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Showing papers in "Indian Journal of Thoracic and Cardiovascular Surgery in 2014"


Journal ArticleDOI
TL;DR: Compared to Western population, this cohort of patients who underwent coronary artery bypass grafting had higher incidence of diabetes mellitus and ischemic cardiomyopathy and low incidence of significant left main disease.
Abstract: Large databases give an insight into patient characteristics and outcomes of patients undergoing coronary artery bypass grafting (CABG) in western populations. However, there is paucity of data in Indian population. This study was designed to understand the clinical characteristics and short-term outcomes of patients undergoing CABG at our institute. All the patients who underwent isolated CABG from January of 2001 to December of 2011 were included in the study. Those who underwent re-operative CABG and concomitant valve surgery were excluded. A total of 4,024 patients underwent CABG during the 11-year period. Mean age of patient population was 57 ± 9.6 years. The incidence of female patients undergoing surgery was 12.6 %. Diabetes mellitus was present in 58.4 % of patients. A total of 1,972 (49 %) patients had prior myocardial infarction. Thirty percent of patients had anterior and anterolateral wall infarction. Nineteen percent of patients had inferior wall infarction; 10.6 % had ischemic cardiomyopathy. Incidence of significant left main disease was 10.9 %. Majority of patients (66.4 %) presented with triple vessel disease. Ninety patients (2. 23 %) died in the early post-operative period. Post-operative stroke rate was 0.15 %. Acute renal failure requiring dialysis and mediastinitis occurred in 0.5 and 0.75 % of patients, respectively. Compared to Western population, this cohort of patients who underwent coronary artery bypass grafting had higher incidence of diabetes mellitus and ischemic cardiomyopathy and low incidence of significant left main disease. Post-operative stroke rate was significantly lower compared to 1–2 % stroke rate reported in western population.

15 citations


Journal ArticleDOI
TL;DR: The M/S ratio should be obtained when limited resection is considered for stage IA NSCLC, and segmentectomy with lymphadenectomy should be preferred for patients with tumor size greater than 1.4 cm.
Abstract: Background The aims of this study were to compare recurrence rate and recurrence-free survival following wedge resection and segmentectomy in stage IA non-small cell lung cancer (NSCLC) and to validate the impact of the type of limited resection, according to tumor size, and surgical margin.

6 citations


Journal ArticleDOI
TL;DR: The Dr. C.S. Sadasivan Memorial Oration is delivered at this 60th Annual Meeting of the Indian Association of Cardiovascular Thoracic Surgeons at picturesque Kovalam, Trivandrum to take the audience through the journey of surgery for coronary artery disease in India.
Abstract: Honourable President Dr. Bhabatosh Biswas, Hon. Sr. Vice President Dr. Kunal Sarkar, Hon. Secretary Dr. S. Rajan, members of this prestigious association, invited guests, ladies and gentlemen! It is my humble privilege to stand before you to deliver the Dr. C.S. SadasivanMemorial Oration for the year 2014 at this 60th Annual Meeting of the Indian Association of Cardiovascular Thoracic Surgeons at picturesque Kovalam, Trivandrum and I thank the association for this honour. Our association instituted an oration in the memory of Dr. C.S. Sadasivan in the year 1981 when the first oration was delivered by Professor N. Gopinath [1]. I start by paying homage to this legendary cardiothoracic surgeon. He graduated with distinction from the Andhra Medical College, Vishakapatnam, did his Masters in Surgery under Dr. Sheppard and was a recipient of the EbdenMemorial Medal. In 1956, he went abroad for training under pioneers like Sir Russel Brock, Dr. Andrew Logan, Professor Crawford, Professor Dubost and many more. He returned to Madras in 1957 and joined the Madras Medical College and Government General Hospital, as a Professor in Cardio-Thoracic Surgery. Dr. Sadasivan had a strong desire to make India self-sufficient in all aspects of cardio thoracic surgery. He started a two years course Masters in Cardio Thoracic Surgery in 1959. He was conferred the Padma Shri Award in 1969 in the field of medicine for his outstanding contributions to cardiothoracic surgery. I salute my illustrious teachers Prof. P. Venugopal, Prof. I.M. Rao, Prof. A. Sampath Kumar, Prof. M.L. Sharma, Prof. BalramAiran, Dr. Bhaba Das and Dr. K.S. Iyer at the All India Institute of Medical Sciences, New Delhi. Dr. V. Mohan Reddy, Dr. K. Samba Murthy and I shared the same platform for our training. I sincerely acknowledge Prof. Sampath Kumar, Prof. Denton Cooley, Dr. K.M. Cherian and Dr. Alexander John for their mentorship and I am touched by the generosity of their encouragement. I joined Dr. GopichandMannam in 1994 and we have been practising cardiac surgery together for the last 2 decades and I express my gratitude for his support and encouragement which enabled me to build an academic career. I also thank all my colleagues at Star Hospitals, Hyderabad. A torch was lit, the flame has journeyed a long way. I wish to take you through the journey of surgery for coronary artery disease in India how havewe adopted the surgical techniques and technology from the Western world, how have we customized these techniques to suit the needs of Indian population and what our contribution of innovations to the science and art of coronary artery surgery is.

