CABG Patients Develop Global DNA Hypermethylation, That Negatively Affect the Mitochondrial Function and Promote Post-Surgical Cognitive Decline: A Proof of Concept in Small Cohort.

Global DNA hypermethylation and mitochondrial dysfunction are reported to be associated with the development of mild cognitive decline (MCI). The present study aims to generate preliminary data that connect the above association with post-surgical coronary artery bypass grafting (CABG) cognitive decline in patients. Data were collected from 70 CABG patients and 25 age-matched controls. Cognitive function was assessed using the Montreal Cognitive Assessment (MOCA) test on day 1 (before surgery) and on the day of discharge. Similarly, blood was collected before and one day after the CABG procedure for mitochondrial functional analysis and expression of DNA methylation genes. Test analysis score suggested 31 (44%) patients had MCI before discharge. These patients showed a significant decrease in complex I activity and an increase in malondialdehyde levels (p < 0.001) from the control blood samples. Post-surgical samples showed a significant reduction in blood MT-ND1 mRNA expression from control and from pre-surgical samples (p < 0.005), along with elevated DNMT1 gene expression (p < 0.047), with an insignificant increase in TET1 and TET3 gene expression. Correlation analysis showed a significant positive relation between cognitive decline and elevated blood DNMT1 and declined blood complex I activity, signifying that cognitive decline experienced by post-surgical CABG patients is associated with increased DNMT1 expression and declined complex I activity. Based on the data, we conclude that both DNA hypermethylation and mitochondrial dysfunction are associated with post-CABG MCI, where the former is negatively correlated, and the latter is positively correlated with post-surgical MCI in CABG cases. Additionally, a multimarker approach that comprises MOCA, DNA methylation, DNMT, and NQR activities can be utilized to stratify the population that is sensitive to developing post-CABG MCI.

Sandwich Technique to Manage Right Ventricular Perforation During Beating Heart Coronary Artery Bypass Grafting.

Identification of an intramyocardial left anterior descending artery remains challenging and many techniques have been proposed for its identification. The exposure technique depends on the surgeon's familiarity and experience with it, and inadvertent right ventricular perforation during exposure on off-pump surgery results in bleeding, which requires urgent cardiopulmonary support and repair. Inadequate repair may result in continued bleeding, closure of the left anterior descending artery, and myocardial infarction. We describe a sandwich technique using the native left anterior descending artery and the bypass graft to repair right ventricular perforation, avoiding closure of this main artery and preserving graft patency.

Minimally Invasive Cardiac Surgery Without Peripheral Cannulation: A Single Centre Experience.

BACKGROUND: A minimally invasive approach without any peripheral cannulation was used as an alternative to median sternotomy for the correction of a wide range of cardiac defects with superior results and good cosmetic outcome. METHODS: From October 2015 to March 2017, 145 patients underwent correction of congenital cardiac malformations with cardiopulmonary bypass through right anterior minithoracotomy (RAMT) with routine cannulation. The average age was 9.69±4.38years (range 2-21) and the average body surface area was 0.91±0.27square metres (range 0.5-1.7). The corrected defects included all types of atrial septal defect (ASD) and ventricular septal defects (VSD), partial atrioventricular septal defects with severe mitral regurgitation, mitral valve repair, repair of tetralogy physiology requiring outlet patch enhancement, isolated pulmonary stenosis (PS) and congenital coronary cameral fistula. RESULTS: There was no operative mortality or major morbidity. All patients were alive at the time of this follow-up. The mean cardiopulmonary bypass time was 64.75±22.28minutes (range 30-175) and mean aortic cross clamp time was 37.53±18.23minutes (range 14-135). Fifty-five (55) patients were extubated in the operating room and the remaining 90 patients were extubated within 3hours in the intensive care unit. Repair and cosmetic results were excellent in all patients. There were no conversions to full sternotomy. No neurological events were reported. CONCLUSIONS: Right anterior minithoracotomy without peripheral cannulation is safe and effective for the correction of a wide range of congenital heart defects including right ventricular outlet obstructions. The cosmetic results are satisfactory, avoiding psychosocial problems.

Recurrent Spontaneous Pneumomediastinum With Concurrent Pneumorrhachis: A Rare Clinical Entity.

Spontaneous pneumomediastinum is the presence of interstitial air in the mediastinal structures without an apparent cause. Pneumorrhachis is defined as the presence of air in the spinal canal. Concurrent pneumorrhachis is an extremely rare epiphenomenon of spontaneous pneumomediastinum without pneumothorax. Diagnosis is confirmed by radiologic imaging of the chest. Spontaneous pneumomediastinum and pneumorrhachis usually resolve with conservative therapy such as bed rest, analgesic agents, and supplemental oxygen. A 20-year-old male patient presented with recurrent spontaneous pneumomediastinum with concurrent pneumorrhachis with a gap of 1 year between the two episodes. Pneumomediastinum and pneumorrhachis resolved with conservative management in both episodes.

