Ectopic atrial rhythm after superior septal approach to the mitral valve - an often under-reported entity.

Purpose: Very few reports elaborate on the changes in P wave following superior septal approach to the mitral valve. We aimed to describe the changes in the P wave axis and other electrocardiographic changes following this approach among patients preoperatively in sinus rhythm. Methods: We did a retrospective review of medical records among all our patients undergoing superior septal approach for mitral valve surgery from September 2014 to September 2019. Electrocardiograms during hospital stay and until 6-month follow-up were analyzed. A deviation in P wave axis from the normal range of + 30 to + 60° was classified as ectopic atrial rhythm. Results: In the study population of 47 patients (age 16-75 years, 51.3 ± 13.6 years; M:F ratio 3.7:1), who were in normal sinus rhythm preoperatively, 34 patients (72.3%) had a visible P wave on electrocardiogram (ECG) at discharge. Among them, the P wave axes of 17 patients (36.2%) were within normal range (normal sinus rhythm), whereas 17 patients (36.2%) had ectopic atrial rhythm at discharge. The most frequent abnormal P wave axis was between 0 and - 30° (12 patients). At 6 months, 8 patients (17.0%) had a persistent ectopic atrial rhythm. These patients underwent a Holter test at 6 months and were followed up for symptomatic bradycardia for 3 years. None of the patients with ectopic atrial rhythm required pacemaker insertion. Conclusion: Persistence of ectopic atrial rhythm at 6 months is common (17%) after superior septal approach. Documentation of P wave axis after this approach will help avoid missing it. These patients may be kept on follow-up to look for symptomatic bradycardia.

Left ventricular mass regression after aortic valve replacement with the TTK Chitra™ monoleaflet tilting disc valve.

Objective: To study the extent of left ventricular (LV) mass regression in aortic stenosis after aortic valve replacement with the TTK Chitra™ tilting disc valve. Methods and materials: This study included patients with severe isolated aortic stenosis (AS), admitted in our department. They had aortic valve replacement (AVR) with the TTK Chitra™ tilting disc valve, between January 2008 and December 2010. Data were collected from consecutive forty-eight patients. LV mass and diametric and functional parameters were recorded preoperatively and compared with echocardiography after 3 months, 6 months, then yearly, up to 3 years. Results: 70.8% of the patients were males and 29.2% were females. The mean duration of illness was 37.92 ± 25.87 months. The mean LV ejection fraction increased 3 months after surgery (61.56 ± 10.10% to 69.31 ± 9.34%) with a sustained increase for the next 3 years. The mean LV end-diastolic diameter decreased (50.16 ± 6.05 mm to 45.69 ± 5.93 mm) after 3 months of surgery, with a sustained decrease for the next 3 years. The mean LV end-systolic diameter decreased (32.84 ± 6.96 mm to 29.41 ± 5.86 mm) after 3 months of surgery and then showed a sustained decrease for the next 3 years. The LV mass assessed with echocardiography regressed from 324.65 ± 97.77 g before surgery to 252.64 ± 71.12 g after 3 months and then showed a sustained decrease over the next 3 years. Conclusion: Significant LV mass regression occurred after AVR with the TTK Chitra™ valve. The maximum reversal was found to be within the first 3 months after surgery with sustained beneficial improvement for the next 3 years.

Outcomes of Coronary Artery Disease Patients with Severe Left Ventricular Dysfunction Undergoing Surgical Management.