6 citations


Journal ArticleDOI
TL;DR: A young boy who presented with tetralogy anatomy, but on evaluation had complete AVSD and an unroofed coronary sinus with LSVC is reported.
Abstract: Complete atrioventricular septal defect (AVSD) in the presence of tetralogy of Fallot is a rare entity. Presence of a common AV valve along with an inlet ventricular septal defect makes repair difficult. Haemodynamically, the pulmonary system is protected from high pulmonary flow due to right ventricular outflow obstruction (RVOT). With these, additional anatomy of presence of left superior vena cava (LSVC) draining to an unroofed coronary sinus defect makes repair even more complex. Committing this coronary sinus to the left atrium at the time of repair will lead to intractable cyanosis, and repair involves its roofing in addition to ventricular and valvular septation, while taking care of RVOT relief, as part of tetralogy surgery. We report a young boy who presented with tetralogy anatomy, but on evaluation had complete AVSD and an unroofed coronary sinus with LSVC. Case report

5 citations


Journal ArticleDOI
TL;DR: Elective repair of abdominal aortic aneurysm is safe, durable with low reintervention rates and easy surveillance protocol, and proof of concept for personalized threshold, globally applicable to Indian and Asian populations is provided.
Abstract: Current threshold for intervention for ubiquitous abdominal aortic aneurysm of 5.5 cm may not be one size fits all on a global perspective. We analysed long-term results with open repair of abdominal aortic aneurysm and postulated to provide proof of concept for personalized threshold, globally applicable for abdominal aortic aneurysm. From 1998 to date, open conventional repair of abdominal aortic aneurysms performed in 274 consecutive patients, with 214 elective and 60 emergent, formed basis of this report. Thirty-two of the elective procedures were performed for small aneurysms of 4–5.4 cm. Concurrently, body weight and height were recorded in 100 patients undergoing computed tomography of abdomen for non-vascular reasons and 32 patients with small aneurysm who underwent elective repair. Aortic diameter was measured at predetermined domains of infrarenal aorta. Thirty-day mortality for elective and emergent groups was 3.73 and 28 %, respectively. Aortic diameter ranged from 1.4 to 1.8 cm and calculated body surface area from 1.44 to 1.7 m2. Normal aortic size, with proven relationship to body surface area, becomes aneurismal when >150 % times its size. Threshold diameter of 5.5 cm has ingrained ‘defining number 3’ considering body surface area in Western males of ≥1.8 m2 (5.5 ÷ 1.8 = 3). Elective repair of abdominal aortic aneurysm is safe, durable with low reintervention rates and easy surveillance protocol. Body surface area, calculated using Mosteller formula from individual’s height and weight, multiplied by threshold factor ‘3’ to determine personalized threshold, so optimal size and time to intervene, in patients with small aneurysm, is at best proof of concept applicable to Indian and Asian populations.

