Concurrent valve replacement and caesarean section for rheumatic mitral valve disease with refractory heart failure in late pregnancy.

Objective: To assess clinical characteristics and outcomes of women who underwent concurrent valve replacement with caesarean section for severe rheumatic mitral valve disease with refractory heart failure. Methods: All women admitted to a single centre from 2011 to 2020 with severe rheumatic mitral valve disease, having recurrent episodes of pulmonary edema on optimal medical therapy and contraindication to percutaneous balloon mitral valvotomy, who underwent concurrent valve replacement (for native valve disease) along with caesarean section, were included. Results: Among 1300 pregnancies with rheumatic heart disease, six underwent the concurrent procedure. All had replacement of mitral valve except one who had both aortic and mitral valve replacements, between 33 and 39 weeks of gestation. There were no maternal deaths, and there was one neonatal loss from late-onset sepsis. Conclusion: Pregnant women with severe rheumatic mitral valve disease with refractory heart failure, unsuitable for minimal access interventions, can be considered for a concurrent valve replacement with caesarean section.

Effect of positive end-expiratory pressure on central venous pressure in the closed and open thorax.

Objective.The magnitude and mechanism of the rise of central venous pressure (CVP) after positive end-expiratory pressure (PEEP) among patients with cardiac disease is poorly understood. Therefore, the study aimed to compare the magnitude of change in CVP after PEEP in patients with TR (tricuspid regurgitation), high CVP, and high PCWP (pulmonary capillary wedge pressure) and in those with no TR, low CVP, and low PCWP. Additionally, we hypothesized that PEEP in the open thorax would also lead to a rise in CVP.Approach.This prospective, quasi-experimental study was conducted in patients undergoing cardiac surgery. Three consecutive readings of variables were obtained at 1 min intervals after PEEP (5 and 10 cm H2O) application in the closed and open thorax. Patients were stratifieda prioriinto low CVP (<10 cm H2O) and high CVP (≥10 cm H2O), no TR and TR, and low PCWP (<15 mm Hg) and high PCWP (≥15 mm Hg) in the closed and open thorax.Main Results.Sixty-two patients were eligible for final analysis. The mean difference (MD) in ΔCVP (CVP10 cm H2O of PEEP-CVPzero end-expiratory pressure) was 2.33 ± 1.13 (95% CI, 2.04-2.62, P = 0.000) and 1.02 ± 0.77 (95% CI, 0.82-1.22, P = 0.000) in the closed and open thorax, respectively. The increase in CVP was higher among patients who had a lower CVP (2.64 ± 0.9 mm Hg versus 1.45 ± 1.17 mm Hg; p=0.000), in patients without TR (2.64 ± 0.97 mm Hg versus 2.14 ± 1.2 mm Hg, p=0.09) and in patients with a lower PCWP (2.4 ± 0.9 mm Hg versus 2.3 ± 1.4 mm Hg, p=0.67) at 10 cm H2O PEEP in the closed thorax.Significance.The rise in CVP was higher among patients without TR, low CVP, and low PCWP. Zero intrathoracic pressure in the open thorax did not abolish the effect of PEEP on CVP rise altogether.

Epicardial blebs and septal hematoma after ventricular septal defect closure.

Rapidly progressive epicardial hemorrhagic blebs during weaning from cardiopulmonary bypass after perimembranous ventricular septal defect closure has not been reported previously. Here, we describe the case of a 3-month-old baby with life-threatening epicardial hemorrhagic blebs and an interventricular septal hematoma after perimembranous ventricular septal defect patch closure.