Differences in the serum metabolic profile to identify potential biomarkers for cyanotic versus acyanotic heart disease.

BACKGROUND: Growth retardation, malnutrition, and failure to thrive are some of the consequences associated with congenital heart diseases. Several metabolic factors such as hypoxia, anoxia, and several genetic factors are believed to alter the energetics of the heart. Timely diagnosis and patient management is one of the major challenges faced by the clinicians in understanding the disease and provide better treatment options. Metabolic profiling has shown to be potential diagnostic tool to understand the disease. OBJECTIVE: The present experiment was designed as a single center observational pilot study to classify and create diagnostic metabolic signatures associated with the energetics of congenital heart disease in cyanotic and acyanotic groups. METHODS: Metabolic sera profiles were obtained from 35 patients with cyanotic congenital heart disease (TOF) and 23 patients with acyanotic congenital heart disease (ASD and VSD) using high resolution 1D 1H NMR spectra. Univariate and multivariate statistical analysis were performed to classify particular metabolic disorders associated with cyanotic and acyanotic heart disease. RESULTS: The results show dysregulations in several metabolites in cyanotic CHD patients versus acyanotic CHD patients. The discriminatory metabolites were further analyzed with area under receiver operating characteristic (AUROC) curve and identified four metabolic entities (i.e. mannose, hydroxyacetone, myoinositol, and creatinine) which could differentiate cyanotic CHDs from acyanotic CHDs with higher specificity. CONCLUSION: An untargeted metabolic approach proved to be helpful for the detection and distinction of disease-causing metabolites in cyanotic patients from acyanotic ones and can be useful for designing better and personalized treatment protocol.

Optimal timing of renal replacement therapy for favourable outcome in patients of acute renal failure following cardiac surgery.

OBJECTIVES: Acute renal failure is a serious complication following cardiac surgery. This may lead to fatal outcome if not treated timely. Continuous renal replacement therapy (RRT) has shown improvement in outcome. There is no clear consensus on the timing of the initiation of RRT in these patients. This study evaluates the factors predicting favourable outcome in this group of patients. METHODS: Patients undergoing cardiac surgery between January 2015 and December 2018 are included in this retrospective study. RRT is required in 24 patients out of 2254 operated during this period. Patients are divided into groups, survivors (group 1, n = 8) and dead (group 2, n = 16). The preoperative information is accessed from the hospital information system and intensive care unit data. Multivariate analysis of pre continuous renal replacement therapy (CRRT) bicarbonate level, pH, potassium, time of initiating CRRT and central venous pressure is performed. RESULTS: The incidence of acute renal failure requiring RRT is 1.06%. Patients in two groups were similar in demographics and presence of risk factors. There was difference in the pre RRT bicarbonate level (p = 0.007). On multivariate analysis, pre RRT bicarbonate levels predict survival (p = 0.003). ROC curve for pre RRT bicarbonate predicts survival for value above 16.83 mg/dl with 80% sensitivity and 78.6% specificity. CONCLUSION: Bicarbonate level in blood predicts the best evidence for initiating the renal replacement therapy in of acute renal failure following cardiac surgery. When urine output drops to < 0.5 ml/kg and not responding to infusion of furosemide, RRT must be initiated at sodium bicarbonate in blood above 16.9 mg%.

Statin reload before off-pump coronary artery bypass graft: Effect on biomarker release kinetics.

