Anticoagulation in pregnant women with mechanical heart valve prostheses: Case reports and a literature review.

The choice and regimen of anticoagulation therapy in pregnant women with mechanical valve prostheses have always been a daunting task. It is a delicate balance that takes into consideration the risk of thromboembolic complications in the mother and the risk of potential Warfarin embryopathy to the foetus. Medical practice in a low socioeconomic setting also has the peculiar challenge of financial constraints on the part of the patients and difficulties in monitoring the efficacy of anticoagulation therapy. We report our experience in managing two pregnant women with mechanical valve prostheses and review the existing literature on this complex but interesting subject.

The challenges of cardiothoracic surgery practice in Nigeria: a 12 years institutional experience.

BACKGROUND: Although the specialty of cardiothoracic surgery has been practiced in Nigeria for many years, open heart surgery (OHS) has only in the last decade become relatively more frequent, mainly through visiting foreign cardiac surgical teams. At this early phase of development it is faced with multiple challenges, especially financing and local skilled manpower for which solutions have to be identified in order to ensure sustainability and future growth. This study is aimed at highlighting these obstacles to growth of cardiothoracic surgery based on our own institutional experience at Lagos State University Teaching Hospital (LASUTH) and the current status of OHS activity in other cardiothoracic centers in Nigeria. METHODS: Prospectively acquired data from our center from March 2004 to December 2015 was reviewed. A telephone survey was also conducted with all other institutions in Nigeria performing cardiac surgery. RESULTS: During the study period 1,520 patients underwent various procedures with a mean age of 37±22.4 years and 813 (53.5%) were males. There were 450 major procedures (29.6%), 889 minor procedures (58.5%) and 181 endoscopic procedures (11.9%). The top ten clinical diagnoses were empyema thoracis (17.5%), malignant pleural effusion (14.7%), chest trauma (12%), hemodialysis access (6.1%), bradyarrhythmia (5.3%), aerodigestive foreign bodies (4.1%), vascular injury (3.9%), pericardial disease (3.8%), lung cancer (3.6%) and congenital heart disease (3.4%). The range of procedures was chest tube insertion (41.6%), endoscopy (11.9%), lung procedures (7%), arterio-venous fistula (6.1%), pacemaker implantation (5.3%), vascular repair (4.4%), OHS (3.4%), esophageal procedures (2.6%), chest wall surgery (2%), video assisted thoracic surgery (2%), closed heart surgery (1.6%), diaphragmatic procedures (1.6%) and thymectomy (1%). Survey of 15 centers in Nigeria with cardiac surgery activity showed a total of 496 OHS cases between 1974 and 2016, with 330 cases (66.5%) done between 2012 and 2016. CONCLUSIONS: Infections, malignancy and trauma currently account for the bulk of cardiothoracic surgery practice in Nigeria, with surgical activity showing a predominance of minor procedures and comparatively minimal OHS activities. Identified challenges to increasing cardiothoracic surgical activity were limitations in manpower development, infrastructure, laboratory support, local availability of consumables, cost of surgery, funding mechanisms for surgery, multiple models for development of cardiac surgery, decentralization of efforts and lack of outcome data. Data collection and reporting of results must be started to enable development of more evidence-based practice.

Off Pump Coronary Artery Bypass Surgery for Multivessel Disease in Pregnancy.

A 31 year old female with known history of coronary artery disease and percutaneous coronary intervention presented with acute coronary syndrome. Unknown that patient was pregnant she had inadvertent radiation exposure to the fetus during cardiac catheterization which showed triple vessel disease and severe left ventricular dysfunction. Patient subsequently underwent multivessel off pump coronary artery bypass surgery with intraaortic balloon pump support after declining the recommendation for abortion. Postoperative course was uneventful and patient subsequently delivered a full term healthy baby several months later.Off pump revascularization with its ability to maintain pulsatile perfusion to the fetus should be considered if technically feasible for severe coronary artery disease requiring surgery during pregnancy.

Commencing open heart surgery in resource limited countries: lessons from the LASUTH experience.

