The surgical outcome of anomalous origin of the left coronary artery from the pulmonary artery.

BACKGROUND: Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly which represents one of the most common causes of myocardial ischemia and infarction in children. This anomaly, if left untreated, results in a very high mortality rate within the first year of life. Yet, immediate surgical correction can lead to excellent results. OBJECTIVES: The present study aimed to determine the surgical outcome of ALCAPA. METHODS: This study was conducted on 53 patients with ALCAPA operated from January 2005 to December 2012. Surgical repair was carried out as soon as the diagnosis was made. Surgery was thus undertaken on an urgent basis (within 48 hours) in the patients with congestive heart failure or critical clinical status and on a semi- elective basis (within a few days) in the remaining children. Operations for all the patients were performed through a median sternotomy using established standard cardiopulmonary bypass technique. Grouped variables were compared using chi-square test with Yates' correction. Besides, McNemar's test was used to assess the relationship between preoperative ejection fraction and mitral incompetence. All the analyses were performed using the SPSS statistical software, version 11.5 (SPSS Inc., Chicago, IL). RESULTS: The patients' median age at presentation was 4 months. The mean preoperative ejection fraction was 36.5%. The results showed a significant relationship between age at presentation and impairment of ejection fraction (P < 0.001). At first, 23% of our patients presented with ejection fraction < 35%. However, 6 months after the operation, the ejection fraction improved to a mean of 53.07% (SD = 8.5) ranging from 38 - 66%. There were 5 postoperative hospital deaths with an overall mortality rate of 9.6%. CONCLUSIONS: Excellent results with desirable long-term outcomes can be achieved in the infants with ALCAPA using coronary artery implantation techniques. The best potential for recovery of the left ventricular function is in younger symptomatic infants despite the worst initial presentation. Normalization of cardiac function is expected within the first year in all operative survivors with a patent dual coronary system.

Esophageal Tuberculosis Presenting As Dysphagia.

Esophageal tuberculosis is rare in both immunocompromised and immunocompetent hosts with advanced pulmonary tuberculosis, even in countries with high prevalence of tuberculosis, e.g., South East Asia. This study presents a case report of esophageal tuberculosis presenting as dysphagia.

The Pattern, Presentation and Management of Pardah Pin Inhalation: Report from a Single Center in Northern India.

OBJECTIVE: To describe the clinical characteristics, presentation and management of Pardah pin inhalation in female teenagers of single center in northern India. METHODS: This was a prospective cross-sectional study being performed in department of cardiovascular and thoracic surgery of Sher-i-Kashmir institute of medical sciences located in northern India from January 2009 to December 2012. We included 36 female patients with Pardah pin inhalation who were admitted to our center during the study period. All patients underwent rigid bronchoscopy under local or general anesthesia. We recorded the baseline characteristics including the demographic information, the site of the pin and clinical findings as well as the management strategies and the outcome of these patients. RESULTS: All patients were female using scarf to wrap their head and neck as religious obligation. Mean age of the patients was 14.3 ± 3.6 years. The most common symptom was chocking followed by cough being reported in all (100%) and 31 (86.1%) patients respectively. Bronchoscopy was successful in removing the pin in 31 (86.1%) patients. Pins were located in right main bronchus in 20 (55.5%) patients, and in left main bronchus in 10 (27.7%) patients. There was no mortality in our series. Pin was removed in 31 (86.1%) patients with the help of bronchoscope, but 5 (13.9%) patients needed bronchotomy for removal of the pin. Average hospital stay was 12.43 ± 1.6 hours. CONCLUSION: Rigid bronchoscopy is an ideal approach in management of Pardah pin inhalation. However some patients may need bronchotomy to remove the Pardah pin.

Comparison of right anterolateral thorocotomy with standard median steronotomy for mitral valve replacement.

OBEJECTIVES: The objectives of this study were to compare and analyze the results of right anterolateral thoracotomy and median sternotomy approach for primary mitral valve replacement with reference to the exposure during Valve Replacement , length of surgical incision, mean cross clamp time, mean bypass time, intensive care unit (ICU) stay, hospitalization, overall comorbidity with sternotomy; sepsis, dehiscence, healing cosmetic issues and cost effectiveness. METHODS: The present study comprised 68 patients with rheumatic mitral valve disease who underwent mitral valve replacement in the Department ofCardiovascular and Thoracic Surgery at Sher­i­Kashmir Institute of Medical Sciences from September 2009 to August 2011. RESULTS: This study comprised 64 patients with 23 (35.9%) males and 41 (64.1%) females. Sternotomy group had 10 males (31.3%) and 22 females (68.7%). Thoracotomy group had 13 males (40.6%) and 19(59.4%) females. The length of incision between the two groups was statistically significant (P<0.0001). Mean incision length were 24.6±2.1 cm and 14.8±2.3 cm in sternotomy and thoracotomy respectively. Statistically significant difference regarding duration of ICU stay was found between the two groups (P<0.0001). Scar visibility was 100% in sternotomy and around 25% in thoracotomy( P<0.0001). CONCLUSIONS: Thoracotomy through a right anterolateral aspect was easy to perform while maintaining maximum security for the patients. Besides its satisfactory cosmetic result especially in female patients, this approach proved to have several advantages. It offers a better exposure to the mitral apparatus even in patients with small left, allowing easy mitral valve replacement which is apparent from the lower cross­clamp time in the test group. The invaluable advantage of the above- mentioned thoracotomy is total eradication of the risk of deep sternal infection. The shorter hospital stay and cost effectiveness of thoracotomy approach are additional relief to the family.

Vascular injuries: trends in management.

ABSTRACT: Vascular injury presents a great challenge to the emergency resident because these injuries require urgent intervention to prevent loss of life or limb. Sometimes serious vascular injury presents with only subtle or occult signs or symptoms. The patient may present weeks or months after initial injury with symptoms of vascular insufficiency, embolization, pseudoaneurysm, arteriovenous fistula etc. Although the majority of vascular injuries are caused by penetrating trauma from gunshot wounds, stabbing or blast injury, the possibility of vascular injury needs to be considered in patients presenting with displaced long bone fractures, crush injury, prolonged immobilization in a fixed position by tight casts or bandages and various invasive procedures. iatrogenic vascular injuries constitute about 10% of cases in most series; however the incidence is an increasing trend because more endovascular procedures such as angioplasty and cardiac catheterization are being performed routinely. Civilian trauma is more frequently seen in young males. However, it can occur at any age due to road accidents, firearms, bomb blasts and diagnostic procedures. Most of the time, civilian trauma causes less tissue damage. There is an epidemic of vascular injuries in Kashmir valley because of problems in law and order in the past two decades. This review deals with the topic in detail.