Rheumatic mitral valve surgery in the fifth decade: our experience.

AIM: Rheumatic mitral patients reach their fifth decade of life more often now than in the past. The purpose of this study is to provide insight into improving morbidity and mortality in these patients. METHODS: This retrospective study included 105 patients aged 50 years or more. Seventy-five underwent mechanical valve replacement and 30 received a bioprosthetic valve. Data were collected from medical records and outpatient department (OPD) registers. Follow-up included transthoracic 2D echocardiography, supported by clinical parameters, and X-ray findings. RESULTS: Mean age was 58.52+/-2.4 years. Follow-up period ranged from one to eleven years (mean 6.8+/-0.9 years). Immediate perioperative mortality included five patients (4.76%) and long term mortality included three patients (3%). 35 patients previously underwent closed and open commissurotomy and balloon valvotomy. Multivariate analysis showed age, repeat surgery, atrial fibrillation, tricuspid valve disease, and preoperative functional status to be incremental risk factors. Freedom from repeat operation at 3 and 6 years was 90% and 85% in group I (<60 years), respectively. Actuarial survival at 4 and 6 years of follow up was 94.24% and 88.52%, respectively. CONCLUSION: With improving life expectancy and early interventions, the number of < or = 50-year old rheumatic valvular disease patients is increasing. The present study showed a marked improvement for this subset of patients, although age still remains the main risk factor along with atrial fibrillation, repeat surgery, stroke and tricuspid valve disease.

Aortic arch interruption with rheumatic mitral stenosis and Ebstein's anomaly. Report of a case with successful surgical outcome.

We present a rare case of a patient with interrupted aortic arch with Ebstein's anomaly of the tricuspid valve and rheumatic mitral stenosis. This patient presented in early adulthood, which makes his case even more unusual. We successfully treated the mitral stenosis and the interrupted aortic arch through a left lateral thoracotomy, but we decided against correcting the Ebstein's anomaly, which was mild. The hemodynamic effects of each lesion, independently and in the presence of each other, are discussed.

Aneurysms of sinus of Valsalva eroding into the interventricular septum: etiopathology and surgical considerations.

OBJECTIVE: To evaluate and discuss etiopathology, clinical manifestations and surgical outcome of a rare subset of unruptured aneurysm of the sinus of Valsalva which erodes into the interventricular septum. METHODS: Between 1989 and 1995, seven cases of unruptured aneurysm of the sinus of Valsalva eroding into the interventricular septum underwent surgical correction at the King Edward VII Memorial Hospital, Bombay. The origin of all these aneurysms was from the right coronary sinus. The mean age of presentation was 31 years. All patients were male. Calcification of the aneurysm was seen in three. Three patients presented without aortic regurgitation; all had complete heart block. Four patients presented with aortic regurgitation and in addition, two had complete heart block. Preoperative left ventricular function was poor in patients with aortic regurgitation (Ejection fraction range; 30-42%), when compared to those without aortic regurgitation (Ejection fraction range; 48-52%). Of those without aortic regurgitation at initial presentation, one patient developed progressive aortic regurgitation after 3 years requiring surgery. While two other patients were operated at earliest for closure of aneurysm, even in the absence of aortic regurgitation. All those with aortic regurgitation required surgery for aortic valve replacement and closure of aneurysm. Aneurysm was closed by direct suturing of the ostium in two patients and by patch closure in five patients. Permanent pacemaker was implanted in five patients. RESULT: There was no operative death. Patients who underwent aortic valve replacement required postoperative ionotropic support. Two patients, who underwent surgery in absence of aortic regurgitation, remain free of aortic regurgitation at the end of 36 and 42 months of follow-up. One of the patients with calcific aneurysmal sac underwent successful re-replacement of the aortic valve for paravalvar leak after a 2 year interval. CONCLUSION: Unruptured aneurysm of the sinus of Valsalva eroding into the interventricular septum should be operated at the earliest, which makes surgery simple and prevents development of complications such as aortic regurgitation and heart block.

Coronary sinus thrombosis after cannulation during cardiopulmonary bypass.

