Spontaneous retroperitoneal haemorrhage after pulmonary endarterectomy surgery.

Spontaneous retroperitoneal hematoma (SRH) is a rare complication of anticoagulation therapy. Presentation may vary from limb paresis to hypovolemic shock due to blood loss. The optimal treatment is controversial. It can be managed conservatively or surgically. We report a case of a 73-year-old man presenting with progressively worsening abdominal pain and severe pain radiating to his left lower limb twenty-five days after his pulmonary endarterectomy (PEA) surgery. He was on anticoagulation per our institutional protocol for PEA patients. Investigations revealed a large, spontaneously occurring iliopsoas hematoma. Our patient was treated conservatively, and the SRH stabilised.

Sub-coronary aortic root replacement post-aortic valve dehiscence: a case report.

This is a case report of a 78-year-old male who underwent a sub-coronary aortic valve and root replacement due to valve dehiscence and aortic root pseudoaneurysm. The patient had complex anomalous coronary anatomy and had undergone a previous tissue aortic valve replacement in 2013. The patient made an uneventful recovery and was discharged from the hospital five days later. The authors suggest that the sub-coronary root replacement technique should be considered in elderly patients and patients with complex coronary anatomy.

Management of anomalous origin of right coronary artery from left coronary sinus.

Aberrant origin of coronary artery is a rare congenital anomaly associated with increased risk of myocardial ischemia and sudden death, with the highest risk lesions being those arising from the opposite sinus of Valsalva. We report a case with an aberrant right coronary artery arising superior to the left coronary cusp, with a slit-like ostium, having an inter-arterial and intramural course through the aortic root, that underwent repositioning of the right coronary artery. We believe such cases warrant surgical correction and reimplantation is a safe, effective and reproducible technique.

Reoperation after failure of mitral valve repair for degenerative disease: A single surgeon experience.

Background: With an increasing number of patients undergoing mitral valve repair, more patients are presenting for reoperation. This study aimed to evaluate factors influencing mortality and survival of patients undergoing reoperation for mitral valve surgery after previous mitral valve repair under a single surgeon. Methods: We retrospectively collected data from 117 patients who underwent reoperation after previous mitral valve repair between 2010 and 2022. We aimed to identify preoperative, operative, and postoperative factors affecting outcomes. The primary outcome was overall survival, and the secondary outcomes included prolonged hospital stay and in-hospital mortality. The mean follow-up was 9.13 ± 10.36 years (median, 6.50 years). Results: Out of 117 patients, 85 underwent mitral valve replacement (MVR) and 32 underwent mitral valve repair (MVr). The mean age was 64.7 ± 12.7 years (65.5 ± 12.2 years in the MVR group and 62.7 ± 14.0 years in the MVr group), and 66 (56.4%) were men. On a standard multivariate analysis of the overall factors influencing mortality, advanced age was associated with a higher risk of overall mortality (hazard ratio [HR], 1.07; 95% confidence interval [CI], f1.03-1.12; P = .001). The urgency of surgical intervention also played a role, with a higher risk of in-hospital mortality in patients undergoing emergency reoperation (HR, 1.55; 95% CI, 1.60-149.05; P = .02). Furthermore, the presence of mixed lesions, encompassing both mitral regurgitation and stenosis, was strongly linked to increased overall mortality (HR, 17.09; 95% CI, 4.06-71.94; P < .001) and in-hospital mortality (HR, 1.75; 95% CI, 15.83-1925.61; P < .001). Infective endocarditis emerged as a prominent risk factor for overall mortality (HR, 992.08; 95% CI, 85.74-11,479.08; P < .001) and in-hospital mortality (HR, 5.83; 95% CI, 514.81-65,932.99; P < .001). Additionally, chronic obstructive pulmonary disease was associated with a significantly increased risk of overall mortality (HR, 4.3; 95% CI, 1.24-14.97; P = .02). Conclusions: Our single surgeon experience demonstrates that mitral valve reoperation after a previous repair is associated with good outcomes and survival.

Immediate and early post-operative sequelae of off-pump total cavopulmonary connection.