BACKGROUND: Surgical revascularization by coronary artery bypass grafting (CABG) is the gold standard treatment for coronary artery disease. But, in patients with severe left ventricular dysfunction (ischemic cardiomyopathy), the result of CABG is different from those with normal left ventricular function. The coronary artery disease pattern in the Indian subconti-nent is different from the western world, due to the diffuse nature of coronary involvement, the smaller size of native vessels, increased prevalence of diabetes mellitus and other risk factors, and more prevalence of severe left ventricular dysfunction. Most of the studies regarding the surgical outcomes in ischemic cardiomyopathy come from western countries. This study attempts to assess the outcomes of surgical management of ischemic cardiomyopathy in the Indian subcontinent. METHODS: A single-center retrospective cohort study was conducted at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram. The data of CAD pa-tients, who underwent surgical coronary revascularization for severe LV dysfunction from January 2010 to December 2014, were collected from the hospital records and through tele-phonic interviews in a structured study proforma. A total of 146 patients satisfied the criteria and were followed up for a period of 5 years. RESULTS: The mean age of the study population was 55.6 (8.8) years. Male preponderance was observed (94.52%; N = 138). CABG alone was done in 62.3% (N = 91) of the study partici-pants. CABG with linear plication was done in 23.3% (N = 34), CABG with MV repair in 7.5% (N = 11), and CABG with DORS in 6.8% (N = 10). The majority of patients (N = 54, 37%) received 4 grafts. Thirty-day mortality observed in the study population was 11 (7.5%). The causes documented were cardiac causes in 9 (82%), cerebrovascular events in one (9%), and septicemia in one (9%). The mean of 5-year survival of the study population was 94.2 (3.5) months with 95% CI 87.32, 101.13. There was a substantial improvement in the degree of mitral regurgitation. Ejection fraction (EF) also showed improvement. The mean preoperative EF was 29.51 (4.84%) and that of post-op was 39.92 (9.0%). CONCLUSION: Despite the challenges of diffusely diseased coronary arteries, severe LV dysfunction, addressing associated significant MR and ventricular aneurysms, the outcome of surgical management of CAD with severe LV dysfunction, in the Indian population can be done with acceptable results. Randomized control studies in this subset can provide more solid evidence in this regard.

Outcomes Following Supracoronary Ascending Aortic Replacement with Aortic Valve Resuspension versus Modified Bentall's Operation for Acute Type A Aortic Dissection

Abstract Introduction: Type A acute aortic dissection (AAD) remains a challenging cardiac emergency despite the availability of various management strategies. This study compared the outcomes of supracoronary ascending aortic replacement (SCAAR) with aortic valve (AV) resuspension with those of modified Bentall's operation for type A AAD and the progression of aortic regurgitation (AR), long-term dilatation of aortic root and proximal arch, and long-term mortality in SCAAR patients. Methods: Sixty patients underwent surgery for type A AAD (January 2005 to December 2015). Forty-three patients underwent SCAAR with AV resuspension and 17 underwent modified Bentall's operation. All patients were followed up. Results: Upon follow-up of SCAAR patients (n=40), there was significant reduction in aortic root size (preoperative 39.3 mm [9.4] vs. postoperative 33.1 mm [9.1]; P<0.001). Three of these patients worsened to severe AR while others had similar or lesser degree of AR. On comparison between preoperative and postoperative dimensions of all patients (n=53), there was no significant difference in distal ascending aorta size (35.7 mm [8.1] vs. 34.4 mm [8.9]; P=0.52). However, an increase in descending thoracic aorta size (28.8 mm [7.8] vs. 33.7 mm [9.9]; P<0.001) was observed. In-hospital and late mortalities for SCAAR vs. modified Bentall's procedure were 11.7% (seven patients) (7% [3] vs. 23.5% [4]) and 28% (15 patients) (15% [6] vs. 69% [9]), respectively. Conclusion: SCAAR with AV resuspension is a safe surgical option for type A AAD. Preservation of AV is associated with better long-term outcomes and reduced mortality. Modified Bentall's operation may be associated with long-term mortality.

Outcomes Following Supracoronary Ascending Aortic Replacement with Aortic Valve Resuspension versus Modified Bentall's Operation for Acute Type A Aortic Dissection.