3 citations


Journal ArticleDOI
TL;DR: Deep Vein Thrombosis usually presents as swelling of the limb, pain and difficulty in walking, but in most of the published series the main goal was to improve the long term patency of the deep veins.
Abstract: Deep Vein Thrombosis (DVT) usually presents as swelling of the limb, pain and difficulty in walking. One or more of the predisposing factors like hypercoagulability, trauma, prolonged surgery, malignancy, old age and prolonged bedrest are usually present. It is rare for cases of acute deep vein thrombosis to present as acute limb ischemia and impending gangrene (Phlegmasia cerulea dolens and Phlegmasia alba dolens) [1]. Phlegmasia Cerulea Dolens (PCD) is a rare complication of DVT and carries a high morbidity and mortality rate. It may result in major amputation or death unless treated in an early phase. Guidelines for treatment are still not clearly documented [2, 3]. The mainstay of therapy for acute DVT includes anticoagulants, thrombolytics, antiplatelets and other supportive conservative measures [4–6]. Venous thrombectomy/ embolectomy has not been a common procedure and even in the current era it’s use is limited. There are reports in literature citing the unfavourable results and high complication rate of the procedure, including mortality. Therefore it‘s use was abandoned at most of the centers worldwide. Recent data however suggests more favorable results [7–10]. In most of the published series the main goal was to improve the long term patency of the deep veins. However in these two cases the main goal of treatment was prevention of gangrene and amputation. There are few absolute indications for venous thrombectomy like Phlegmasia cerulea dolens and Phlegmasia alba dolens. Other indications are severe DVT not responding to conservative treatment, iliac vein thrombosis in cases of renal transplant and where there is contraindication to use of anticoagulants. Endovascular treatment for deep vein thrombosis involves the placement of inferior vena cava filters to prevent pulmonary embolism [11] and use of percutaneous suction devices.

2 citations


Journal ArticleDOI
Dheeraj Arora1, Rajeev Juneja1, Yatin Mehta1, Shalini Arora1, Naresh Trehan1 
TL;DR: A case of cold agglutinin disease undergoing Coronary Artery Artery Bypass Grafting (CABG) is presented and detection ofcold agglUTinins before cardiac surgery may alter the perioperative management.
Abstract: Cold agglutinin disease is an autoimmune disease caused by the presence of coldreacting antibodies against red blood cells. These antibodies react at low temperature andmay cause red cell agglutination and complement mediated haemolysis. Detection of cold agglutinins before cardiac surgery may alter the perioperative management. We present a case of cold agglutinin disease undergoing Coronary Artery Bypass Grafting (CABG).

2 citations


Journal ArticleDOI
TL;DR: A case report of a successful brachial artery embolectomy using Swan Ganz catheter threaded over a guidewire in a patient presenting late after axillary artery embolism is presented.
Abstract: Embolism is the most common cause of acute arterial occlusion in the extremities [1]. In majority of the patients, embolectomy is successful if performed within hours of embolism and carries a good prognosis. However, successful embolectomy can be performed even days after an acute occlusion if patient has persistent symptoms of rest pain or claudication pain in the absence of signs of irreversible motor and sensory loss [2]. But, in patients presenting late after embolism, it may be difficult to revascularize the limb as it may be difficult to negotiate the Fogarty catheter across the organized thrombus. We present a case report of a successful brachial artery embolectomy using Swan Ganz catheter threaded over a guidewire in a patient presenting late after axillary artery embolism. Case report

2 citations


Journal ArticleDOI
TL;DR: Myxomas are most common benign primary tumors of the heart and may be asymptomatic or present with chronic or acute congestive heart failure, syncope, and arrhythmias with or without systemic findings.
Abstract: Myxomas are most common benign primary tumors of the heart. Clinically, patients may be asymptomatic or present with chronic or acute congestive heart failure, syncope, and arrhythmias with or without systemic findings. Surgical excision is warranted as soon as diagnosis is established because of high risk of valvular obstruction or systemic embolization.

