Surgical management of divided atrial chambers.

BACKGROUND AND AIM: The morphological variations when one, or both, of the atrial chambers is subdivided, are many and varied. We sought to address clinical presentations, potentially misdiagnosed cases, diagnostic modalities, surgical approaches, and outcomes of this "family" of uncommon lesions. METHODS: A total of 193 published investigations were synthesized. Diagnostic information was provided by clinical presentation, and multimodality imaging studies. RESULTS: Almost three-quarters of patients with divided atrial chambers present during infancy with severe pulmonary hypertension and cardiac failure. Associated cardiac and extra-cardiac defects are present in between half and nine-tenths of cases. Acquired division of the left atrium has been reported after the Fontan operation, orthotopic cardiac transplantation, and complicated aortic valvar infective endocarditis. Surgery under cardiopulmonary bypass remains the definitive treatment. Balloon dilation may be considered in anatomically compatible variants in the setting of cardiac failure and pregnancy as a bridge todefinitive treatment. Overall, mortality has been cited between nil to 29%. Presentation during infancy, associated congenital anomalies, pulmonary hypertension, and surgery in the previous era, have been the reported causes of death. The operative survivors have long-term favourable outcomes, with near normal cardiac dimensions and low risk of recurrence. While asymptomatic patients with division of the right atrium do not need treatment, surgical resection of the dividing partition under cardiopulmonary bypass is recommended in symptomatic patients with complex anatomy, the spinnaker malformation, or associated cardiac anomalies. Balloon dilation may be considered in uncomplicated patients with less obstructive lesions. Hybrid intervention and endoscopic robotic correction also have been performed. CONCLUSIONS: Resection of the dividing shelf allows the survivors to regain near normal dimensions with a low risk of recurrence. We submit that an increased appreciation of the anatomic background to division of the atrial chambers will contribute to improved surgical management.

Streptokinase irrigation through a percutaneous catheter helps decrease the need for necrosectomy and reduces mortality in necrotizing pancreatitis as part of a step-up approach.

BACKGROUND: Percutaneous catheter drainage in pancreatic necrosis with a predominant solid component has a reduced success rate. To improve the efficacy of percutaneous catheter drainage, we used streptokinase in the irrigation fluid in the present study. METHODS: In this retrospective analysis of 4 prospective randomized studies performed at our center from 2014 to 2019, 108 patients were evaluated. We assessed the safety, feasibility, and efficacy of streptokinase irrigation compared to saline irrigation. Data were also analyzed between 50,000 IU and 150,000 IU streptokinase. RESULTS: There were 53 patients in the streptokinase irrigation group and 55 in the saline irrigation group, and both groups were comparable in terms of age, sex, etiology, APACHE II score, and percutaneous catheter drainage characteristics. The modified computerised tomography severity index and modified Marshall score at the onset of pain were significantly higher in the streptokinase group. Sepsis reversal was significantly higher in the streptokinase group (75% vs 36%), and the need for necrosectomy (34% vs 54%) was also lower in the streptokinase group. Mortality was lower in the streptokinase group than in the saline group (32% vs 40%). The incidence of bleeding in the streptokinase group was lower than that in the saline group (7% vs 18%). A higher dose of streptokinase (150,000 IU) resulted in lower rates of necrosectomy, bleeding, and mortality compared to those with 50,000 IU streptokinase. CONCLUSION: Significant reductions in the need for surgery and sepsis reversal were noted in the streptokinase group. The results using 150,000 IU streptokinase were superior to those using 50,000 IU streptokinase.

A rare case of Kawasaki disease with giant coronary artery aneurysm.

Kawasaki disease (KD) is an acute, self-limiting vasculitis that occurs in children of all ages. This was first described by Kawasaki in 1967. Spontaneous regression is observed; however, 25% of patients develop coronary artery aneurysm (CAA). These may result in ischaemic heart disease causing myocardial infarction, rupture leading to pericardial tamponade and distal embolization which culminate in sudden cardiac death. Diagnosis of KD relies on clinical suspicion with no gold standard diagnostic test. A case of KD with giant CAA in a 14-year-old female is described with emphasis on challenges pre- and peri-operatively. The review provided post description of the case emphasizes on pathophysiology with clinical course of CAA in association with KD and justification of our approach with an insight into newer treatment modalities.

Aortic dissection in a young male with isolated interrupted aortic arch: an unusual association.

