the two groups in terms of the incidence of postoperative arrhythmias, duration of mechanical ventilation, length of intensive care unit or hospital stay. The requirement of inotropes was no different in the PTFE patch group as compared to the Pericardial patch group (16.84 ± 7.04 vs. 17.90 ± 6.71, median 19vs. 20, P =0.825). The re-exploration rate was higher in the PTFE group as compared to thepericardial patch group (6vs. 1). Postoperative Echocardiography revealed no difference in the RV systolic function between the two groups before discharge.
Conclusion:In patients undergoing TOF repair, using a PTFE patch yields comparable results. However, the efficacy of PTFE will only be established once mid-termand long-term results are available.
Results of surgery for discrete membranous subaortic stenosis
SachinTalwar, Abhishek Anand, Shiv KumarChoudhary, Balram Airan
Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi, India
Background: We reviewed the long term results of surgery for discrete subaortic membrane from a single institute.
Methods: A retrospective review of medical records of all patients (n=148) who underwent resection of subaortic membrane (SAM) for discrete subaortic stenosis between 1990 and 2015 at the All India Institute of Medical Sciences, New Delhi, India was undertaken.
Results: Median age at surgery was 9.0 years (9 months -47 years). There was one early death. Preoperative peak left ventricular outflow tract (LVOT) Doppler gradient was 83.4 ± 26.2 mmHg (range: 34 to 169 mmHg) and aortic regurgitation (AR) was present in up to 52.5% of patients (No AR- 47.5%, Mild AR – 25.7%, Mod AR- 19.8%, Sev AR- 6.9%). The LVOT gradient reduced to 15.1 ± 6.2 mm Hg and the difference was significant (p<0.001). The actuarial freedom from gradients were 93.2 ± 0.03 % at 5 years, 88.5 ± 0.04% at 10 years and 78.1 ± 0.07% at the end of 15 years of followup. 14 patients (9.4%) who have had residual/recurrent significant gradients are on medical followup or awaiting surgery. Overall there was improvement in AR for operated patients with freedom from AR of 92.6 ± 0.03% at 15 years. Freedom from reoperation at 15 years was 94 ± 0.03%.Overall Kaplan-Meier survival at 10 years was 93.0 ± 3.9% (95% CI: 79.6, 97.7).
Conclusions: The overall long term results of surgery for discrete SAM are acceptable. Resection of membrane along with septal myectomy decreases the risk of recurrence.
Immediate and early post operative sequelae of off-pump total cavopulmonary connection
Sachin Talwar, Aabha Divya, Neeti Makhija, Shiv Kumar Choudhary, Balram Airan
Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
Background: Extracardiac total Cavopulmonary venous connection (TCPC) is emerging as the operation of choice in single ventricle palliation. In our study, we used off pump extracardiac TCPC to effectively avoid the harmful sequel of CPB and reduce subsequent long term ICU and hospital stay.
Methods: Between 2012 and 2015, 72 consecutive patients, underwent single ventricle palliation via TCPC without cardiopulmonary bypass.
Results: Intraoperatively, mean SVC clamp time was 15.19±3.8min and IVC clamp time was 16.93±3.31 min. In the early results, there were three early deaths. One patient required revision of the Fontan circuit due to narrowing at the anastomosis between the graft and the inferior vena cava that was caused by placement of excessive sutures to control bleeding. No patient required conversion from off CPB to CPB. The median inotropic score was 4.73±5.9, mean time to extubation was (9.5±5.82 hours), drainage in ICU was 551.57 ml±452.77 ml and average ICU stay was 2.27±3.09days. The average daily pleural drainage was 163.7±88.01 ml, time to removal of pleural tubes was 15.76±8.4 days and the total hospital stay was 17.03±8.62 days. In immediate follow-up, all surviving patients (n=69) reported to be doing well subjectively with normal ventricular function on echocardiography. Patients continued to remain on antiplatelet and anticoagulation therapy (INR≈2.0). No thrombotic events were reported.
Conclusions: Off pump extracardiac TCPC is a low risk procedure, effectively avoiding the harmful effects of CPB and improving early post-operative course. There is decreased ICU stay resulting in lesser ICU expenses. Decrease in patient morbidity is seen with lower pleural drainage and shorter hospital stay.
Mid-Term Results Of Correction Of Tetralogy Of Fallot With Absent Pulmonary Valve
Sachin Talwar, Aabha Divya, Shiv Kumar Choudhary, Balram Airan
Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India.
Background: Tetralogy of Fallot and absent pulmonary valve (TOF/APV) is associated with significant pulmonary artery dilatation and airway compression.
Methods: We performed a retrospective review of 73 consecutive patients who underwent repair for TOF/APV between January 2005-August 2015. Mean age was 6.4±5.6 years (28 days—22 years). The right ventricular outflow tract (RVOT) was reconstructed using varied techniques. Freedom from RVOT gradients and re-operation was studied.
Results:There were four (5.5%) early deaths, two each in infants and older children. Median ICU stay was 2 days (range, 1 to 12 days). Mean ICU stay for, infants (<1 year old) and children (1-18 year old) and adults (>18 year), was 6.5±6.04, 2.75±2.45, and 2.33± 1.03 days, respectively (p=0.0762). Median hospital stay was 6 days (range, 4 to 15 days). Mean hospital stay for, infants and children and adults was 7±2, 78 days, 675±2.39, and 6.33± 1.63 days, respectively (p=0.325). Mean follow up was 65 ± 36.6 months (median 56 months, range 7 to 126 months). Fourteen (21.21%) had no pulmonary regurgitation as compared to 21 (31.81%) patients, 8 (12.12%) patients and 19 (28.78%) patients had mild, moderate and severe pulmonary regurgitation. There were five (7.5%) reoperations.
Five and ten year survival was 95% ± 2.12 and 92.3 %±3.45 respectively. Freedom from RVOT reoperation was 93 ±2.62% and 89±3.87% at 5 and 10 years.
Conclusions: In contrast to children and adults with TOF/APV, infants carry significant early mortality. But the mid-term outcome for patients who survive the initial repair of TOF/APV is acceptable.
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Abstracts of the 63 rd Annual Conference of IACTS, February 2017 . Indian J Thorac Cardiovasc Surg 33, 74–101 (2017). https://doi.org/10.1007/s12055-017-0489-y
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DOI: https://doi.org/10.1007/s12055-017-0489-y