Supracardiac Total Anomalous Pulmonary Venous Connection in Adolescence.

Background Supracardiac total anomalous pulmonary communication (TAPVC) constitutes a rare congenital cardiac anomaly. Most babies with supracardiac TAPVC are diagnosed in infancy and undergo complete surgical repair during infancy. Delayed presentation of supracardiac TAPVC is rare, and the surgical outcomes are not well known. This retrospective study was conducted to determine the presentation and surgical outcome of supracardiac TAPVC among adolescents, which constitutes an extremely rare subgroup of TAPVC. Methodology This retrospective analysis was conducted among 15 adolescent patients with supracardiac TAPVC who underwent surgical repair in the cardiothoracic surgery department of a tertiary care center in India. This study aimed to assess the intraoperative, postoperative, immediate, early, and late outcomes of adolescent patients with supracardiac TAPVC who had undergone surgical repair between 2010 and 2014 in a tertiary care center in India. Results The study included 15 patients with a diagnosis of isolated supracardiac TAPVC. A mild degree of cyanosis was present in eight patients, recurrent episodes of lower respiratory tract infections were present in five patients, and dyspnea (New York Heart Association I/II) was noted in 12 patients. Mean oxygen saturation was 92% (range = 85-93%), and mean pulmonary artery pressure was 24 mmHg (range = 15-50 mmHg). After median stenotomy, a wide anastomosis was made between the common pulmonary venous chamber and the posterior wall of the left atrium. A fenestration was made in the Dacron patch in three patients who had raised pulmonary vascular resistance (PVR) preoperatively. Twelve patients were weaned off cardiopulmonary bypass (CPB) with minimal inotropic support. Three patients who had high preoperative PVR had difficulty in weaning from CPB. The mean CPB and cross-clamp time was 75 ± 12 minutes and 58 ± 9 minutes, respectively. Atrial fibrillation was noted in five (33.3%) patients in the early postoperative period, and three (20%) patients had pulmonary artery hypertensive crises postoperatively. There was no superficial or deep sternal wound infection in the postoperative period. Mild and moderate right ventricular dysfunction was present in four (26.67%) and two (13.3%) patients, respectively, in the postoperative period. On two-dimensional echocardiography during follow-up at the end of one year, there was no gradient across the anastomosis, and pulmonary artery pressure was normal in all patients. Conclusions Surgical repair of supracardiac TAPVC in adolescence has an excellent outcome. Survival of patients with supracardiac TAPVC until adolescence depends on the presence of a dilated vertical vein and a large atrial septal defect facilitating unobstructed pulmonary venous flow. The aim of the surgical repair should be to create a wide anastomosis between the left atrium and the pulmonary venous chamber which should be bigger than the size of the mitral valve orifice indexed to the body surface area as it would amount to no or negligible anastomotic gradient postoperatively.

Percutaneous Thrombin Injection with Balloon Protection for a Large Iatrogenic Femoral Artery Pseudoaneurysm: A Case Report with Review of Literature.

Iatrogenic femoral artery pseudoaneurysms (IFAPs) are not uncommon due to the increase in various minimally-invasive endovascular procedures. Percutaneous thrombin injection is an established technique for large pseudoaneurysms. When ultrasound-guided compression of an aneurysmal neck is not feasible, percutaneous thrombin injection can be combined with endovascular balloon occlusion to prevent leakage of thrombin into the parent artery. We describe a large IFAP following the removal of the femoral dialysis catheter after an inadvertent arterial puncture, which was managed with percutaneous ultrasound-guided (USG) thrombin injection with simultaneous balloon occlusion at the level of the aneurysmal neck without any complications. Follow-up imaging showed thrombosed IFAP without any recurrence.

Carotid Body Tumors: Institutional Experience of 10 Cases and a Review of Literature.

Carotid body tumors are slow growing neck masses that arise from the neural crest cells at the carotid bifurcation. Majority are asymptomatic and are diagnosed incidentally. Surgical excision is accepted as the treatment of choice to reduce complications. In the present series, we report 10 cases of carotid body tumors and our institutional experience. All patients underwent radiological evaluation with an ultrasonography with Doppler, contrast enhanced computed tomography and MR angiography. 6 cases were operated by a transcervical excision. The tumor was excised in tototranscervically. One of the cases required saphenous vein graft intraoperatively due to vascular injury and also had postoperative vocal cord palsy. The rest had an uneventful recovery. Carotid body tumors although rare and seemingly indolent can cause substantial symptoms if left untreated. A prompt multi modality approach is needed for both diagnosis and treatment to avoid major complications.