The challenge of commencing cardiac surgery in developing countries of Africa is onerous. We present a model from the experience of carrying out open cardiac surgical procedures at the Lagos State University Teaching Hospital (LASUTH) with three separate missions between 2004 and 2006. This paper details the challenges of starting open heart surgery in a resource limited environment. We propose that owing to the huge financial investment needed, government sponsorship as well as collaboration with overseas based and local non-governmental agencies may be required to jump start the process of open cardiac surgery. Local staff training opportunities are also provided by such missions and this can further be complemented by overseas exposure in areas of need for capacity building. In our centre, the initial investment has led to the recruitment of additional trained staff including 2 cardiothoracic surgeons. Further benefits of training of 2 perfusionists and a nurse has improved capacity in cardiac surgery service at our center.

Heart surgery in end-stage renal disease: is outcome worse for african american patients?

General results of open heart surgery in end-stage renal disease patients (ESRD) have been well-documented. However, it is unknown if the African American subgroup with known decreased access to advanced healthcare services and a higher prevalence rate of ESRD have a worse long-term survival after heart surgery. Thirty of 150 African American patients who underwent open heart surgery by a single surgeon at an urban community hospital between 1996 and 2010 were identified to have ESRD and were on chronic maintenance hemodialysis prior to surgery. Clinical and outcome data from both groups were retrospectively analyzed. There were no significant differences in the baseline demographic characteristics of the patients, but the ESRD cohort showed a significantly higher prevalence of peripheral vascular and cardiovascular diseases [P < 0.001]. Compared to the non-ESRD subjects, the predicted logistic EuroSCORE was 16.4% vs. 9.4%, [P < 0.001], while the observed 30 days operative mortality was 16.6% vs. 4.2% [P < 0.02], respectively. In isolated coronary artery bypass graft cases, operative mortality was 20.8% and 3.0%, respectively. The 5- and 10-year post-surgery survival was 40% and 25% vs. 72% and 57% [P < 0.01], respectively, in the ESRD and non-ESRD groups. Operative mortality and survival was worse in ESRD patients compared to non-ESRD patients based on their preoperative risk scores. Although the operative mortality of our ESRD patients was high, long-term survival was comparable to reports from both the United States Renal Data System and a Japanese ESRD cohort.

Self-expanding stents in treatment of esophageal leaks post bariatric surgery.

The Alimaxx self-expanding metal stents were used in two morbidly obese patients with esophageal leaks complicating reoperative bariatric surgery. Although the patients could be maintained on oral intake with their sepsis controlled, surgery was ultimately required for non-healing after 3 weeks of conservative management. Self-expanding metal stent should be considered the preferred treatment in small esophageal leaks less than 1 cm in morbidly obese patients who generally pose a higher operative risk due to concomitant co-morbidities. Stents are also useful adjuncts in patients with larger leaks that are either inoperable or need further stabilization at presentation and those preferring an initial 2-3 weeks trial of conservative management before contemplating surgery.

Isolated severe tricuspid regurgitation in a post pneumonectomy patient with chronic atrial fibrillation.

Severe primary tricuspid regurgitation is a rare entity, with most cases of tricuspid regurgitation being functional and secondary to pulmonary hypertension from left heart pathologies. We report an unusual case of a female patient with a history of left pneumonectomy and chronic atrial fibrillation many years earlier, and who subsequently developed tricuspid annular dilatation, resulting in severe isolated primary tricuspid regurgitation despite normal pulmonary artery pressures and left ventricular systolic function. She required multiple hospitalizations for right heart failure and continued to be NYHA class IV despite receiving maximal medical management. She finally underwent an isolated tricuspid valve ring annuloplasty, which gave her symptomatic relief. Postoperatively, she improved to NYHA class 1-II still with chronic atrial fibrillation and mild to moderate tricuspid regurgitation at the time of her death 9 years later from pneumonia.

Right atrial papillary fibroelastoma.

Papillary fibroelastoma (PFE) is a benign cardiac tumor rarely seen in the right atrium and often misdiagnosed as atrial myxoma or thrombus. We report one such case found in the right atrium during workup in a patient presenting with transient ischemic attack (TIA). PFEs are found most frequently in the valvular endocardium of the left heart. When encountered in the right heart and symptomatic, they tend to be larger in size presumably due to a longer latent period of growth. Although histologically the tumors are benign, they have the potential for fatal complications due to their propensity to embolize.

Arrow injury to the heart.

Arrow injury to the heart is a common cause of penetrating trauma in rural areas of underdeveloped nations. We report such a patient who survived 3 days after such an injury and traveled 1000 km with a pulsating arrow in the chest for treatment. The literature on such injuries is reviewed.