Objectives: Statins confer protection from ischemia/reperfusion through various pathways including pleiotropic mechanisms. Following chronic administration, activation of intrinsic cellular mechanisms causes attenuation of these pleiotropic effects. Methods: Since coronary artery bypass surgery (CABG) represents a reversible ischemia-reperfusion sequence, we assessed if statin reload is effective in patients undergoing off-pump CABG (n = 100) in limiting myocardial injury. Patients received loading dose of rosuvastatin (40 mg initiated 7 days before surgery) while nonloaded patients continued whatever statin dose they were receiving and served as controls. Cardiac biomarkers (Troponin-I, creatine kinase muscle/brain [CK-MB], and B-type natriuretic peptide [BNP]) were measured at 8, 24, and 48 h postoperatively. The primary end-point was the extent of perioperative myocardial injury (area under the curve [AUC]: AUC of each biomarker). Results: Despite similar baseline levels, all biomarkers at 8, 24, and 48 h were significantly lower in the loaded group. The AUC for each biomarker was also significantly lower in the loaded group (cTnI 37.96 vs. 70.12 ng. hr/ml, CK-MB 229.64 vs. 347.04 ng. hr/ml, and BNP 5257.56 vs. 15606.68 pg. hr/ml, all P < 0.001). Delta cTnI (change from baseline to peak level) (1.00 ± 1.34 vs. 2.25 ± 2.59), delta CK-MB (4.54 ± 5.89 vs. 10.68 ± 9.95), and delta BNP (120.41 ± 172.48 vs. 449.23 ± 790.95) all P < 0.001 were also significantly lower in the loaded group. Those loaded with rosuvastatin had lower inotrope duration (22.9 ± 23.33 vs. 31.26 ± 25.39 h, P = 0.04) and ventilator support time (16.94 ± 6.78 vs. 23.8 ± 20.53 h, P = 0.03). Conclusion: In patients undergoing off-pump CABG, statin reload can "recapture" cardioprotection in patients already on statins with favorable effect on release kinetics of biomarkers and postoperative outcomes.

Hyperkalemia in ambulant postcardiac surgery patients during combined therapy with angiotensin-converting enzyme inhibitor, spironolactone, and diet rich in potassium: A report of two cases and review of literature.

Introduction: Potassium is the most abundant cation in intracellular compartment. A deficiency or excess of its serum concentration can be deleterious to the one suffering from a cardiac ailment. Post cardiac surgery patients are often on multiple drugs like angiotensin receptor blockers (ARBs), angiotensin converting enzyme inhibitors (ACEI), diuretics including potassium sparing diuretics which are known to predispose for hyperkalemia. We report two postoperative cases who developed life threatening hyperkalemia despite normal renal function due to a combination of factors like treatment with ACEI, potassium sparing diuretics, high dietary intake of potassium and we also discuss renal handling of potassium in this review of literature. Methodology: We present a case series of two cases of cardiac surgery, who presented in the emergency department with hyperkalemia, managed conservatively and detailed history revealed that patient were also on very high nutritional potassium. Result: Both the patients responded to conservative management and there was no recurrence of such episodes once the dose of diuretics was adjusted and diet modification advised. Conclusion: In India, many patients are from a low socioeconomic background and often resort to cheap and filling food items like bananas. This dietary factor should be kept in mind while prescribing patients with these medications and adequate counseling regarding diet should be done.

Unrecognized hyperlucent lesion on lateral film of chest X-Ray.

We report an interesting case of bulla right lung, incidently found during CABG surgery.

IL-10(-592A/C) gene variant a predictor of postoperative atrial fibrillation in the north Indian population.

BACKGROUND: There is an accumulating body of evidence indicating a strong association between inflammation and the pathogenesis of atrial fibrillation (AF) in different ethnicities across the globe. AF increases the risk of stroke and heart failure. Despite various researches on IL-10 response, there is limited clinical evidence present, which demonstrate a role of these immunity regulators in AF. Therefore, this study was designed to decipher the role of IL-10(-592A/C) polymorphism in the development of postoperative AF (post-OP AF). METHOD: The study was designed for north Indian patients. The study included 90 patients with AF and 126 controls in sinus rhythm undergoing surgery at Department of Cardiovascular and thoracic surgery, SGPGIMS, Lucknow, India. DNA samples were genotyped for common single nucleotide polymorphism (SNP) in gene IL-10(-592A/C). The PCR-based RFLP technique was used to assess the genotype frequencies. The multivariable logistic regression analysis was performed to study the association of other risk factors with AF. RESULTS: The distribution of IL-10(-592A/C) genotypes (CC, AC, and AA) was found to be 48.41%, 47.61%, and 3.98% in controls and 41.11%, 45.55%, and 13.34% in cases, respectively (P = .0385). The frequency of allele A in cases was significantly higher than the control group (36.11% vs 27.77%, P = .0654). Compared with CC, AA genotype had increased risk of AF in both unadjusted and adjusted analyses. CONCLUSIONS: This study suggests that IL-10(-592A/C) polymorphism may have significant association with post-OP AF development in north Indian patients.