Delayed complication of balloon mitral commisurrotomy. a rare case scenario.

The last two decades has seen percutaneous transmitral commissurotomy turn out to be the standard of care in most patients with symptomatic mitral stenosis with a large body of evidence reporting excellent outcome on the short- and long-term with low incidence of serious complications. Complications necessitating urgent surgery are rare and include acute severe mitral regurgitation from mitral valve tear and cardiac tamponade due to cardiac chamber perforation. We report a rare extracardiac bleeding complication of balloon valvotomy presenting a month after the procedure with severe symptoms and mediastinal shift warranting emergency redo sternotomy and mediastinal thrombectomy.

Sinus venosus atrial septal defect with severe mitral stenosis: a rare variant of Lutembacher's syndrome.

Lutembacher's syndrome refers to the rare combination of congenital atrial septal defect, usually secundum type and acquired mitral stenosis. However, the presence of sinus venosus atrial septal defect along with severe mitral stenosis and severe pulmonary hypertension is rarely seen, and this article reports on this rarity with its management.

Spontaneous arterial catheter fracture and embolisation: Unpredicted complication.

Arterial cannulation is a common procedure in the care and management of critically ill patients. Blood pressure measurement, arterial blood sampling and cardiac output determinations are a few primary reasons for arterial cannulation. This invasive catheter placement also imposes certain risks and clinical management problems like bleeding, thrombosis and hematoma formation. Fracture and embolisation of arterial catheters placed in the femoral region is a rare and serious complication that may result in arterial occlusion and thrombosis. Percutaneous retrieval of the foreign body is frequently reported to be the technique of choice, leaving the surgical option to a small group. We report two consecutive cases of catheter fracture that was successfully retrieved by a combination of surgery and balloon tip retrieval device.

Tricuspid valve endocarditis following central venous cannulation: The increasing problem of catheter related infection.

A central venous catheter (CVC) is inserted for measurement of haemodynamic variables, delivery of nutritional supplements and drugs and access for haemodialysis and haemofiltration. Catheterization and maintenance are common practices and there is more to the technique than routine placement as evident when a procedure-related complication occurs. More than 15% of the patients who receive CVC placement have some complications and infectious endocarditis involving the tricuspid valve is a rare and serious complication with high morbidity and mortality. Overenthusiastic and deep insertion of the guide wire and forceful injection through the CVC may lead to injury of the tricuspid valve and predispose to bacterial deposition and endocarditis. We report a case of tricuspid valve endocarditis, probably secondary to injury of the anterior tricuspid leaflet by the guide wire or the CVC that required open heart surgery with vegetectomy and repair of the tricuspid valve.

Use of the internal mammary artery to graft an anomalous left main coronary artery in an adult.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) syndrome is a rare congenital coronary artery anomaly especially when diagnosed in an adult patient and remains an important cause of sudden cardiac death. We report a 46-year-old patient with ALCAPA syndrome managed with left main coronary artery (LMCA) interruption and grafting of the LMCA with left internal mammary artery so as to restore antegrade coronary flow. This approach of restoring dual-coronary-artery system by grafting the LMCA allows antegrade blood flow as in a normal coronary artery to a large area of viable myocardium, is more physiological, and is practical and easy to accomplish in an anteriorly placed and dilated LMCA as seen in our case.

Right atrial mass after open heart surgery: tumour or thrombus?

Detection of a rapidly growing mass in the right atrium during routine inter-echocardiogram follow-up period in two patients after corrective open-heart surgery raises concerns about nature of the mass and the probable cause. One turned out to be an atrial myxoma that grew rapidly over a eight month period and the other a well encapsulate thrombus in a fully anticoagulated patient. Preoperative transthoracic echocardiogram had reported both the cases to be a myxoma. This article highlights the importance of considering rare causes in the face of a seemingly obvious diagnosis and possible use of imaging modalities in the management of these cases.

Venoatrial shunt-assisted cavopulmonary anastomosis.

The bidirectional Glenn shunt operation is conventionally performed under cardiopulmonary bypass. Between June 2007 and September 2009, 218 consecutive patients underwent off-pump bidirectional Glenn shunt institution for single ventricle with pulmonary stenosis complex. Their mean age was 4.72 ± 1.80 years (range, 4 months to 6 years) and median weight was 10.12 kg (range, 4.1-19 kg). A temporary shunt was created between the innominate vein and the right atrium, with a 3-way connector for de-airing. Fifty-five patients had bilateral cavae. The mean internal jugular venous pressure on clamping the superior vena cava was 24.69 ± 1.81 mm Hg. Continuous end-tidal CO2 and O2 saturation were monitored. Adequate oxygen saturation and blood pressure were maintained by optimizing inotropics, volume, and inspired oxygen. The mean duration of ventilation was 10.17 ± 8.96 h (range, 1-73 h). There were no gross neurological complications. Postoperative pleural effusion developed in 6 (2.75%) patients, and 4 (1.83%) had nodal rhythm. Four (1.83%) patients died in the immediate postoperative period due to low cardiac output syndrome. Venoatrial shunt-assisted bidirectional Glenn shunt surgery can be performed safely by optimizing intraoperative management strategies. It is economical and avoids the deleterious effects cardiopulmonary bypass.