INTRODUCTION: Type A acute aortic dissection (AAD) remains a challenging cardiac emergency despite the availability of various management strategies. This study compared the outcomes of supracoronary ascending aortic replacement (SCAAR) with aortic valve (AV) resuspension with those of modified Bentall's operation for type A AAD and the progression of aortic regurgitation (AR), long-term dilatation of aortic root and proximal arch, and long-term mortality in SCAAR patients. METHODS: Sixty patients underwent surgery for type A AAD (January 2005 to December 2015). Forty-three patients underwent SCAAR with AV resuspension and 17 underwent modified Bentall's operation. All patients were followed up. RESULTS: Upon follow-up of SCAAR patients (n=40), there was significant reduction in aortic root size (preoperative 39.3 mm [9.4] vs. postoperative 33.1 mm [9.1]; P<0.001). Three of these patients worsened to severe AR while others had similar or lesser degree of AR. On comparison between preoperative and postoperative dimensions of all patients (n=53), there was no significant difference in distal ascending aorta size (35.7 mm [8.1] vs. 34.4 mm [8.9]; P=0.52). However, an increase in descending thoracic aorta size (28.8 mm [7.8] vs. 33.7 mm [9.9]; P<0.001) was observed. In-hospital and late mortalities for SCAAR vs. modified Bentall's procedure were 11.7% (seven patients) (7% [3] vs. 23.5% [4]) and 28% (15 patients) (15% [6] vs. 69% [9]), respectively. CONCLUSION: SCAAR with AV resuspension is a safe surgical option for type A AAD. Preservation of AV is associated with better long-term outcomes and reduced mortality. Modified Bentall's operation may be associated with long-term mortality.

Diminished substrate-mediated cardiac mitochondrial respiration and elevated autophagy in adult male offspring of gestational diabetic rats.

OBJECTIVE: Heart diseases are common in offspring of gestational diabetic mother (ODM). Defects in mitochondrial metabolism and autophagy may be one of the basic reasons behind the abnormal structural and functional behaviour of offspring's heart. So the main objective of the present study was to explore the cardiac mitochondrial respiration and autophagy in male and female offspring of diabetic pregnancy at two different developmental stages of life. METHODS: High-resolution respirometry was used to measure substrate-mediated mitochondrial respiration in isolated mitochondria from ventricular tissues of offspring of streptozotocin-induced diabetic mother rats. To find the expression of proteins involved in autophagic process and oxidative stress, western blotting and densitometric analysis were done. RESULTS: Mitochondrial complex I and complex II respiration was found to be decreased in adult male offspring while it was unaltered or less affected in weaning male and female offspring. Elevated autophagy was shown by adult male, while there was no change observed in adult female. Also absence of elevated expression of oxidative stress markers was observed in all groups. CONCUSION: The present study reports altered cardiac mitochondrial respiration and autophagy in male offspring of diabetic mothers than the control ones. The study also analysed the expression of various candidates of cardiac autophagic process in male and female offspring of diabetic pregnancy at two time points of development.

Survival and long-term outcomes after concomitant mitral and aortic valve replacement in patients with rheumatic heart disease.

INTRODUCTION: Double valve replacement (DVR) with a mechanical prosthesis is associated with a higher risk of mortality. We planned to study the survival rate, early and late mortality and major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing DVR for rheumatic heart disease, with various generations of prosthetic valves ranging from ball in cage to bileaflet prosthesis and tilting disc valves. MATERIALS AND METHODOLOGY: We followed up 277 patients with rheumatic heart disease who underwent DVR between August 1999 and November 2009, retrospectively, at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram. Two hundred and fifty-nine patients were followed up for a minimum period of 10 years, and the follow-up period varied between 10 and 20 years. Eighteen patients were lost to follow-up after the surgery and could not be contacted. Their data was included till the time they appeared for follow-up last, for survival analysis. Survival analysis was carried out using the life table method to calculate the freedom from reoperation, survival rates and freedom from MACCE at 1 year, 5 years and 10 years post-DVR. RESULTS: The median duration of hospital stay was 8 days. The number of patients with stroke was 11 (4.26%), 21 (8.7%) and 29 (12%) at the end of 1 year, 5 years, and 10 years, respectively. A total of 5 (2%) patients underwent reoperation by the end of 10 years. Seven patients died either in hospital or in the first 30 days following operation, making the early mortality 2.5%. At the end of 1 year, a total of 16 patients (5.8%) died. The mortality at the end of 5 years was 6.8% (19 patients), and at the end of 10 years, it was 7.2% (20 patients). The survival rate of the study population was 94.9%, 93.02% and 93.02% at the completion of 1 year, 5 years and 10 years, respectively. The freedom from MACCE was 93.8%, 88.6% and 85% at 1 year, 5 years and 10 years, respectively. The freedom from re-operation was 98% at 10 years. Kaplan-Meier analysis showed an overall survival time of 226.3 months in the entire study population. The mean survival time in males was 227.5 months and in females was 206.3 months, with no statistically significant difference between the two. Univariate logistic regression analysis revealed an association with mortality when DVR was combined with concomitant tricuspid valve repair procedures, with an odds ratio of 4.5 (p value 0.005). Multivariate logistic regression analysis also showed an association with mortality when tricuspid valve procedures were combined with DVR with an odds ratio of 5.25 (p value 0.003). CONCLUSION: The operative mortality and morbidity for DVR have been significantly reduced with advancements in operative techniques, myocardial preservation and postoperative care. Patients can have an improved functional status following surgery, with good rates of freedom from re-operation and MACCE.