Radio-opaque tricuspid aortic valve seen in X-Ray chest as mercedes-benz sign.

We are presenting a very interesting X-ray image of the calcific aortic valve in a septuagenarian male patient who underwent successful aortic valve replacement.

A case report of combined radical pericardiectomy and beating heart coronary artery bypass grafting in a patient with tubercular chronic constrictive pericarditis with coronary artery disease.

We here report a successful midterm outcome following combined off-pump radical pericardiectomy and coronary artery bypass surgery (CABG) in a 65-year-old male patient who was suffering from chronic constrictive calcified tubercular pericarditis with coronary artery disease. Simultaneous off-pump CABG and radical pericardiectomy for nonsurgical constrictive pericarditis is reported very rarely in English literature.

Chronic Periaortitis of Ascending Aorta With Bilateral Ostial Coronary Stenosis in a Young Female.

An 18-year-old woman without any risk factors for coronary artery disease or systemic vasculitis and infection presented with recurrent angina at rest. Coronary angiography revealed 100% occlusion of the ostial left main coronary artery and severe ostial right coronary artery stenosis. She underwent successful coronary artery bypass graft surgery. At surgery, the external surface of the ascending aorta was covered with a soft-tissue thickened mass; histopathology of the mass revealed chronic nonspecific inflammatory aortitis.

Right-atrial myxoma clinically mimicking recurrence of rheumatic valve disease long time after mitral valve repair.

Right atrial myxomas are rare. Its occurrence in a previously operated patient of rheumatic mitral stenosis posed clinical diagnostic challenge. We herein report a case of right atrial myxoma who had undergone mitral valve repair 20 years ago and now presented in congestive heart failure. The tumor was arising from the ostium of the coronary sinus and prolapsed into the right ventricle causing significant right ventricular inflow and outflow obstruction. Urgent repeat cardiac surgery was successfully performed to remove the tumor along with mitral valve replacement. We review the diagnostic and therapeutic problems resulting from this unusual association.

Simultaneous Trans-Diaphragmatic Approach for Wedge Resection of the Solitary Ipsilateral Lung Metastasis in Renal Cell Carcinoma.

About one third of newly diagnosed renal cell carcinoma (RCC) patients present with synchronous metastatic disease. Twenty to 40 % with localized disease at diagnosis eventually develop metastases. Complete metastasectomy confers five year survival rate of 35 % to 50 %. Traditional thoracic approach for lung metastasectomy carries increased morbidity. We report a less morbid trans-diaphragmatic approach. Right cytoreductive nephrectomy with liver and simultaneous trans-diaphragmatic lung resection was performed with uneventful perioperative course in a 60 year male with metastatic RCC. Trans-diaphragmatic resection of peripheral lung metastasis can be considered electively approach in selective cases of RCC with ipsilateral resectable inferior lung metastases.

Salvage pneumonectomy for pulmonary arteriovenous malformation in a 12-year-old boy with brain abscess and hemiparesis: A fatal outcome.

Large pulmonary arteriovenous malformations (PAVMs) constitute an uncommon cause of central cyanosis with septic embolism and brain abscess. This large right to left shunt can lead to chronic severe hypoxemia and significant morbidity and mortality if untreated. Conservative parenchyma-sparing lung resection was used widely as treatment of choice. However, with the advent of embolotheraphy, it is considered the preferred mode of treatment with less invasiveness. We here report a 12-year-old boy with large aneurysmal pulmonary arteriovenous fistula presented with brain abscess and hemiparesis. He underwent thoracotomy and pneumonectomy for large PAVMs, and it was complicated with bleeding and massive blood transfusion. The patient developed acute renal failure as a postoperative complication and succumbed to it. We suggest proper look out for systemic collateral and their management by embolitheraphy either alone or in combination should be tried first. We also suggest median sternotomy and intrapericardial approach for pneumonectomy in such difficult situation can be helpful.