Veno-venous shunt-assisted cavopulmonary anastomosis.

OBJECTIVE: The bidirectional Glenn shunt is commonly performed under cardiopulmonary bypass for conditions that lead to a single ventricle repair. We report our experience of bidirectional Glenn shunt done without cardiopulmonary bypass. METHODS: Between June 2007 and May 2009, 186 consecutive patients underwent off-pump bidirectional Glenn shunt for a variety of complex cyanotic congenital heart defects. Age ranged from four months to six years and the median weight was 11.17 kg (range 4.3 - 18). After systemic heparinization, the procedure was done by creating a temporary shunt between the innominate vein and the right atrium connected across a three way connector for de-airing. Fifty one patients had bilateral cavae. All cases underwent complete clinical neurological examination. RESULTS: No case required conversion onto cardiopulmonary bypass. Four patients (2.14%) died in the immediate postoperative period. The mean internal jugular venous pressure on clamping the decompressed superior vena cava was 24.69 +/- 1.81 mm Hg. There was no intra-operative hemodynamic instability and oxygen saturation was maintained at more than 70% throughout. Post Glenn shunt, the saturations improved to mid 80s. Seventy four cases had documented forward flow across the pulmonary valve. The mean duration of ventilation was 10.17 +/- 8.96 hours and there were no neurological complications. Six patients (3.22%) developed pleural effusions, 4 patients (2.15%) had nodal rhythm and 9 patients (4.83%) had superficial sternal wound infection. CONCLUSIONS: Our results show that off-pump bidirectional Glenn shunt can be done safely in patients not requiring associated intra-cardiac correction. It avoids cardiopulmonary bypass and its related complications, is economical and associated with excellent results. In our opinion, this is the largest series of off-pump bidirectional Glenn shunt in the literature.

Tricuspid valve repair with neopapillary muscle from right ventricular trabecula.

Congenital abnormalities of the tricuspid valve without downward displacement of the septal and posterior tricuspid leaflets are uncommon causes of tricuspid regurgitation. Progressive tricuspid regurgitation can lead to right heart dilatation, arrhythmia, and irreversible deterioration of right ventricular function. Tricuspid valve repair is an important method to stabilize symptomatic children because tricuspid valve replacement has a poor prognosis. We report the successful use of right ventricular trabecula as a "neopapillary muscle" for treating severe low-pressure tricuspid regurgitation in children.

Midterm results of repair of perimembranous or conal ventricular septal defects using the transaortic direct suture technique.

BACKGROUND: A midterm retrospective analysis of the transaortic primary suture repair of perimembranous or conal ventricular septal defects with aortic valve prolapse was conducted. METHODS: From January 1998 to January 2006, 56 patients underwent transaortic repair of perimembranous or conal ventricular septal defects using the direct suture technique. The mean age at operation was 7.7+/-5.0 years (37 males). Twenty-eight patients had none or trivial aortic regurgitation (AR), 19 had mild AR, and 9 had moderate or severe AR. The mean defect size was 7.0+/-2.6 mm at operation. RESULTS: There was no early mortality. In the immediate postoperative period, AR remained unchanged in 32 patients, improved in 17, and worsened in 9, including 2 patients who required early reoperation. Median follow-up was 3 years (range, 2 months to 8 years). There was 1 late death. Aortic regurgitation had deteriorated in 21 patients, 3 of whom required late reoperation, and improved in 5 compared with the preoperative state. Freedom from deterioration in AR was 97% at 2 years and 71% at 4 years. Deterioration in aortic valve function was independent of demographic and morphologic features. CONCLUSIONS: This surgical technique does not prevent progressive aortic valve dysfunction, which may be related to structural deficiency of the valve leaflet or distortion of the annulus by direct suture closure of the ventricular septal defect. Early closure may prevent structural leaflet damage, whereas adaptation of the transaortic technique to include a shallow ventricular septal defect patch may be beneficial in older patients.

The mitral hooks: visualization of mitral valve made easy.

Historically the mitral valve has been exposed through a variety of approaches from the standard left atriotomy to cardiac autotransplantation. Regardless of the approach, adequate exposure to the mitral valve is crucial to a successful valve repair or replacement. We describe a simple and effective way of bringing the mitral valve into view through a standard left atriotomy with the use of specially designed and modified mitral hooks. The mitral hooks provide excellent unobstructed view of the mitral valve, which is suitable for repair and replacement.