2 citations


Journal ArticleDOI
TL;DR: Speculation of acquired MH due to the sloughing effect or being a genuine case of associated congenital diaphragmatic hernia is raised.
Abstract: The association between catamenial pneumothorax (CP) and Morgagnian hernia (MH) has never been reported to our knowledge. The presence of anterior diaphragmatic defect could be part of a delayed presentation of MH or part of diaphragmatic involvement in diffuse endometriosis. Such a case highlights the wide variation inthe presentations of thoracic endometriosis. Morgagni described a substernal herniation of abdominal contents in 1769. Larrey described a surgical approach addressing the anterior diaphragmatic defect in 1828 [1]. Synonyms for MH include retrosternal hernia, subcostosternal hernia, and Larrey’s hernia [1]. CP is considered to be a sequel to thoracic endometriosis. Schwarz described lung parenchymal endometriosis in 1938 [2]. In 1958, Maurer described CP and later in 1972, and Lillington coined the name [3]. The ongoing flow of literature over the years has contributed to better understanding of this entity evidenced by the many theories of etiology and various treatment approaches. Theories presented over the years include retrograde menstruation through lymphatics or hematogenous spread as described by Schron and Ruysh [2]. Maurer described the intraperitoneal air theory in 1958 followed in 1972 by Lillington who described the subpleural implants theory [4]. Rossi and Goplerud in 1974 described the Prostaglandin F2α and its bronchvascular spasm effect in the pathogenesis of CP [4]. Sloughing and desquamation of these endometrial tissues cause the rupture of bullae and blebs or creation of diaphragmatic defects. Here, we raise the speculation of acquired MH due to the sloughing effect or being a genuine case of associated congenital diaphragmatic hernia.

2 citations


Journal ArticleDOI
TL;DR: The use of intra-operative autologous blood donation and transfusion improves haemostasis, decreases the post-operative blood loss and improves the post -operative outcome in terms of intensive care unit stay, hospital stay, morbidity and mortality.
Abstract: The technique of ‘blood pooling’ before the onset of cardiopulmonary bypass (CPB) has been shown to be beneficial as a single technique in patients having elective open heart surgery. We sought to more clearly evaluate the role of intra-operative autologous donation also known as acute normovolemic haemodilution in open heart surgery. The study was conducted in the Department of Cardiothoracic and Vascular Surgery, King George’s Medical University, Lucknow, India, in patients who underwent open heart surgery under cardiopulmonary bypass. Autologous blood transfusion was used in all the patients who underwent surgery on CPB since August 2009. Patients were divided into two groups: group I (study group)—patients operated between August 2009 and December 2011 and who received autologous blood and group II (control)—those operated before August 2009 and who did not receive autologous blood transfusion. The post-operative haemoglobin and coagulation profile measured on the first post-operative day differed significantly between the two groups. Intensive care unit (ICU) stay, hospital stay, inotropic support and ventilatory support were significantly less in group 1. Mediastinal drainage was found to be significantly higher in the control group compared to the study group. The mean volume of packed red blood cell, fresh frozen plasma and platelet units transfused per patient in the study group were significantly less than the control group. The use of intra-operative autologous blood donation and transfusion improves haemostasis, decreases the post-operative blood loss and improves the post-operative outcome in terms of intensive care unit stay, hospital stay, morbidity and mortality.

Journal ArticleDOI
TL;DR: Surgery for hydatid cysts of the lung can be safely performed, with low morbidity and a negligible mortality rate and is the treatment of choice.
Abstract: Hydatid cysts are the most common parasitic disease of the lungs. We reviewed our experience with pulmonary hydatid cysts focusing on clinical symptoms, diagnostic methodology, operative management and their outcome in our centre. Between October 2008 and September 2013, 37 patients were operated in our department for lung parenchymal hydatid cysts. Twenty-six patients were female and 11 were male. The mean age of the patients was 30.6 years with a range of 16–44 years. The cysts were located in the right lung in 22 (59.46 %) patients, left lung in 14 (37.84 %) and bilaterally in 1 (2.70 %). We performed enucleation and capitonnage in 29 cases, cystotomy-drainage and capitonnage in 6 cases, wedge resection in 1 case and lobectomy in 1 case. Albendazole was given postoperatively to selected patients considered to be at high risk for recurrence. Chest X-ray, computerized tomographic scanning of the thorax was done in all cases for diagnosis. Most of the patients presented with solitary pulmonary cysts. One patient had bilateral pulmonary cysts and four patients had concomitant liver cysts. Postoperatively, there was no major morbidity. There was no in-hospital or 30-day mortality. The follow-up data was complete for 29 of the 37 patients. The mean follow-up period was 2.6 years with a range of 6 months to 5 years. During the said period, none of the patients had shown any recurrence. Surgery for hydatid cysts of the lung can be safely performed, with low morbidity and a negligible mortality rate and is the treatment of choice.