Lower extremity pseudoaneurysms and their interventional radiological management: a pictorial review.

Lower extremity pseudoaneurysms (PsAs) are mostly developed after traumatic or iatrogenic injury to the arteries. Unless treated, they can be complicated by adjacent mass effects, distal embolism, secondary infection, and rupture. Imaging helps in the diagnosis and planning of therapeutic intervention. Ultrasonography (USG) is often diagnostic, while CT angiography aids in vascular mapping required for intervention. Image-guided therapy offers to manage these pseudoaneurysms in a minimally invasive approach, obviating the need for surgery. A smaller, superficial, and narrow-necked PsA can easily be managed with local USG-guided compression or thrombin injection. When the percutaneous approach is not a feasible option, PsA from expendable arteries can also be managed with coiling or glue injection. Wide-necked PsA from an unexpendable artery necessitates stent graft placement, although coiling of the neck may be a viable and cheaper alternative for a long- and narrow-necked PsA. Presently, vascular closure devices are also used to seal a small arterial rent through a direct percutaneous approach. This pictorial review entails various techniques to deal with lower extremity pseudoaneurysms. An idea about the various intervention radiological approaches will help in choosing appropriate methods to tackle lower extremity pseudoaneurysms.

Non-Valvular Atrial Fibrillation in Young Adults in Eastern India: A Clinico-Aetiological Retrospective Analysis in a Tertiary Care Hospital.

BACKGROUND: The development of atrial fibrillation adds a lot to the morbidity and mortality of individual patients. The spectrum of non-valvular atrial fibrillation among young adults is less known. The present observational study aims to analyze the clinical-aetiological spectrum of non-valvular atrial fibrillation among young adults between 18 and 40 years of age. METHODS: A retrospective observational study was carried out to analyze the clinical-aetiological spectrum of non-valvular atrial fibrillation among young adults less than 40 years of age attending the cardiac outpatient department in a tertiary care hospital in Eastern India over a period of two years. Patients with any form of organic valvular heart disease and patients more than 40 years of age were excluded from the study. One hundred and seventeen patients under 40 years of age were analysed with respect to demographic, aetiological, and clinical profiles. RESULTS: Most common aetiologies behind non-valvular atrial fibrillation in young adults (<40 years) were hypertension (40%) and the presence of left ventricular systolic dysfunction (31%). Thyrotoxicosis, obesity, obstructive sleep apnoea, the presence of congenital heart disease, coronary artery disease, myopericarditis, chronic kidney disease, dyselectronemia, diabetes mellitus, and the presence of chronic obstructive pulmonary disease contributed towards the development of non-valvular atrial fibrillation in the young population in less proportion of cases. Most of the cases were symptomatic with palpitation, shortness of breath, or diaphoresis. Less number of cases (17%) had left atrial thrombus which may be due to early clinical attention with the proper therapeutic anticoagulation regimen. CONCLUSIONS: Hypertension and the presence of left ventricular systolic dysfunction contribute to the majority towards the development of non-valvular atrial fibrillation among young adults. Accurate measurement and monitoring of blood pressure among young adults and careful assessment of left ventricular systolic dysfunction with subsequent appropriate management of hypertension and left ventricular systolic dysfunction in young can decrease the burden of non-valvular atrial fibrillation among the young population.

Hematological Parameters as an Early Marker of Deep Vein Thrombosis in Diabetes Mellitus: An Observational Study.

