Histopathological changes in the right atrial appendages triggering atrial fibrillation: A tertiary care center study.

BACKGROUND: Atrial fibrillation(AF) is as an abnormal irregular rhythm with chaotic generation of electrical signals in the atria of the heart. Various studies in the West have proved that atrial substrates, like isolated atrial amyloidosis can trigger the development of atrial fibrillation. In India, these structural changes have been analyzed on autopsied hearts. AIM: To determine the role of Atrial Amyloid as a substrate for Atrial fibrillation in ante mortem hearts. METHODS AND RESULTS: Atrial appendages were obtained from seventy five patients undergoing open heart surgery at a tertiary care hospital in south India. They were stained with Hematoxylin &Eosin, Masson's Trichrome and Congo red stains and were examined for myocarditis, fibrosis and amyloidosis, respectively. 30 (40%) patients were in AF. Amyloid deposits were seen in 3 cases. All the three were in AF and had undergone mitral valve replacement (MVR) (P<0.05). 2 out of the 3 amyloid-positive cases showed active myocarditis and severe scarring but there was no statistically significant correlation between these factors. CONCLUSION: Amyloid and myocarditis, independently act as an arrythmogenic substrates in the development of atrial fibrillation and are also increasingly associated with female gender and MVR. We hypothesize that the amyloid deposits are due to isolated atrial amyloidosis as they were seen only in young individuals. Some patients in sinus rhythm (SR) had large left atria and myocarditis and probably are at a higher risk for developing AF. Hence, follow-up of these patients is required for prevention of severe organ damage and timely therapeutic intervention.

Re-implantation of an anomalous right coronary artery arising from the left coronary sinus and coursing between the great arteries.

The patient with a coronary artery anomaly remains a treatment dilemma. We present a 62-year-old woman who underwent re-implantation of her anomalous right coronary artery (ARCA) from the left coronary sinus and describe our techniques according to potential anatomic variations of ARCA. The ARCA from the left coronary sinus is increasingly being recognized as a cause of angina, acute myocardial infarction, syncope, and sudden death. We describe a case that was treated by direct coronary artery re-implantation into the right coronary sinus and suggest that this technique be the first considered when planning surgical correction.

Cutaneous microangiopathic thrombosis complicated by pyoderma gangrenosum in post-cardiac surgery heparin-induced thrombocytopaenia.

Thrombotic cutaneous gangrene is a rare complication of heparin-induced thrombocytopaenia after cardiac surgery. We report a case and discuss management issues with cardiopulmonary bypass for cardiac surgery in this condition.

Concomitant diaphragmatic hernia repair with coronary artery bypass grafting surgery.

Congenital Bochdalek diaphragmatic hernia (DH) is often diagnosed incidentally in adulthood. It is recommended that all cases of DH be repaired immediately at diagnosis since acute presentation after the complications have already developed has higher morbidity and mortality. A 47-year-old male presented with Grade III angina and dyspnea. A routine chest radiograph revealed bowel shadows in the right thorax, and subsequent computerized tomography (CT) scan confirmed the same. Coronary angiogram revealed coronary artery disease which needed surgery. Off-pump coronary artery bypass grafting followed by DH repair under one-lung ventilation.

Coronary artery to pulmonary artery fistula with dual origin--embryological, clinical and surgical significance.

Coronary artery fistulae are rare anomalies encountered in 0.1-0.2% of angiographic series. We recently encountered a patient evaluated for mitral valve disease who incidentally had bilateral coronary artery fistulae detected on preoperative angiogram. These fistulae drained into the pulmonary artery. She underwent successful transpulmonary closure of the fistula along with mitral valve repair. We discuss the embryological basis of this anomaly and the clinical as well as surgical significance.

Emergency surgery after percutaneous transmitral commissurotomy: operative versus echocardiographic findings, mechanisms of complications, and outcomes.