Quantitative estimation of LIMA blood flow between extraluminal papavarine vs extraluminal papavarine plus intraluminal vasodilator cocktail in CABG patients.

Objective: In this study, we aimed at a comparative quantitative estimation of the difference in LIMA blood flow between LIMAs treated with topical papaverine alone and LIMAs treated with a combination of topical papaverine plus an intraluminal cocktail of papaverine, nitroglycerine, and milrinone. Methods: Nearly 50 consecutive patients with similar demographics undergoing elective on-pump CABG were recruited for the study. After pedicled LIMA harvest, topical papaverine was sprayed on the pedicle and kept enveloped in papaverine soaked gauze. LIMA flow was then estimated. Later, intraluminal vasodilator solution of papaverine, NTG, milrinone, and heparinized blood were instilled in LIMA, and LIMA flows were estimated. Results: The mean LIMA flows with topical papaverine alone was 47.19 mL/min whereas the mean LIMA flows with topical papaverine plus intraluminal cocktail was 104 mL/min. There was a significant difference between the two flows as their mean was 56.815 mL/min and the paired t-test for significance had a P value of 0.0001. Conclusion: There was a significant difference in the LIMA flow when the LIMA had been treated with the intraluminal instillation of the vasodilator cocktail in addition to the topical application of papaverine solution. Therefore, intraluminal vasodilator cocktail of milrinone, NTG, and papaverine mixed with heparinized blood in addition to topical papaverine is a simple and effective method for LIMA preparation in CABG.

Fluid responsiveness to passive leg raising in patients with and without coronary artery disease: A prospective observational study.

Introduction: Hemodynamic stability and fluid responsiveness (FR) assume importance in perioperative management of patients undergoing major surgery. Passive leg raising (PLR) is validated in assessing FR in intensive care unit patients. Very few studies have examined FR to PLR in intraoperative scenario. We prospectively studied FR to PLR using transesophageal echocardiography (TEE), in patients with no coronary artery disease (CAD) undergoing major neurosurgery and those with CAD undergoing coronary artery bypass grafting (CABG). Methods: We enrolled 29 adult consenting patients undergoing major neurosurgery with TEE monitoring and 25 patients undergoing CABG. After induction of anesthesia, baseline hemodynamic parameters were obtained which was followed by PLR using automated adjustment of the operating table. Clinical and TEE-derived hemodynamic parameters were recorded at 1 and 10 min after PLR following which patients were returned to supine position. Results: A total of 162 TEE and clinical examinations were done across baseline, 1 and 10 min after PLR; and paired comparison was done at data intervals of baseline versus 1 min PLR, baseline versus 10 min PLR, and 1 min versus 10 min PLR. There was no significant change in hemodynamic variables at any of the paired comparison intervals in patients undergoing neurosurgery. CABG cases had significant hemodynamic improvement 1 min after PLR, partially sustained at 10 min. Conclusion: Patients undergoing CABG had significant hemodynamic response to PLR, whereas non-CAD patients undergoing neurosurgery did not. A blood pressure-left ventricular end-diastolic volume combination represented strong correlation in response prediction (Pearson's coefficient 0.641; P < 0.01).

Tricuspid Regurgitation in Ostium Secundum Atrial Septal Defects: Repair or Not?