BACKGROUND: Extracardiac Fontan (ECF) is currently the final operation of choice for patients with a univentricular heart. Performing this procedure without cardiopulmonary bypass (CPB) carries potential benefits. In this study, we report the early results of ECF without CPB. PATIENTS AND METHODS: Between 2012 and 2015, 72 consecutive patients underwent Fontan without CPB. Their medical records were examined in detail. RESULTS: Mean age was 11.8 ± 5.2 (range 5 to 23, median 10) years. Intraoperative mean superior vena cava clamp time was 15.19 ± 3.8 min, and the inferior vena cava clamp time was 16.93 ± 3.31 min. There were three early deaths. No patient required conversion from off-CPB to CPB. Mean inotropic score was 4.73 ± 5.9 (range 0 to 25, median 2.5). Mean time to extubation was 9.5 ± 5.82 (range 3 to 29, median 8) hours. Pleural drainage in intensive care unit (ICU) was 551.57 ± 452.77 (median 470) ml, and mean ICU stay was 2.27 ± 3.09 (median 1.5) days. Mean daily pleural drainage after discharge from the ICU was 163.7 ± 88.01 (median 140) ml, and mean time to removal of pleural tubes was 15.76 ± 8.4 (median 14) days. Total hospital stay was 17.03 ± 8.62 (median 15) days. At an early follow-up of 2-40 (median 25) months, all survivors (n = 69) had a patent Fontan circuit with normal ventricular function on echocardiography. There were no late deaths or thromboembolic complications. CONCLUSIONS: Off-pump ECF is a low-risk procedure that avoids the harmful effects of CPB. Post-operative course of these patients is predictable with substantial savings in costs.

Mid-term results of correction of Tetralogy of Fallot with absent pulmonary valve.

BACKGROUND: Tetralogy of Fallot and absent pulmonary valve (TOF/APV) is associated with significant pulmonary artery dilatation and airway compression. METHODS: We performed a retrospective review of 73 consecutive patients who underwent repair for TOF/APV between January 2005-August 2015. Mean age was 6.4±5.6years (28days-22years). The right ventricular outflow tract (RVOT) was reconstructed using varied techniques. Freedom from RVOT gradients and re-operation was studied. RESULTS: There were four (5.5%) early deaths, two each in infants and older children. Median ICU stay was 2days (range, 1-12days). Mean ICU stay for, infants, children and adults, was 6.5±6.04, 2.75±2.45, and 2.33±1.03days, respectively (p=0.0762). Median hospital stay was 6days (range, 4 to 15days). Mean hospital stay for, infants and children and adults was 7±2, 6.75±2.39, and 6.33±1.63days, respectively (p=0.325). Mean follow up was 65±36.6months (median 56 months, range 7-126 months). On follow up echocardiography, 14 (21.21%) had no pulmonary regurgitation. 21 (31.81%) had mild PR patients, 8 (12.12%) moderate PR and 19 (28.78%) had severe PR. There were five (7.5%) reoperations. Five and ten-year survival was 95%±2.12 and 92.3%±3.45 respectively. Freedom from RVOT reoperation was 93±2.62% and 89±3.87% at 5 and 10 years. CONCLUSIONS: In contrast to children and adults with TOF/APV, infants carry significant early mortality. But the mid-term outcome for patients who survive the initial repair of TOF/APV is acceptable. However, these patients require constant surveillance and irrespective of the methods of RVOT management, the reoperation rates are expected to be high as more of these patients survive into adulthood.

Correlation of the Day 3 FSH/LH Ratio and LH Concentration in Predicting IVF Outcome.

BACKGROUND: This study was undertaken to evaluate the role of day 3 FSH/LH ratio and day 3 LH level as predictors of IVF cycle outcomes. METHODS: This prospective observational study was undertaken in the IVF and Reproductive Biology Centre and Lok Nayak Hospital, affiliated to Maulana Azad Medical College, in New Delhi, India. The study included 105 women who underwent controlled ovarian hyperstimulation for in vitro fertilization. Characteristics of IVF cycles and outcomes were studied in patient subgroups based on day 3 FSH/LH ratio (<2 and ≥2) and day 3 LH levels (>3 and ≤3 mIU/ml). The student t-test, Bartlett's test, chi-squred (χ(2) ) and Fisher's exact test, and linear regression model were used for data analysis. A p-value less than 0.05 was considered as statistically significant. RESULTS: Women with an elevated FSH/LH ratio ≥2 (n = 31) required higher doses of gonadotrophins (3019.34 vs. 2482.43 IU). The outcome of IVF was poor in these patients and they had fewer number of mature follicles (>16 mm) (5.44 vs. 6.09), less E2/mature follicle ratio (4.65 vs. 6.36), fewer retrieved oocytes (6.67 vs. 9.09) and fewer pregnancy rates (11.1% vs. 33.8%). On the other hand, patients with low basal LH levels (≤3 mIU/ml) did not differ significantly in terms of response to controlled ovarian hyperstimulation except for fewer number of retrieved oocytes (7.33 vs. 7.91) but there was a trend towards poor pregnancy rates (7.33 vs. 7.91) but there was a trend towards poor pregnancy rates as compared to subgroup with LH levels >3 mIU/ml. CONCLUSION: Elevated day 3 FSH/LH ratio is associated with inferior outcome in IVF treatment cycles and it could be used as an additional predictor of decreased ovarian reserve.

Plasma circulatory markers in male and female patients with coronary artery disease.