Coronary sinus thrombosis was found at autopsy of a boy who had undergone intracardiac repair of tetrology of Fallot. During the operation persistent left superior vena cava was cannulated through the right atrium via the coronary sinus. There was also evidence of myocardial infarction in the region of the interventricular septum.

Cardiac surgery and plasma digoxin levels.

Cardiopulmonary bypass (CPB) can induce several haemodynamic alterations and therefore influence pharmacokinetics of various drugs. In order to assess the effect of CPB on plasma digoxin levels, these were monitored in patients undergoing open heart surgery involving CPB (n = 11), over a 24 hour period, starting just prior to commencement of surgery. For comparison, plasma digoxin was also monitored in a group of patients (n = 10) who underwent cardiac surgery not involving CPB. In 7 of the 11 patients in the CPB group, plasma digoxin levels (ng/ml) were significantly (p < 0.01) lower at the end of 24 hours (0.654 +/- 0.094) than basal levels (1.3114 +/- 0.2498). In contrast, in the non CPB group, 7 of 10 patients showed significantly higher (p < 0.001) plasma levels (ng/ml) at the end of 24 hours (0.477 +/- 0.125) as compared to basal levels (0.26 +/- 0.098). Thus, rather than the type of surgery, it appears that the pre-operative levels of plasma digoxin influence its pharmacokinetics.

Right-ventricular fibroma presenting as tricuspid stenosis--a case report.

A male child presented with suspicion of tricuspid stenosis. Echocardiography revealed the presence of a mass arising from the free wall of the right ventricle and causing right-ventricular inflow obstruction but not involving the tricuspid valve. The tumour was excised via right ventriculotomy using cardiopulmonary bypass, resulting in survival and a satisfactory clinical course. Histological examination showed the tumour to be a fibroma. Tricuspid stenosis is an unusual presentation of right ventricular fibroma. Careful examination is essential to early diagnosis of cardiac fibromas, particularly in children with unexplained cardiac problems. Echocardiography is still a good method for confirmation of the diagnosis and for follow-up. In view of the unknown natural history of cardiac fibroma, surgical excision should be undertaken. Early detection and prompt excision results in immediate and complete relief of symptoms and prolongs the life span.

Surgical considerations in the management of significant acute mitral regurgitation following mitral valvotomy.

Repair of the mitral valve should be the primary goal in the surgical management of acute mitral regurgitation following valvotomy. The earlier the repair is done, the better it is because the preoperative haemodynamics affect the overall outcome. The disadvantages and anticoagulation of prosthetic valves are avoided. Besides, it is economical to avoid the high cost of the prosthetic valves in a poor socio-economic group of patients. With good patient selection and additional effort by the surgeon to acquire the necessary expertise to reproduce the techniques of mitral valve repair, a superior quality of life can be offered to these patients. The present study is a retrospective analysis of 14 patients who required emergency open heart surgery following balloon or closed mitral valvotomy. The valve was successfully repaired in 8 patients. The medium term follow-up indicates that repair is reproducible, safe, reliable, and a stable procedure free of complications.

Surgical considerations in management of left hemianomalous pulmonary venous connections.

Anomalous pulmonary venous connection of the entire left lung into the left innominate vein is very rare. 5 patients with this anomaly were managed in the authors' institution over the last 12 years. Clinically they were diagnosed as cases of pretricuspid left-to-right shunt at atrial level. Cardiac catheterisation and angiography demonstrated the anomalous drainage of the entire left lung into the left innominate vein. Anastomosis between the vertical vein and the left atrium was established using conventional cardiopulmonary bypass, hypothermia, and cold cardioplegic diastolic arrest of the heart. Postoperative course was uneventful. 4 of the 5 patients presented for follow-up during 1-12 years (mean 6.5 years). All are asymptomatic and have been studied with echocardiography, angiography, and magnetic resonance imaging techniques. The anastomatic site was found to be non obstructive in all the patients.

Right-ventricular myxoma presenting as right-ventricular outflow-tract obstruction--case report and review of the literature.