Evidence of apoptosis in right ventricular dysfunction in rheumatic mitral valve stenosis.

BACKGROUND & OBJECTIVES: Right ventricular (RV) dysfunction is one of the causes of morbidity and mortality in valvular heart disease. The phenomenon of apoptosis, though rare in cardiac muscle may contribute to loss of its function. Role of apoptosis in RV in patients with rheumatic valvular heart disease is investigated in this study. METHODS: Patients with rheumatic mitral valve stenosis formed two groups based on RV systolic pressure (RVSP) as RVSP <40 mmHg (group I, n=9) and RVSP ≥40 mmHg (group II, n=30). Patients having atrial septal defect (ASD) with RVSP <40 mmHg served as control (group III, n=15). Myocardial performance index was assessed for RV function. Real-time polymerase chain reaction was performed on muscle biopsy procured from RV to assess expression of pro-apoptotic genes (Bax, cytochrome c, caspase 3 and Fas) and anti-apoptotic genes (Bcl-2). Apoptosis was confirmed by histopathology and terminal deoxynucleotide-transferase-mediated dUTP nick end labelling. RESULTS: Group II had significant RV dysfunction compared to group I (P=0.05) while caspase 3 (P=0.01) and cytochrome c (P=0.03) were expressed excessively in group I. When group I was compared to group III (control), though there was no difference in RV function, a highly significant expression of pro-apoptotic genes was observed in group I (Bax, P=0.02, cytochrome c=0.001 and caspase 3=0.01). There was a positive correlation between pro-apoptotic genes. Nuclear degeneration was present conforming to apoptosis in valve disease patients (groups I and II) while it was absent in patients with ASD. INTERPRETATION & CONCLUSION: Our findings showed evidence of apoptosis in RV of patients with valvular heart disease. Apoptosis was set early in the course of rheumatic valve disease even with lower RVSP, followed by RV dysfunction; however, expression of pro-apoptotic genes regressed.

Pressure bandage over venous conduit harvesting site causing compartment syndrome in a patient with intra-aortic balloon pump: An unusual cause.

Intra Aortic Balloon Pump (IABP) is conventionally used to support coronary perfusion and weaning from cardiopulmonary bypass. IABP in situ has its own share of complications. We present a case where a patient on IABP support who had reduced peripheral pulsations of the ipsilateral limb and was initially misdiagnosed as IABP catheter associated thromboembolism. A negative embolectomy ruled out the same. Further looking for the cause of reduction of ipsilateral pulses it was found that the tight compressive bandage at saphenous vein conduit harvesting site had led to development of compartment syndrome (CS).

Successful surgical management of atherosclerotic dual right coronary artery with short-term follow-up.

Congenital anomalies of the coronary arteries are present in 0.2-1.4% of the general population. Dual right coronary artery is one of the rarest congenital anomalies (0.01%) of the coronary arteries. We report a patient with unstable angina with severe triple vessel disease who had diseased dual right coronary artery. He was successfully managed with surgical revascularization and followed up with computed tomography angiography. Surgical revascularization of both the coronary arteries of right side is hardly reported in literature.

Differential release kinetics of cardiac biomarkers in off-pump coronary bypass.