OBJECTIVE: Inflammatory processes play a role in the pathogenesis of atherosclerosis, and plasma circulatory markers have been associated with cardiovascular risk. There is no single report in which adhesion molecule and circulatory cytokines have been evaluated in a single population set with coronary artery disease (CAD) on the basis of gender. Thus, we evaluated plasma circulatory markers in patients with CAD and in controls that were divided by gender (because functioning of circulatory markers and response toward conventional factors are not identical in men and women) and by conventional risk factors such as smoking and alcohol intake. METHODS: A total of 192 patients with CAD (148 male and 44 female) and 192 controls with no symptoms of CAD (142 male and 50 female) were enrolled. Detection of concentration to high-sensitivity C-reactive protein (hsCRP), interleukin (IL)-2, IL-4, IL-6, IL-8, IL-10, IL-13, interferon (IFN)-gamma, tumor necrosis factor (TNF)-alpha, and adhesion molecules (intercellular adhesion molecule [ICAM]-1 and vascular adhesion molecule [VCAM]-1) was performed using enzyme-linked immunosorbent assay kits. RESULTS: In male patients with CAD, levels of IL-4, IL-6, IL-8, IL-13, ICAM-1, VCAM-1, hsCRP (P < .001), and IFN-gamma (P = .003) were significantly higher compared with controls; however, levels of IL-10 were significantly lower (P < .001). In female patients with CAD, levels of IL-4, hsCRP, VCAM-1 (P = .001), and IL-13 (P = .028) were significantly higher and IL-10 levels were significantly lower (P < .001) compared with controls. In addition, levels of circulatory markers were strongly associated with male smokers and imperceptibly associated with male alcoholics and female smokers and alcoholics. CONCLUSION: This study compared the plasma circulatory markers between patients with CAD and healthy controls, between patients with CAD who smoke and controls, and between alcoholic patients with CAD and controls divided by gender. Moreover, among circulatory markers studied, higher levels were found for IL-4, IL-13, hsCRP, and VCAM-1, and lower levels were found for IL-10 in male and female patients with CAD compared with healthy controls.

Early termination of pregnancy by single-dose 800 microg misoprostol compared with surgical evacuation.

OBJECTIVES: To assess the efficacy, safety, and acceptability of early termination of pregnancy by vaginal administration of a single dose of misoprostol. SETTING: Healthy women seeking abortion in an institutional research environment in a tertiary-care hospital. DESIGN: Prospective randomized controlled clinical trial. PARTICIPANTS: One hundred forty women seeking termination of pregnancy up to 49 days' gestational age were alternatively assigned to undergo medical or suction termination. INTERVENTION(S): Saline-soaked prostaglandin E(1) analogue, misoprostol (800 microg), was administered vaginally in group I, and group II underwent suction evacuation. Transvaginal sonography was performed on two subsequent visits to assess outcome. MAIN OUTCOME MEASURE(S): Efficacy, side effects, complications, and acceptability were assessed in both groups. RESULT(S): Complete abortion rate between the misoprostol and the surgical group was 94.2% versus 95.5%, respectively. Side effects were fewer in the misoprostol group and it had a higher acceptability rate. CONCLUSION(S): Single dose of vaginal misoprostol alone has a success rate comparable with surgical method for termination of early pregnancy. Side effects were fewer in women who received misoprostol, and the method was well accepted.

Prevalence of Chlamydophila pneumoniae is higher in aorta and coronary artery than in carotid artery of coronary artery disease patients.

Coronary artery disease (CAD) is a public health problem accounting for an estimated one-third of deaths overall. A potential link between infectious agents and atherosclerosis has been suggested. Data obtained from several seroepidemiological studies have suggested that infection with Chlamydophila pneumoniae, Helicobacter pylori, cytomegalovirus and herpes simplex virus-1 can initiate or maintain the atherosclerotic process. However, there is no single study in which multiple infectious agents have been detected together in different vascular locations in the same population. This would help in determining if there is any leading pathogen in atheromatous plaques of CAD patients. Hence, we screened for C. pneumoniae, H. pylori, CMV and HSV-1 in different vascular locations of CAD patients using quantitative real-time (RT) PCR. We performed multiplex RT-PCR for detecting pathogens, viz. C. pneumoniae, H. pylori, CMV and HSV-1 in different vascular locations of CAD patients. Percent positivity scores for C. pneumoniae, H. pylori, CMV and HSV-1 in different vascular locations were as follows: aorta (64.7, 35.3, 11.7 and 11.7 respectively); carotid (27.2, 27.2, 9 and 0 respectively); coronary artery (58.3, 33.3, 16.6 and 8.3 respectively). Combined positivity for C. pneumoniae (C. pneumoniae IgA and RT-PCR for C. pneumoniae) was the highest compared with all other groups. Aorta and coronary artery were more susceptible to these pathogens as compared with carotid artery. Moreover, CAD patients' characteristics were associated with C. pneumoniae positivity (C. pneumoniae IgA and RT-PCR), suggesting thereby that C. pneumoniae may have caused chronic persistent infection in CAD.