Implication of d-dimer in rheumatic severe mitral stenosis - A tertiary centre study.

BACKGROUND: In rheumatic mitral stenosis (MS), left atrial (LA) thrombus and LA spontaneous echo contrast (LA SEC) reflect hypercoagulability. The study focuses on whether D-dimer levels predict the existence of LA thrombus and SEC in patients with severe MS. METHODS: 95 consecutive patients with severe MS referred for transesophageal echocardiogram (TEE) between July 2011 and March 2012 to evaluate LA thrombus prior to balloon mitral valvotomy (BMV) were included in the study. D-Dimer levels in these patients were observed. RESULTS: Out of the 95 patients, 15 (15.8%) had LA thrombus and 52 patients had LA SEC (54.7%). Any correlation between D-Dimer levels and existence (or non-existence) of LA thrombus was not noticed from the receiver operating characteristics (ROC) curve with an area of .535. For patients with LA SEC, the D-Dimer levels were found to be considerably higher (776 ± 866 µg/L vs. 294 ± 331 µg/L, p = .001). An ideal cut-off level of 393 µg/L for diagnosing LA SEC was illustrated by the ROC curve with a sensitivity of 63.4%, specificity of 83.72%, positive predictive value of 82.5% and a negative predictive value of 65.45%. CONCLUSIONS: D-dimer levels were not representative of the presence or absence of LA thrombus in patients with severe MS. Nonetheless, this study demonstrated the substantial link between D-Dimer level and LA SEC. If a D-Dimer level of 400 µg/L or higher is taken as positive, it has high specificity and positive predictive value for diagnosing LA SEC.

Immediate and late clinical outcomes of balloon mitral valvotomy based on immediate postballoon mitral valvotomy mitral valve area & percentage gain in mitral valve area-A tertiary centre study.

AIM: The aim of the study was to compare the immediate and late clinical outcomes of balloon mitral valvotomy (BMV), based on the immediate post-BMV valve area and percentage gain in mitral valve area (MVA). METHODS: Clinical data of 818 consecutive patients who underwent BMV in our institute from 2000 to 2008 were analyzed retrospectively. They were categorized into three groups based on the postprocedural MVA and percentage gain in valve area-(1) 50% gain with final MVA <1.5 cm2, group 1 (fair result); (2) final MVA of ≥1.5 cm2, group 2 (good result); and (3) <50% gain with final MVA <1.5 cm2, group 3 (suboptimal result). RESULTS: The baseline characteristics of the three patient groups were clearly distinct. Those who had <50% gain with final MVA <1.5 cm2 were older and had higher incidence of atrial fibrillation (17 [22.4%]), heart failure (32 [42.1%]), pulmonary artery hypertension (45 [59.2%]), and significantly deformed valves (39 [51.3%]) at baseline. At a mean follow-up period of 5.64 ± 3.84 years, incidence of redo BMV (23 [4.6%]) and mitral valve replacement (17 [3.4%]) was higher in them than those with immediate MVA ≥1.5 cm2. Among those with MVA <1.5 cm2, events on follow-up were similar irrespective of the percentage gain in MVA. CONCLUSIONS: Immediate postprocedural MVA of ≥1.5 cm2, and not percentage gain, predicts better long-term clinical outcomes after BMV. Patients who had less than 50% gain with final MVA <1.5 cm2 represent high-risk population with advanced mitral valve disease and comorbidities.

Surgical Closure of Aortopulmonary Window in a Topsy-Turvy Heart: A Surgical Challenge.

Topsy-turvy heart is a rare congenital cardiac anomaly characterized by a 90° rotation of the heart along its long axis. The great vessels originate posteroinferiorly, and the arch vessels are elongated and join the aorta well below the carina. It is usually associated with aortic arch and tracheobronchial anomalies. Cardiopulmonary bypass is challenging in these patients because of the abnormal position of the great vessels. We describe the surgical management of aortopulmonary window in a topsy-turvy heart in a 14-day-old girl.

Demonstration of circular shunt in fetal Ebstein anomaly.

Ebstein's anomaly was diagnosed in a fetus at 24 weeks of gestation. There was significant cardiomegaly and severe tricuspid regurgitation (TR). There was functional pulmonary atresia with severe pulmonary regurgitation (PR) and this was causing a circular shunt. There was no fetal hydrops.

Long-term outcome following catheter valvotomy for pulmonary atresia with intact ventricular septum.

OBJECTIVES: This study investigated the outcome for all patients undergoing catheter valve perforation for pulmonary atresia with intact ventricular septum (PAIVS) 21 years after the first procedure at their center. BACKGROUND: Catheter perforation for PAIVS is now an established procedure. However, the management of the borderline right ventricle (RV) is controversial, and there may be a place for novel techniques such as stenting of the arterial duct. METHODS: There were 37 successful valve perforations (total 39 patients). Median length of follow-up was 9.2 years (range 2.2 to 21.0 years). Seventeen patients had stenting of the arterial duct. The mean (SD) initial z-score for the tricuspid valve was -5.1 (±3.4), and a further 142 sets of measurements were taken to assess the growth of the RV of survivors. RESULTS: There were 8 deaths (21%), and no deaths after the first 35 days. There were no late arrhythmias or ischemic events. Twenty-five patients (83% of survivors) have a biventricular circulation. For patients who had stenting of the arterial duct, significant reductions in early reintervention (0 vs. 7 patients, p = 0.009) and hospital stay (17.4 ± 18.1 days vs. 33.8 ± 28.6 days, p = 0.012) occurred, with no increase in mortality or morbidity. There was no catch-up growth of the RV in patients who had a biventricular outcome (z-score increase +0.08/year, p = 0.26). CONCLUSIONS: Long-term survival is good, and even small RVs may be amenable to this procedure. Multiple interventions may be required to achieve biventricular circulation, but stenting of the arterial duct may reduce hospital stay and repeat procedures.