OBJECTIVE: This study was undertaken to determine the clinical profile of patients undergoing emergency surgery after balloon mitral valvotomy, to note operative findings and compare them with those of transthoracic echocardiography, to describe the mechanisms of complications, and to describe outcomes. METHODS: A retrospective study was undertaken of patients requiring emergency surgery after percutaneous mitral valvotomy with an Inoue balloon from January 1990 to December 2003. The data analyzed included demographic variables, causes and clinical presentations of complications, and outcome. In 14 consecutive cases of mitral regurgitation, an observational study comparing the operative findings with echocardiography was also undertaken. RESULTS: In 1388 cases of valvotomy, complications necessitating urgent surgery occurred in 31 cases (2.2%). Acute mitral regurgitation occurred in 23 cases (74.2%), and cardiac tamponade occurred in 8 cases (25.8%). Mitral regurgitation was due to leaflet tearing in all cases: anterior leaflet in 20 cases and posterior leaflet in 3 cases. Hypotension, orthopnea, and pulmonary edema were the clinical presentation for mitral regurgitation. Transthoracic echocardiography underestimated the severity of mitral valve pathology. Bilateral severe commissural fusion and pliable leaflet with paracommissural calcium was seen in anterior leaflet tearing. Cardiac tamponade with hemodynamic compromise occurred as a result of left atrial perforation in 6 cases, right atrial perforation in 1 case, and left ventricular perforation in 1 case. High septal puncture led to atrial perforation. Operative mortality was 9.6%, and low cardiac output developed in 29%. CONCLUSION: Acute mitral regurgitation and cardiac tamponade were the causes of emergency surgery after balloon valvotomy. Transthoracic echocardiography underestimated the severity of valve pathology.

Late thoracic aortic dissecting aneurysm following balloon angioplasty for recoarctation after subclavian flap aortoplasty in childhood--successful surgical repair under circulatory arrest.

Balloon angioplasty is universally accepted presently as the primary therapeutic strategy for recoarctation following surgery during infancy and early childhood. This report concerns a 26-year-old lady with cephalobrachial hypertension on beta-blocker who presented with left sided chest pain since 3 months, having undergone surgery for coarctation in early childhood and balloon angioplasty at 17 years of age. Chest X-ray showed prominent aortic knuckle. CT scan chest showed features of residual coarctation with "double-barrelled" upper thoracic aorta of 5cm diameter. Surgery consisted of interposition graft repair of distal arch and upper thoracic aorta under total circulatory arrest through posterolateral thoracotomy leading to excellent recovery.

Comparison of tapentadol with tramadol for analgesia after cardiac surgery.

BACKGROUND: Tapentadol is a relatively new analgesic. We decided to compare it with tramadol for their various effects after cardiac surgery. SETTING: A study in a tertiary care hospital. MATERIALS AND METHODS: Sixty adults undergoing cardiac surgery were divided into 2 groups of 30 each by computerized random allotment (Group X = tapentadol 50 mg oral and Group Y = tramadol 100 mg oral). Informed Consent and Institutional Ethics Committee approval were obtained. The patients were given either drug X or drug Y after extubation in this single blinded study, wherein the data collectors and analyzers were blinded to the study. All patients received oral paracetamol qds and either drug X or drug Y tds. The pain score was noted on a Visual Analog Scale before each drug dose, 3 h later and on coughing. Heart rate, respiratory rate, and blood pressure were recorded before the drug dose and 3 h later. Postoperative nausea or vomiting (PONV), temperature, and modified Glasgow Coma Scale readings were recorded. The above readings were obtained for 6 doses (up to 48 h after extubation). STATISTICS: t-test, Pearson Chi-square test, Fisher exact test, and Mantel-Haenszel test were used for statistics. RESULTS: Tapentadol group patients had significantly better analgesia 3 h after the drug and "on coughing" than tramadol group. The difference in their effects on blood creatinine levels, temperature, hemodynamics, oxygen saturation, and respiratory rate were not clinically significant. Tapentadol produced lesser drowsiness and lesser vomiting than tramadol. CONCLUSIONS: Tapentadol, due to its norepinephrine reuptake inhibition properties, in addition to mu agonist, is a better analgesic than tramadol and has lesser PONV.

Implications for cardiac surgery in patients with factor XII deficiency.