Background Although the association between the presence of diabetes mellitus and the development of deep vein thrombosis (DVT) is well known, the role of novel biomarkers in predicting the development of DVT in diabetic patients is not yet known to a large extent. Studies have shown that complete blood count (CBC) and CBC-derived parameters such as neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) can be used as surrogate markers to detect DVT. This study was conducted to assess the utility of NLR and PLR as a marker of DVT in diabetic patients. Methodology This case-control study was conducted among a calculated sample size of 109 DVT patients in one arm and 109 non-DVT patients in another arm. Hematological tests including total leucocyte count, differential leucocyte count, total neutrophil count, total lymphocyte count, total platelet count, NLR, and PLR were performed. Results We found a significant difference in NLR and PLR between the DVT and the non-DVT groups. In addition, we found that NLR and PLR were significantly higher in the diabetic group, indicating the presence of inflammation in association with diabetes mellitus. Analysis of the receiver operating characteristic curve showed that at a cut-off value of 2.83, NLR can detect DVT in diabetic patients with 67% sensitivity and 92% specificity. Similarly, PLR at a cut-off value of 131.46 can detect DVT in diabetic patients with 56% sensitivity and 90% specificity. Conclusions We conclude that NLR and PLR are novel inflammatory markers that can help in the early detection of DVT in diabetic patients.

A Retrospective Study on Drug and Dietary Patterns in Patients With Severe Rheumatic Valvular Heart Disease in Eastern India.

Background India has a high prevalence of rheumatic valvular heart diseases. Empirical treatment in rheumatic heart disease curtails morbidity and mortality. Less is known about the drug and dietary management of severe rheumatic heart disease at the pretertiary care level, which forms the building stone in the management of rheumatic heart disease. The present study was carried out to evaluate the drug and dietary patterns of patients with severe rheumatic valvular heart disease at a pretertiary care level, which is the backbone of the management of rheumatic heart disease. Methodology This cross-sectional study was carried out in a tertiary care center in Eastern India between May 2020 and May 2022 across 1,264 study subjects. The drug and dietary patterns of the patients with severe rheumatic valvular heart disease during their index visit to the cardiac department were studied and analyzed. Patients aged less than 18 years; patients with mild or moderate rheumatic valvular heart diseases; patients with coexisting end-stage organ disease (chronic liver disease and chronic kidney disease), malignancy, and sepsis; and patients not willing to participate in the study were excluded. Results Most of the patients were on diuretic therapy, and diuretic therapy was overprescribed across the patients with mitral regurgitation, aortic stenosis, and aortic regurgitation. Most of the patients across each spectrum of rheumatic valvular heart disease were lacking the cornerstone therapy such as beta-blockers in mitral stenosis and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in mitral and aortic regurgitation. The recommended injectable benzathine penicillin prophylaxis was prescribed in a very small number of patients (5%), and most of the patients were on oral penicillin prophylaxis (95%) in spite of its reported high failure rate in prophylaxis. Empirical rationale prescriptions in severe rheumatic valvular heart disease were lacking in the pretertiary care level in Eastern India. Conclusion Each spectrum of severe valvular heart disease was lacking the cornerstone therapy such as beta-blockers in mitral stenosis and ACE inhibitors or angiotensin receptor blockers (ARBs) in mitral and aortic regurgitation along with recommended injectable benzathine penicillin prophylaxis. Diuretics and digoxin were overprescribed across the spectrum of rheumatic heart disease. Improvement of this essential gap in the treatment of severe rheumatic heart disease would bring down morbidity and improve mortality in the future.

Socioeconomic Burden of Critically Ill Patients: A Descriptive Study.

Background The cost of critical illness treatment is generally recognized as expensive and increasing in India. Critical illness of the individual will affect the socioeconomic status of the individual and the family. The direct and indirect costs of intensive care and its impact on the socioeconomic status of critically ill patients and their families need to be estimated. The present study was carried out to evaluate the socioeconomic burden of critically ill patients admitted to ICUs in Eastern India. Methods A descriptive survey was conducted to measure the socioeconomic burden. One hundred fifteen critically ill patients and their family members were conveniently selected for the study. Critically ill patients admitted to ICUs and those who were bedridden for more than seven days along with anyone the family member, i.e., spouse, father, or mother, were included in the study to estimate the impact of long-term illness on the care providers in the family. Socio-demographic and socioeconomic burdens were analyzed through the interview method. Results Half (49.6%) of the critically ill patients were heads of the family, and their employment is the primary source of income for the family members. Most (60.9%) of the patients belonged to lower socioeconomic status. Critically ill patients spend a maximum (38169.6±3996.2) amount for pharmaceutical expenses. Eventually, the family members accompanying patients lost maximum working days because of the long length of hospital stay. Below upper-lower (p=0.046) class socioeconomic family, age less than 40 (p=0.018) years, and those families depending (p=0.003) on patients' income significantly reported higher socioeconomic burden. Conclusions Critical care hospitalization of patients increases the socioeconomic burden on the whole family, especially in lower-middle-income countries like India. It soberly affects younger age group patients with low socioeconomic status and families depending on the patient's income during their man days.