BACKGROUND: Differential release kinetics of the cardiac biomarkers (B-type natriuretic peptide, troponin I, and creatine kinase-MB) following off-pump coronary artery bypass are not well characterized. METHODS: Biomarker levels were assessed at 6, 24, 48 h, and 1 month preoperatively, in 80 patients who underwent off-pump coronary artery bypass. RESULTS: All biomarkers increased within 6 h of surgery. Peak B-type natriuretic peptide levels occurred at 24-48 h in 96% of patients, but only two-thirds had peak troponin I and creatine kinase-MB levels at this time, reflecting different release patterns. Levels of all biomarkers declined within 48 h, but 42% of patients still had B-type natriuretic peptide >100 pg·mL(-1) at 1 month. Those with baseline B-type natriuretic peptide > 100 pg·mL(-1) had a lower left ventricular ejection fraction (43.6% vs. 55.6%, p < 0.01) and longer inotropic (43.8 vs. 31.4 h, p = 0.03) and ventilator support (34 vs. 25.5 h, p = 0.04) than those with lower levels. B-type natriuretic peptide levels correlated positively with angiographic Syntax score (p = 0.02) and negatively with left ventricular ejection fraction (p < 0.001). Only baseline B-type natriuretic peptide predicted the durations of inotropic support (p = 0.01) and ventilation (p = 0.02). Postoperative B-type natriuretic peptide at 6, 24, and 48 h and delta B-type natriuretic peptide were significant predictors of mean ventilation time. CONCLUSION: Even in patients undergoing off-pump surgery, there is significant natriuretic peptide and myocardial enzyme release. Only B-type natriuretic peptide levels had an association with postoperative variables.

Reconstruction of trileaflet pulmonary valve using autologous pericardium.

Tetralogy of Fallot with atretic or absent pulmonary valve may require pulmonary valve replacement or reconstruction. We propose a technique of reconstruction of a trileaflet valve at the level of the pulmonary annulus using untreated autologous pericardium. Six cases operated upon, using this technique, had trivial pulmonary regurgitation with a median gradient of 24 mmHg (18-38) across the newly created valve. This approach can be considered in cases with limited availability of more suitable alternatives.

Pericardial monocusp for pulmonary valve reconstruction: a new technique.

Enhancing the pulmonary annulus renders the pulmonary valve incompetent in cases of tetralogy of Fallot. A pressure-loaded right ventricle may change to a volume-loaded ventricle, which may dilate and eventually dysfunction. This study evaluated a new technique of fashioning a monocusp valve from untreated autologous pericardium suspended on a transannular patch. It was assessed in 40 children undergoing complete repair of tetralogy of Fallot between January 2005 and December 2007. 24 patients had a transannular patch alone (group A) and 16 received a transannular patch with the autologous pericardial monocusp valve (group B). All patients were followed up for 1 year with transthoracic echocardiography to determine pulmonary insufficiency. There was no significant difference in cardiopulmonary bypass or aortic crossclamp times, postoperative chest tube drainage, duration of inotropic usage, intensive care unit or hospital stay between groups. Univariate analysis showed significantly lower grades of pulmonary insufficiency in group B. This technique for creating an autologous pericardial monocusp valve is an inexpensive, simple, and reliable procedure that effectively reduces pulmonary insufficiency at the 1-year follow-up.

Valvuloplasty in the treatment of rheumatic tricuspid disease.

Organic involvement of the tricuspid valve is uncommon. Valve repair is preferred over replacement as it results in a low gradient across the valve and obviates the risk of prosthesis-related complications. From October 2002 to October 2004, 37 patients who required tricuspid valve repair for organic involvement were included in this study. They were divided into 2 groups depending on the surgical procedure for valve repair: 20 patients in group 1 had tricuspid commissurotomy and De Vega annuloplasty; 17 in group 2 had tricuspid commissurotomy only. There were significant reductions in peak and mean tricuspid gradients and right ventricular systolic pressure in both groups. Annular shortening was similar in both groups (median, 23% in group 1, 21% in group 2), but the ratio of the tricuspid regurgitation jet area to right atrial area was greater in group 2 (median, 0.40 in group 2, 0.19 in group 1). There was no postoperative death. We recommend supporting the tricuspid annulus with annuloplasty in patients with organic tricuspid valve disease and no dilatation of the annulus, if annular shortening is < 30%.