BACKGROUND: Longstanding ostium secundum atrial septal defects lead to functional tricuspid regurgitation. Significant functional tricuspid regurgitation associated with left heart valve disease is addressed at the time of primary left heart valve surgery. In contrast, there is no global recommendation for tricuspid regurgitation associated with atrial septal defects. This study assesses changes in tricuspid regurgitation after isolated atrial septal defect closure. METHODS: Retrospectively, records were examined of 100 patients who underwent isolated ostium secundum atrial septal defect closure without tricuspid valve repair. Echocardiograms were done preoperatively and 3 days, 3 months, and 1 year after surgery. Data on tricuspid regurgitation status, right ventricle dimensions, and pulmonary artery hypertension status were collected and analyzed. RESULTS: After surgical closure, echocardiography showed a regression of tricuspid regurgitation to mild or less in 76% of patients at 3 days, 89% at 3 months, and 93% at 1 year. Severe pulmonary artery hypertension (32% patients preoperatively) showed statistically significant regression: 14% at 3 days, 10% at 3 months, and 2% at 1 year. Preoperatively, the mean right ventricular internal diameter was 37.9 mm, which decreased to 34 ± 5.5 mm (mean ± standard deviation) at 3 days, 32.3 ± 5.3 mm at 3 months, and 31.3 ± 5.4 mm at 1 year. It was also noted that regression favored patients who were <25 years old. CONCLUSION: Tricuspid valve repair may not be required in patients with ostium secundum atrial septal defect with functional tricuspid regurgitation.

Combined effect of left stellate ganglion blockade and topical administration of papaverine on left internal thoracic artery blood flow in patients undergoing coronary revascularization.

Background: Left stellate ganglion blockade (LSGB) may have additive effect to topical administration of papaverine on prevention of vasospasm of left internal thoracic artery (LITA). Aims: This study aims to compare LITA blood flow with topical application of papaverine alone or in combination with LSGB. Setting: Tertiary care hospital. Design: Prospective randomized controlled study. Materials and Methods: A total of 100 patients operated for coronary revascularization were randomly and equally allocated into two groups. In control Group-C, papaverine was applied topically during the dissection of LITA. In Group-S, the additional LSGB was performed. Blood flow was measured from cut end of the LITA for 15 s. Primary objectives of the evaluation were to observe differences in the LITA blood flow. Observing incidence of radial-femoral arterial pressure difference after cardiopulmonary bypass (CPB) was secondary objective. Statistical Analysis: Student's unpaired t-test and Fisher's exact test to find out a significant difference between the groups. Results: LITA flow in Group-S was insignificantly more (49.28 ± 7.88 ml/min) than Group-C (47.12 ± 7.24 ml/min), (P = 0.15). Radio-femoral arterial pressure difference remained low for 40 min after termination of CPB in the Group-S compared to the Group-C (-0.99 ± 1.85 vs. -1.92 ± 2.26). Conclusion: Combining LSGB with papaverine does not increase the LITA blood flow compared to when the papaverine is used alone. However, ganglion blockade reduces radial-femoral arterial pressure difference after CPB. Blockade can be achieved successfully under the ultrasound guidance without any complications.

Impaired substrate-mediated cardiac mitochondrial complex I respiration with unaltered regulation of fatty acid metabolism and oxidative stress status in type 2 diabetic Asian Indians.

BACKGROUND: The cardiovascular complications associated with type 2 diabetes mellitus could be attributed to changes in myocardial mitochondrial metabolism. Though it is a known fact that permeabilized cardiac muscle fibers and isolated mitochondria are metabolically compromised in the Caucasian population, studies of Asian Indian myocardial mitochondrial function are lacking. Thus, the objective of the present study is to analyze if there is altered cardiac mitochondrial substrate utilization in diabetic Asian Indians. METHODS: Mitochondrial substrate utilization was measured using high-resolution respirometry in isolated mitochondria prepared from right atrial appendage tissues of diabetic and nondiabetic subjects undergoing coronary artery bypass graft surgery. Western blotting and densitometric analysis were also done to compare the levels of proteins involved in fatty acid metabolism and regulation. RESULTS: The mitochondrial oxygen consumption rate for fatty acid substrate was shown to be decreased in diabetic subjects compared to nondiabetic subjects along with an unvaried mitochondrial DNA copy number and uniform levels of electron transport chain complex proteins and proteins involved in fatty acid metabolism and regulation. Decreased glutamate but unchanged pyruvate-mediated state 3 respiration were also observed in diabetic subjects. CONCLUSION: The current study reports deranged cardiac mitochondrial fatty acid-mediated complex I respiration in type 2 diabetic Asian Indians with comparable levels of regulators of fatty acid oxidation to that of nondiabetic myocardium. Altered glutamate-mediated mitochondrial respiration also points toward possible alterations in mitochondrial complex I activity. When compared with previous reports on other ethnic populations, the current study suggests that Asian Indian population too have altered cardiac mitochondrial substrate utilization.