Risk Perception and Preventive Practice During the COVID-19 Pandemic in the General Population.

Background People's perceptions of the COVID-19 pandemic and its associated risk are very essential to prevent the spread of the infection. The awareness among individuals may contribute to preventing COVID-19 infections. Coronavirus disease is a serious public health issue. However, preventive practices toward COVID-19 are relatively unknown. The present study aims to survey the risk perception and preventive practice during the COVID-19 pandemic among the general population in Odisha. Method A cross-sectional online survey among 395 participants was conducted by adopting the convenience sampling technique. The tools used for the survey consist of three divisions: collection of sociodemographic data, assessment of risk perception toward COVID-19, and assessment of preventive practices during COVID-19 through an online survey method. Results The majority (83.29%) of the participants strongly agreed that social distancing is necessary to control the transmission of COVID-19, 65.82% strongly agreed that lockdown is relevant to control COVID-19 spread, 49.62% strongly agreed that wearing a mask protects from the infection, and 40.25% strongly agreed that they will be able to connect with healthcare professionals if they are infected with COVID-19 infection. The finding revealed that the highest number of participants are always practicing all the preventive measures such as maintaining hand hygiene (77.21%), wearing a mask (68.10%), avoiding shaking hands (87.59%), willingness to seek medical help (90.37%), avoiding going to the market or meeting friends (80.75%), discussing preventive measures related to COVID-19 with their family members (76.45%), and eating only homemade food (87.34%). Conclusion This study found that an average number of study participants who had the highest level of practice on preventive measures are those who had higher perceived risk among the general population. Expanding the knowledge regarding the infection and its ill effect on health through the proper channel can bring a drastic change in the attitude of the general public. As many people depend on television and social media for acquiring information about COVID-19, any information that reaches the public should be accurate and based on evidence. To avoid miscommunication and the further spread of COVID-19, health education and awareness have to be implemented to increase self-efficacy and risk identification among the general public, which eventually increases the practice of preventive measures.

Paracentral Acute Middle Maculopathy As the Presenting Sign of Ischemic Cardiomyopathy.

Paracentral acute middle maculopathy (PAMM) is a type of ischemic maculopathy affecting intermediate and deep retinal capillary plexuses. A typical presentation is acute onset scotoma with or without vision loss. It is characterized by greyish-white parafoveal lesions. Sometimes very subtle lesions can be missed on clinical examination. The main diagnostic modality is spectral domain optical coherence tomography (SD-OCT) wherein focal or multifocal lesions are seen as bands of hyperreflectivity in the inner nuclear and outer plexiform layers. This entity can be associated with systemic microvascular diseases. Here, we report an interesting case of PAMM as the only presenting sign in a patient with ischemic cardiomyopathy, highlighting the necessity for a thorough systemic examination in such patients.

Macro T-wave Alternans in Jervell and Lange-Nielsen Syndrome.

Here, we report a rare case of a three-year-old boy with Jervell and Lange-Nielsen (JLN) syndrome who presented with two episodes of nocturnal agonal gasp provoked by fever mimicking syncope in the last six months with a history of sudden cardiac death in one elderly sibling. Interestingly, an electrocardiogram (EKG) revealed macro T-wave alternans (TWA) indicative of a high risk of malignant ventricular arrhythmia in the form of ventricular fibrillation and sudden cardiac death. TWA in JLN syndrome has not been described in the global literature so far. Our case is unique and the first to describe macro TWA in JLN syndrome and is a teaching point to young cardiologists to always look for macro TWA in the EKG of long QT syndrome for risk stratification, management, and, most importantly, avoiding the risk of sudden cardiac death.

Bleeding From Left Atrial Appendage During Atrial Septal Defect Closure Through Right Anterolateral Thoracotomy: An Unusual Complication.