Factor XII deficiency is associated with a prolonged activated partial thromboplastin time and activated clotting time used for monitoring during cardiopulmonary bypass. It does not predispose to an increased risk of bleeding. We present the strategy used for a case of coronary artery bypass grafting in a patient with factor XII deficiency, followed by a brief discussion of the important clinical considerations when patients with factor XII deficiency undergo cardiac surgery. Monitoring of heparin and the avoidance of anti-fibrinolytic agents are the main intraoperative issues. Postoperative care must include careful thromboembolic prophylaxis and vigilance against infection.

Diffuse coronary artery spasm treated by extracorporeal membrane oxygenation.

Diffuse coronary vasospasm is an unpredictable and serious complication following coronary artery bypass surgery. The treatment of this emergency is dependent on patient suitability for angiography and direct injection of vasodilators into the affected vessels. In patients unable to proceed to angiography the diagnosis can only be suspected but treatment is nevertheless still towards reinstitution of coronary blood flow. We present one such case in which re-grafting and extracorporeal membranous oxygenation proved successful in restoring cardiac function in a patient with diffuse coronary artery spasm.

Late presentation digital ischemia after radial artery harvest for coronary artery bypass.

The radial artery is increasingly being used as a coronary artery bypass graft. Morbidity from harvesting is rare, yet it does occur. We present a case of digital ischemia presenting late after surgery and suggest that although preoperative assessment may be normal, comorbidities such as collagen vascular disease in conjunction with atherosclerotic peripheral vascular disease should be carefully considered as a contraindication to radial artery harvest.

Surgical management of invasive pulmonary fungal infection in hematology patients.

BACKGROUND: The purpose of this study was to analyze our institutional results with pulmonary resection in neutropenic patients with hematologic malignancies and suspected invasive pulmonary fungal infections. METHODS: We performed a retrospective medical record review of 25 immunocompromised patients with hematologic malignancies who underwent pulmonary resection between 2000 and 2007. We analyzed preoperative diagnostic technique, degree of pulmonary resection, and postoperative morbidity and mortality to determine whether surgery is a viable treatment option in this subset of patients. RESULTS: Twenty-three of 25 patients had a minithoracotomy compared with 2 who had video-assisted thorascopic surgery resection only. Thirteen had wedge resections, 9 had lobectomies, and 3 had segmentectomies. Early surgical morbidity was 2 of 25, involving 1 pneumothorax and 1 empyema. In-hospital mortality was 2, with 1 death primarily related to surgery. Median survival was 342 days, and survival was significantly better in patients with only one lesion. No patient experienced late recurrence of invasive pulmonary fungal infection. Resected pulmonary tissue also provided the best chance for a proven diagnosis in 19 of 25 (76%). CONCLUSIONS: This study confirms that pulmonary resection in high-risk immunocompromised patients with suspected invasive fungal infection can be carried out with excellent operative morbidity and mortality.

Long-term patency of 1108 radial arterial-coronary angiograms over 10 years.

BACKGROUND: To avoid late vein graft atheroma and failure, we have used arterial grafts extensively in coronary operations. The radial artery (RA) is the conduit of second choice. This study determined the long-term patency of the RA as a coronary graft. METHODS: Two independent observers evaluated 1108 consecutive postoperative RA conduit angiograms performed between January 1997 and June 2007 for cardiac symptoms. Mean time to postoperative angiography was 48.3 months (range, 1 to 132 months). An RA graft was considered failed (nonpatent) if there was stenosis exceeding 60%, string sign, or occlusion. Patency was determined over time, by coronary territory grafted and by the degree of native coronary artery stenosis (NCAS). RESULTS: At a mean of 48.3 months, 982 of the 1108 RA grafts (89%) were patent. RA patencies for the left anterior descending were 96% (24 of 25), diagonal/intermediate, 90% (121 of 135); circumflex marginal, 89% (499 of 561); right coronary, 83% (38 of 46); posterior descending, 89% (253 of 286); and left ventricular branch/posterolateral, 86% (47 of 55). Patency was 87.5% (56 of 64) for NCAS of less than 60% compared with 89% (926 of 1044; p = 0.89) for NCAS exceeding 60%. Of 318 RAs in place more than 5 years, 294 (92.5%) were patent, and for 107 RAs in place for more than 7 years, 99 were patent (92.5%). Patency was consistent through each year of the decade. Mechanisms of failure did not involve development of atherosclerosis. Patent RA grafts were smooth, with no angiographic evidence of atheroma. CONCLUSIONS: Late patencies of RA grafts are excellent and justify continuing use of the RA in coronary operations.