Interruption of the aortic arch (IAA) is a rare congenital anomaly which has been infrequently documented in the adult population. Aortic dissection (AD) is an emergency often presenting as acute chest pain and warranting urgent intervention. A 32-year-old male presented to Emergency Department with acute chest pain. Clinical examination revealed feeble pulses in bilateral lower limbs with a blood pressure difference between upper and lower limbs. Two-dimensional Echocardiography was suggestive of IAA with AD in the descending thoracic aorta. This was confirmed on computed tomography scan of the aorta which revealed complete interruption of the aortic arch distal to left subclavian artery along with the presence of an intimo-medial flap in descending thoracic aorta. A diagnosis of IAA with AD was made. The patient underwent an urgent aortic repair surgery following which he has been largely asymptomatic. A suspicion of AD should always be made in any patient presenting with acute onset chest pain radiating to the back along with accelerated hypertension/feeble pulses in extremity. Occurrence of AD in an adult with IAA is a distinct rarity and has been documented only thrice.

A Review of the Surgical Management of Aorto-ventricular Tunnels.

We present a synthesis of 95 published investigations of the exceedingly rare tunnels that can exist between the aortic root and the left or right ventricles. From the 220 suitable cases included in these investigations, we reviewed the clinical presentations, modalities used for diagnosis, surgical approaches, and outcomes. Diagnostic information was provided by clinical presentation, radiographic findings, saline contrast echocardiography, computed tomographic angiocardiography, magnetic resonance imaging, cardiac catheterization, and angiocardiography. These techniques elucidated the coronary arterial origins and associated defects and defined the disease before surgery. Patients occasionally present with an asymptomatic cardiac murmur and cardiomegaly, but most suffer cardiac failure in the first year of life when the tunnel enters the left ventricle. Antenatal diagnosis by fetal echocardiography is reliable after 18 weeks of gestation. Associated defects, involving the proximal coronary arteries or the aortic or pulmonary valves, are present in nearly half the cases. Prompt diagnosis and surgical repair are important for a favorable outcome. Overall, operative mortality has been cited to be between 3% and 8.3%. Associated congenital coronary arterial anomalies, residual severe aortic stenosis, poor left ventricular function, and rupture of an infected suture line have been the reported causes of death. Despite early surgical intervention, an incidence of 16% to 60% postoperative residual aortic regurgitation of varying severity has been reported. The requirement of further repair or replacement of the aortic valve ranges from 0% to 50%. We submit that an increased appreciation of these details relative to the tunnels will contribute to improved surgical management.

Enigma of apnea test for brain death on ECMO-an ongoing discussion-case study and review of literature.

Coma, absent brain stem reflexes, and apnea are considered the neurological criteria of brain death. As membrane oxygenator does almost entire gas exchange in patients with severely diseased lungs who are on extracorporeal membrane oxygenation (ECMO), it is not possible to carry out apnea test in routine manner. We described the difficulties we faced conducting the apnea test and the other ancillary tests in our patient on veno-venous ECMO who suffered a major cerebral insult and reviewed the literature of brain death testing in patients on ECMO.

Total Pericardiectomy Using a Modified Left Anterolateral Thoracotomy Without Cardiopulmonary Bypass.

BACKGROUND: We sought to ascertain the short- and long-term results of total pericardiectomy for chronic constrictive pericarditis using a modified left anterolateral thoracotomy without cardiopulmonary bypass on postoperative low cardiac output, normalization of intracardiac pressures, survival, and reoperations. METHODS: Between January 2005 and December 2019 a series of 127 consecutive patients (91 male patients) between ages 4 and 72 years (median, 25 years; interquartile range, 18-38) underwent radical total pericardiectomy using a modified left anterolateral thoracotomy without cardiopulmonary bypass. RESULTS: Operative and late mortalities were 3.1% and 1.6%, respectively. Thirty-one patients (24.4%) had postoperative low cardiac output, and none required reoperations. At a median follow-up of 99 months (interquartile range, 56-141) the actuarial survival was 97.6% ± 0.01% months (95% confidence interval, 92.8-99.2). At their last follow-up 113 (93.4%) and 8 (6.6%) survivors were in New York Heart Association class I and II, respectively. CONCLUSIONS: Total pericardiectomy is associated with lower perioperative and late mortality and decreased low cardiac output syndrome and confers significant long-term advantage of superior hemodynamics.

Delayed presentation of superficial femoral artery pseudoaneurysm 45 years following gunshot injury.

This case report is a description of an uncommon delayed presentation of penetrating trauma of lower limb with history of inciting event being 45 years ago, as there are only 4 such reported cases in the literature. A 65-year-old male presented with progressive enlargement of swelling over the anterior aspect of the right thigh with difficulty in walking due to mechanical effects and paraesthesia in the affected limb. Clinical signs of a large lump in the right anteromedial thigh with no pulsations were present. Computerised tomographic angiography revealed the presence of a superficial femoral artery pseudoaneurysm. The open surgical management involved resection of the pseudoaneurysm and autologous vein patch angioplasty. The rarity of incidence and paucity of physical signs suggest that a high index of suspicion, careful clinical review and radiological investigation is indispensable to diagnose and treat this condition.