Anterolateral thoracotomy is frequently used for the closure of ostium secundum atrial septal defect (ASD). The cosmetic result has become an important feature. There are various complications of anterolateral thoracotomy like persistent postoperative pain, phrenic nerve injury, atelectasis, and bleeding. We report a case of ASD closure through anterolateral thoracotomy who had bleeding of the left atrial appendage (LAA), which is an unusual and rare complication.

Diagnosis of absent right superior vena cava with intraoperative transesophageal echocardiography in a child with Holt-Oram syndrome: Anesthetic and perfusion implications.

Holt-Oram syndrome is a rare autosomal disorder with cardiac, vascular, and upper limb anomalies. Previous reports have described anesthetic and perioperative challenges including difficulty in arterial and venous cannulations, airway management and rhythm, and temperature abnormalities. There are no previous reports of absent right superior vena cava (SVC) in children with Holt-Oram syndrome. We present images of a case where the diagnosis of absent right SVC with persistent left SVC was made with intraoperative transesophageal echocardiography and discuss the anesthetic and perfusion implications of such findings.

Peripheral Cardiopulmonary Bypass in Two Patients With Symptomatic Tracheal Masses: Perioperative Challenges.

Tracheal tumors or masses causing critical airway obstruction require resection for symptom relief. However, the location and extent of these tumors or masses often preclude conventional general anesthesia and tracheal intubation. Peripheral cardiopulmonary bypass often is required before anesthetizing these patients. Herein, two cases of patients with tracheal masses, in whom awake peripheral cardiopulmonary bypass was instituted, are reported. The first case was that of an obese male child weighing 102 kg, with tracheal rhinoscleroma, who developed Harlequin, or north-south, syndrome after institution of femorofemoral venoarterial partial cardiopulmonary bypass. The second case was that of a female patient with adenoid cystic carcinoma of the trachea causing near-total central airway occlusion. She had severe pulmonary artery hypertension, which prevented the use of venovenous bypass. Instead, femoral vein-axillary artery venoarterial bypass was established to avoid Harlequin syndrome. Some of the challenges encountered were the development of Harlequin syndrome with risk of myocardial and cerebral ischemia, type and conduct of extracorporeal bypass, choice of monitoring sites, and provision of regional anesthesia for peripheral extracorporeal cannulations. Management of such patients needs frequent troubleshooting and multidisciplinary coordination for a successful surgical outcome.

Surgical repair of postcatheterization radial artery pseudoaneurysm.

Radial artery pseudoaneurysm (RAP) at the site of transradial access (TRA) for coronary angiography is rare. A clean puncture, secure bandage, and watchful follow-up are must to prevent complete occlusion and aneurysm formation at the access site. This illustration describes surgical repair as one of the successful strategies to repair a postcatheterization RAP after TRA.

Effect of mitral valve replacement on reduction of left atrial size.

INTRODUCTION: asymptomatic left atrial enlargement is not uncommon in rheumatic mitral valve disease. We studied the change in size of the left atrium after mitral valve replacement. PATIENTS AND METHODS: between January and December 2005, 116 patients underwent isolated mitral valve replacement. Two groups were identified based on left atrial size: group 1 < 60 mm (n = 79) and group 2 > 60 mm (n = 37). The patients were followed up for 40.4 ± 19.3 months Clinical assessment, preoperative and last postoperative echocardiograms were considered for analysis. RESULTS: the left atrium decreased by 5.84 mm ± 10.5 in group 1 compared to 20.9 mm ± 10.64 in group 2 (p = 0.0001). This correlated with preoperative mitral valve area (p = 0.009), preoperative mitral regurgitation (p = 0.000), and preoperative atrial fibrillation (p = 0.022). Linear regression analysis revealed atrial fibrillation (p = 0.001, b1 = 6.006), a high grade of mitral regurgitation (p = 0.001, b1 = -3.812), and larger size of the left atrium (p = 0.000, b1 = -0.701) predicted a greater reduction of left atrial size during follow-up. Left atrial size decreased by 28 mm in patients with a preoperative left atrium >60 mm (75% sensitivity and 100% specificity). CONCLUSION: the asymptomatic left atrium reduces in size considerably after mitral valve replacement, and the decrease is greater in patients with a left atrium >60 mm in size.