Auto-Pericardial Mitral Valve Implantation: A Pilot Study.

INTRODUCTION: Developing nations continue to grapple with rheumatic heart disease, particularly in the young. There is a need for an alternative to prosthetic mitral valve replacement in irreparable mitral valves, which avoids the need for anticoagulation and risks of thromboembolism. METHODS: Twelve (12) patients with irreparable severe mitral valve disease underwent auto-pericardial mitral valve implantation from August 2020 to February 2021. The mitral valve leaflets were excised. Autologous pericardium treated with 0.5% glutaraldehyde for 8 minutes was fashioned into anterior and posterior mitral leaflets as per the dimensions on an indigenously designed template based on the studies by Ranganathan and Lam. The pericardial leaflets were sutured onto an appropriately sized mitral annuloplasty ring. The ring with the leaflets was implanted onto the mitral annulus. The leaflets were supported with neo-chordae prepared with Gore-Tex (W L Gore and Associates, Inc. Newark, DE, USA) and polyester sutures to mimic a repaired mitral valve in its structure and dynamics. RESULTS: The mean cross-clamp time was 138±21.7 minutes. None of the patients required re-exploration. On the third postoperative day, a mean mitral valve orifice area of 3±0.47 cm and mean mitral valve gradient of 2±1.04 were observed. None of the patients had any more than 1+ mitral regurgitation. None of them have required a re-intervention for mitral insufficiency to date. DISCUSSION: Auto-pericardial mitral valve re-implantation is a safe and effective procedure for severe, irreparable, mitral valve pathologies. However, the mid-term and long-term results need to be compared with conventional mitral valve replacement with a prosthetic valve in a randomised controlled trial.

The String Puppet Technique to Improve Exposure in Totally Endoscopic Mitral Valve Surgery.

AIM: To determine the feasibility of the string puppet technique as a flexible, dynamic alternative to atrial retractors in totally endoscopic non-robotic mitral and tricuspid valve surgeries. METHOD: Fifty-one (51) consecutive patients were operated on for totally endoscopic mitral valve repair from July 2017 to February 2018. A 3 cm peri-areolar (males) or submammary (females) incision was placed on the right chest. The thoracic cavity was accessed via the fourth intercostal space. A temporary pacing wire was placed transcutaneously as a puppeteering sling in the thoracic cavity under endoscopic vision. Multicoloured sutures were used to expose the right atrium and interatrial septum by weaving and suspending the sutures on the sling. The sling was tightened to pull up the walls of the cardia and manipulate them externally, like a puppet on a string, to improve selective exposure. RESULTS: We were able to obtain adequate exposure of the mitral and tricuspid valves in all patients without the use of atrial retractors. No patient required conversion to sternotomy due to lack of exposure. None of our patients had postoperative mitral regurgitation of more than 1+ over a mean follow-up of 2 years. CONCLUSIONS: The string puppet technique improves exposure of mitral and tricuspid valves in totally endoscopic cardiac surgery. It is safe, effective, easy to perform, and inexpensive.

Re-do pericardial reconstruction of the aortic valve in Brucella endocarditis.

We report a 12-year-old boy who had undergone an auto-pericardial aortic valve implantation 3 years ago for rheumatic aortic regurgitation. He presented with Brucella endocarditis of the auto-pericardial leaflets with new-onset severe aortic regurgitation, congestive cardiac failure and systemic sepsis. He had an aortic root abscess with multiple pseudoaneurysms in relation to the aortic sinus. Following medical stabilisation, he underwent re-do surgery with debridement of the root abscess, closure of the pseudoaneurysms, excision of the auto-pericardial aortic leaflets and reconstruction of the aortic valve with donor pericardium. He had an uneventful recovery and is asymptomatic on follow-up.

Aberrant Aortopulmonary Venous Fistula: An Intraoperative Surprise.

An isolated systemic artery to pulmonary vein arteriovenous fistula is a rare clinical entity. We report a 20-year-old woman diagnosed with myxomatous mitral valve prolapse with severe mitral regurgitation and planned for mitral valve repair. An aberrant aortopulmonary venous fistula was suspected intraoperatively due to flooding of the left atrium with blood from the left inferior pulmonary vein on cardiopulmonary bypass. The mitral valve was repaired successfully. A postoperative computed tomography angiogram revealed an anomalous fistula between the descending thoracic aorta and left inferior pulmonary vein. The patient underwent successful percutaneous device closure of the fistula.

Protocol for a cluster randomised trial evaluating a multifaceted intervention starting preconceptionally-Early Interventions to Support Trajectories for Healthy Life in India (EINSTEIN): a Healthy Life Trajectories Initiative (HeLTI) Study.

INTRODUCTION: The Healthy Life Trajectories Initiative is an international consortium comprising four harmonised but independently powered trials to evaluate whether an integrated intervention starting preconceptionally will reduce non-communicable disease risk in their children. This paper describes the protocol of the India study. METHODS AND ANALYSIS: The study set in rural Mysore will recruit ~6000 married women over the age of 18 years. The village-based cluster randomised design has three arms (preconception, pregnancy and control; 35 villages per arm). The longitudinal multifaceted intervention package will be delivered by community health workers and comprise: (1) measures to optimise nutrition; (2) a group parenting programme integrated with cognitive-behavioral therapy; (3) a lifestyle behaviour change intervention to support women to achieve a diverse diet, exclusive breast feeding for the first 6 months, timely introduction of diverse and nutritious infant weaning foods, and adopt appropriate hygiene measures; and (4) the reduction of environmental pollution focusing on indoor air pollution and toxin avoidance.The primary outcome is adiposity in children at age 5 years, measured by fat mass index. We will report on a host of intermediate and process outcomes. We will collect a range of biospecimens including blood, urine, stool and saliva from the mothers, as well as umbilical cord blood, placenta and specimens from the offspring.An intention-to-treat analysis will be adopted to assess the effect of interventions on outcomes. We will also undertake process and economic evaluations to determine scalability and public health translation. ETHICS AND DISSEMINATION: The study has been approved by the institutional ethics committee of the lead institute. Findings will be published in peer-reviewed journals. We will interact with policy makers at local, national and international agencies to enable translation. We will also share the findings with the participants and local community through community meetings, newsletters and local radio. TRIAL REGISTRATION NUMBER: ISRCTN20161479, CTRI/2020/12/030134; Pre-results.

3D printing guided closure of submitral aneurysm-an interesting case.

Submitral aneurysm is a congenital outpouching of the left ventricular wall invariably occurring adjacent to the posterior leaflet of the mitral valve. It usually presents with heart failure symptoms. We report a case of a 59-year-old gentleman with a posterolateral submitral aneurysm who underwent aneurysm patch repair and mitral valve repair. Good knowledge about the interrelationship between the aneurysmal sac and mitral valve was obtained enabling proper surgical repair.