Pulmonary Atresia with Ventricular Septal Defect: Rare Presentation with Coronary-to-Pulmonary Artery Collaterals from Both Right and Left Coronaries.

Pulmonary atresia with ventricular septal defect and coronary-dependent pulmonary circulation arising from both major coronary arteries is rare. Dependence of pulmonary blood flow on the coronaries and the risk of early development of pulmonary vascular obstructive disease warrant early surgical repair in these patients. We report a case of a ten-month-old infant with pulmonary atresia with ventricular septal defect and coronary artery-to-main pulmonary artery connections who was successfully managed with ligation of the coronary fistulas and intracardiac repair.

Outcomes of Mitral Valve Replacement after Closed Mitral Valvotomy: A Retrospective Cohort Study.

BACKGROUND: The incidence of rheumatic fever and rheumatic heart disease still remains high in the developing countries. Mitral stenosis is predominantly due to rheumatic origin and affects females more than males. Historically, closed mitral valvotomy (CMV) was the first effective intervention for mitral stenosis. We studied the immediate and early surgical outcomes of MVR in patients with history of CMV to see whether their disease behaves differently, when compared with patients without prior CMV undergoing MVR. METHODS: This single center retrospective cohort study was conducted in Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. Patients who underwent MVR from January 2008 to December 2012 at our institute were studied. The hospital records of 90 patients were analyzed both in the CMV cohort and also in the non-CMV cohort. Preoperative details, intraoperative parameters, immediate postsurgery echocardiography parameters, and follow-up echocardiography details at 1 year and 5 years were studied. RESULTS: Both the cohorts were similar in age, height, weight, and BSA. In the CMV cohort, 67% were females and in the non-CMV cohort 48% were females. Most of the patients in both the cohorts presented with functional classes 2 and 3. The mean duration between onset of symptoms and MVR in the CMV cohort and the non-CMV cohort was 24.6 years and 6.25 years, respectively. Fifty-nine patients in the CMV cohort had preoperative atrial fibrillation, whereas 47 patients in the non-CMV cohort presented with atrial fibrillation. The mean left atrial (LA) size of patients with sinus rhythm and atrial fibrillation was 46.34 (SE, 0.852) and 55.21(SE, 0.808), respectively. Preoperative echocardiographic assessment revealed a mean ejection fraction of 62% and 63%, mean mitral stenosis gradient of 13 mm Hg and 14.7 mm Hg, mean LA size of 53.2 mm and 50.5 mm, and mean right ventricular systolic pressure of 47.5 mm Hg and 43.6 mm Hg in the post-CMV cohort and in the non-CMV cohort, respectively. The CMV cohort had a longer cardiopulmonary bypass time (111.5 minutes) in comparison with the non-CMV cohort (97 minutes). The aortic cross-clamp time remained similar in both the cohorts. Thirty-six percent of the post-CMV cohort patients had a valve size of 25, and 48% of patients belonging to the non-CMV cohort had a valve size of 27. The percent of moderate-to-severe subvalvar pathology was 88 in both the cohorts. Patients belonging to the post-CMV cohort had a median ventilation time of 16.35 hours, and the patients of the non-CMV cohort had a median ventilation time of 13.75 hours. The duration of ICU stay was 4.41 (SE, 0.188) days and 4.13 (SE, 0.153) days, and length of hospital stay was 8.93 (SE, 0.230) days and 9.13 (SE, 0.313) days in the CMV and the non-CMV cohorts, respectively. Inotropic requirement, measured by the vasoactive inotropic score, was higher in the post-CMV group (11.9), when compared to the other cohort (9.7). Right ventricular (RV) function and pulmonary arterial hypertension assessed in the immediate postoperative period, at 1 year, and at 5 years did not show any significant difference. CONCLUSION: The percentage of females in the CMV cohort is higher. Delaying the valve replacement by performing a surgical palliative procedure like CMV, is beneficial in female patients in the child-bearing age group so that they can complete the families. The disease process started earlier in the CMV cohort, and they had a longer duration of illness before undergoing MVR. Even with the longer duration of disease, the RV function, LA size, PA pressures, and mitral stenosis gradients were comparable. Therefore, CMV prevented progression of the disease in the CMV group. The mean LA size is significantly higher in patients with atrial fibrillation. The CMV cohort had a longer cardiopulmonary bypass time. The duration of ventilation, ICU stay, and hospital stay were similar in both cohorts. Inotrope requirement was higher in the post-CMV group. RV function and pulmonary arterial hypertension assessed in the immediate postoperative period, at 1 year, and at 5 years did not show any significant difference.