Safe use of recombinant activated factor VIIa for recalcitrant postoperative haemorrhage in cardiac surgery.

The aim of this case series is to review the effect of recombinant activated factor VIIa (rFVIIa) on refractory haemorrhage, despite aggressive treatment with conventional blood products and medications at our institution. All patients undergoing cardiac surgery who received rFVIIa as rescue therapy for persistent uncontrollable haemorrhage were studied. We examined coagulation immediately before and after rFVIIa was given; international normalized ratio (INR), activated partial thromboplastin (APTT) fibrinogen and platelet levels, in addition to the use of red cell and non-red cell blood products, morbidity and mortality. Thirty patients (0.6%) received 31 doses of rFVIIa for bleeding refractory to conventional treatment. Twenty received rFVIIa in theatre after primary surgery, three after re-exploration and eight in the intensive care unit (ICU). Hospital mortality was 6.5% (2/30) and there were no documented thromboembolic phenomena. There was significant reduction in red blood cell and product transfusion before and after rFVIIa administration (P<0.001). There was significant correction in coagulation parameters after rFVIIa. Recombinant FVIIa appears to be safe, and is effective in reducing red blood cell and product transfusion requirements and may impact on early and late outcomes in this small complex subgroup of patients.

Contemporary results show repeat coronary artery bypass grafting remains a risk factor for operative mortality.

BACKGROUND: Reoperative coronary artery bypass grafting (redo CABG) shows improving outcomes, but with varying degrees of improvement. We assessed contemporary outcomes after redo CABG to determine if redo status is still a risk factor for early postoperative complications and midterm survival. METHODS: Isolated CABG procedures (June 1, 2001 to May 31, 2008) within the Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database were included. Redo status as a predictor for early outcomes was assessed with logistic regression analysis. Midterm survival was determined from the National Death Index. Effect of redo status on midterm survival was assessed using a Cox proportional hazards model. RESULTS: Inclusion criteria were met by 13,436 patients, and 458 (3.4%) underwent redo CABG. Operative mortality was 4.8% for redo CABG and 1.8% for first-time CABG (p < 0.001). After adjustment, redo status remained a predictor for operative mortality (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.3 to 3.6), myocardial infarction (OR, 2.8; 95% CI, 1.6 to 6.0), and prolonged ventilation (OR, 1.5; 95% CI, 1.1 to 2.0). Unadjusted survival was lower for the redo CABG group vs the first-time CABG group at up to 6 years (p = 0.01, log-rank test. After adjusting for differences in patient variables, redo status was not a predictor of midterm survival (OR, 1.03; 95% CI, 0.78 to 1.35; p = 0.85). CONCLUSIONS: Early postoperative outcomes of redo CABG are encouraging. Midterm survival is excellent; however, redo remains a significant risk factor for operative mortality in contemporary practice.

Surgical considerations in chronic pseudoaneurysms involving the celiac axis.

Aneurysms involving the celiac axis are rare. We present a case of thoracoabdominal aortic aneurysm involving the celiac artery origin. A 46-year-old man was diagnosed to have an aortic aneurysm, when he presented with a one year history of abdominal pain. He underwent a laparotomy for aneurysm repair at another institution and was deemed to be inoperable. He underwent surgical repair thoracophrenolaparotomy using a 'clamp and sew method'. Approach to the aneurysm, preservation of critical structures and collaterals, resulted in an excellent patient recovery.

Pulmonary hypertension alters natural history of anomalous left coronary artery.

A girl who was diagnosed at 8 months old with anomalous left coronary artery from the pulmonary artery and was subsequently lost to follow-up, presented at the age of 11 years with congestive heart failure and severe mitral regurgitation with supra-systemic pulmonary artery pressure. With progressive mitral regurgitation, coronary steal is reduced by the rising pulmonary artery pressure, and patients present late with severe valvular cardiomyopathy.