Myxoma of the right ventricle is of very rare occurrence. An adult male patient presented with Class III dyspnoea and occasional haemoptysis and clinically was suspected to have pulmonary stenosis. Magnetic resonance imaging study revealed presence of myxoma arising from the right-ventricular free wall and prolapsing into the pulmonary artery but not involving the pulmonary valve. The myxoma was excised via right ventriculotomy using cardiopulmonary bypass. The patient had an uneventful recovery. The relevant literature is reviewed.

Enhancement of haemopoietic stem cell adherence to bone-marrow derived stroma by phyto-haemagglutinin treated leucocyte conditioned medium (PHA-LCM).

Stem cell adhesion to bone-marrow derived stroma, plays a crucial role in haemopoiesis. However, there is very little information as to the nature of the adhesion molecule. In this paper we have shown that human bone-marrow derived stroma can be established in tissue culture. This stroma is able to adhere human bone-marrow mononuclear cells including the multipotent stem cell, viz. CFU-GEMM. Their adherence increases when the stroma is treated with lymphokines in the form of PHA-treated leucocyte conditioned medium (PHA-LCM). Triton X-100 extracts of the untreated and PHA-LCM treated stroma were analysed on single dimension PAGE. It was observed that PHA-LCM treated stromal extracts showed two extra bands and an increase in the density of a band of approximately 14 kDa. Whether these changes have anything to do with the increased adhesion of stem cell is not yet known.

Surgical considerations in the management of thoraco-abdominal aortic aneurysms.

Nineteen patients of Thoraco-abdominal aortic aneurysm were operated during a nine year period. All were larger than 10 cm. in size. Four were operated in emergency. Seven underwent patch aortoplasty while eleven required tube inlay aortoplasty with visceral vessel reimplantation. One patient continued to be paraplegic postoperatively. Two (10.52%) had acute renal failure and there were two (10.52%) deaths. A sincere effort to keep the aortic and renal occlusion times to minimum and successful reimplantation of lower intercoastals and visceral branches appear to offer significant help in accomplishing successful repair with justifiable expectancy.

Surgical correction of aneurysms of sinus of Valsalva--a report of 22 cases.

Twenty two cases of aneurysm of sinus of Valsalva managed during a 12 year period are analysed. The right coronary sinus was involved in 14 and the non-coronary sinus in eight cases. It had ruptured in 20 patients while in the other two it had produced right ventricular outflow tract (RVOT) obstruction. Six patients had associated ventricular septal defect (VSD), and eight had aortic regurgitation (AR), five of these requiring aortic valve replacement (AVR). Aortocameral approach was preferred and was used in 18 patients. Recurrence had occurred in one. Surgical management and results are discussed.

Double-orifice mitral and tricuspid valves in association with the Raghib complex.

A 19-year-old woman presented clinically with a left to right pretricuspid shunt. Echocardiography revealed a large ostium primum defect and a double-orifice mitral valve. Operative findings revealed additionally a double-orifice tricuspid valve and a left superior vena cava draining to the roof of the left atrium. The atrioventricular valves were competent. The primum defect was patched and the left superior vena cava was rerouted.

Temporary intravascular shunts for peripheral vascular trauma.

Polyvinylchloride (PVC) disposable endotracheal suction catheters were successfully used as temporary intravascular shunts in 5 patients of popliteal artery trauma. These simple shunts should be used routinely in such conditions to immediately re-establish blood supply to the ischaemic limb particularly in patients of polytrauma where systemic anticoagulation is contraindicated. This avoids the inherent delay prior to vascular repair and reduces the incidence of irreversible ischemia.

Unruptured congenital aneurysm of the left sinus of Valsalva presenting as acute right ventricular failure.

A patient with unruptured congenital aneurysm of the left coronary sinus of Valsalva presented with acute right-sided heart failure due to right ventricular outflow tract obstruction. The mechanism for such an acute presentation may have been a sudden increase in the size of the aneurysm. The surgical importance of this lesion is the combined aortocameral approach which is seldom required for correction of such aneurysms.