Patient prosthesis mismatch and its impact on left ventricular regression following aortic valve replacement in aortic stenosis patients.

INTRODUCTION: Patient prosthesis mismatch is known to alter post-operative remodeling of left ventricle adversely in aortic stenosis patients. An indexed orifice area of 0.85 is considered as conventional cutoff for patient prosthesis mismatch based on hemodynamic principles. Many patients have smaller annulus and annulus enlargement techniques may be required to avoid this benchmark which complicates the surgery. AIMS AND OBJECTIVES: To determine incidence of patient prosthesis mismatch (PPM) in our population, to assess left ventricle (LV) regression and impact of indexed effective orifice area on LV regression, and to determine a minimum acceptable cut off indexed orifice area that will result in LV regression. MATERIALS AND METHODS: A single-center retrospective observational study of all patients who underwent aortic valve replacement surgery for severe aortic stenosis between July 2015 and December 2015 was conducted. Patients who underwent concomitant revascularization or other valve surgery were excluded. Data regarding conventional risk factors for PPM, valve type, and indexed orifice area as well as pre-operative and late post-operative LV mass were collected. OBSERVATIONS: Thirty-seven of the 91 patients satisfied inclusion criteria. All patients had significant regression in LV mass. The incidence of PPM was 68%. Regression of indexed left ventricular mass showed a positive correlation of with indexed effective orifice area of the prosthetic valve. The correlation coefficient is + 0.48 (95% CI 0.18-0.698). Left ventricular mass regression was significantly higher in patients with indexed effective orifice area more than 0.75 (68.89 ± 29 vs 122.55 ± 58.84, p = 0.028). Relative left ventricular regression also was significantly higher in patients with an indexed effective orifice area more than 0.75 (39.53 ± 13.13 vs 49.73 ± 15.56, p = 0.022). There is a positive correlation between left ventricular regression and the reduction in mean gradient achieved by valve replacement. The correlation coefficient was + 0.35 (95% CI 0.03-0.61). CONCLUSIONS: The incidence of PPM was found to be comparable to literature. There is a positive correlation between left ventricular regression and indexed effective orifice area of the prosthetic valve. Left ventricular regression was significantly higher in patients with an indexed effective area more than 0.75. This can be considered as criteria for significant PPM in study population.

Submitral Aneurysm After Pulmonary Artery Banding-A Case Report.

Submitral aneurysms are rare clinical entities occurring predominantly in young adults of African descent. A host of etiologies have been proposed for this entity. We present a unique case of submitral aneurysm which developed after pulmonary artery banding in a three-year-old girl with complex congenital heart disease. The aneurysmal sac was burrowing into the interatrial septum.

Repair of Double Orifice Left AV Valve (DOLAVV) with Endocardial Cushion Defect in Adult.

Double orifice left atrioventricular valve (DOLAVV) or double orifice mitral valve (DOMV) is a rare congenital cardiac anomaly manifesting either as an isolated lesion (mitral stenosis or mitral insufficiency) or in association with other congenital cardiac defects. Signs of mitral valve disease are usually present along with the symptoms of associated coexistent congenital heart diseases. Mitral insufficiency due to annular dilatation is seen when DOLAVV is associated with endocardial cushion defects. Surgical intervention like mitral valve repair or replacement is required in 50% of patients and yields good results. We report a case of a 56-year-old lady who successfully underwent surgical correction of DOLAVV with partial atrioventricular canal defect.