Journal ArticleDOI
TL;DR: Congenital cystic adenomatoid malformation of the lung (CCAM) is an uncommon anomaly of lung development, characterised by proliferation of dilated bronchiolarlike airspaces of varying sizes and/or distribution.
Abstract: Congenital cystic adenomatoid malformation of the lung (CCAM) is an uncommon anomaly of lung development, characterised by proliferation of dilated bronchiolarlike airspaces of varying sizes and/or distribution. Its aetiology and pathogenesis remain obscure. The dysregulation of lung epithelial cell turnover, increased cell proliferation and decreased apoptosis are some of the proposed mechanisms for its causation [1]. The clinical presentation may range from intrauterine effects in the form of hydrops, preeclampsia, polyhydramnios to respiratory failure at birth. Still later, the presentation may be as recurrent pneumonias usually beyond the 6 months of age.

Journal ArticleDOI
TL;DR: A 20-year-old young man, truck driver by occupation, was struck in an accidental explosion of truck tyre in an automobile repair workshop, and presented to us with left pyopneumothorax and worsening sepsis after 7 days of injury.
Abstract: Accidental barotraumatic perforation of oesophagus is one of the rare causes of oesophageal injury reported in literature. A 20-year-old young man, truck driver by occupation, was struck in an accidental explosion of truck tyre in an automobile repair workshop. He suffered left pneumothorax which was treated with tube thoracostomy at a local hospital. He presented to us with left pyopneumothorax and worsening sepsis after 7 days of injury. Computed tomography chest detected left sided intra-thoracic oesophageal perforation at T8-T9 level. Surgical exploration revealed 9-cm linear tear in thoracic oesophagus. The patient underwent segmental oesophageal resection with proximal cervical oesophagostomy and distal oesophageal exclusion, tube gastrostomy and feeding jejunostomy. He recovered well and was discharged in stable condition.

Journal ArticleDOI
TL;DR: The patient came off smoothly from cardio pulmonary bypass and he had an excellent recovery and he is maintaining a normal sinus rhythm with no episode of heart failure.
Abstract: Submitral left ventricular aneurysm is an aneurysm of the left ventricular wall present adjacent to posterior leaflet of mitral valve in relation to the posterior mitral annulus, producing valve incompetence and left ventricular dysfunction. Only 37 cases have been reported in the literature so far. It is most prevalent in the young African black population and rarely reported in Indian population [1, 2]. It is caused by a defect of the fibrous layer at the level of Atrioventricular (AV) junction [3]. Ventricular arrhythmia and cerebral embolism are the most common manifestations [4, 5]. We discuss our experience with this rare disease. for coronary artery disease (Fig. 1). Immediate aneurysmorraphy along with mitral valve replacement was planned for the patient. Operation was performed via median sternotomy using cardiopulmonary bypass and moderate hypothermia. The cardiopulmonary bypass was instituted using distal ascending aortic and bicaval cannulation after systemic heparinization. Left Atrium (LA) was opened longitudinally. Mitral valve was found to be incompetent and posterior mitral leaflet was thinned out. No clot or vegetations were present in LA cavity. Left ventricular aneurysm was present beneath the posterior leaflet. It was about 6 cm×4 cm in dimensions. The aneurysm was entered from outside from back of the heart. No thrombi or clot were present. Interrupted Ethibond 2–0 sutures (Johnson &Johnson) buttressed with teflon felt pledgets were passed through the neck of aneurysm (Fig. 2). A continuous prolene suture was used to reinforce the repair (Fig. 3). Mitral valve replacement with 27 St. Jude bileaflet mechanical mitral valve was done. Anterior mitral leaflet was excised. Posterior mitral leaflet with chordae was preserved. LA cavity was closed after proper de airing. The patient came off smoothly from cardio pulmonary bypass. The post op period of the patient was uneventful and he had an excellent recovery. Excised aneurysmorectomy tissue on histopathologic examination revealed cardiac muscle with foci of degenerative changes. Now it has been 1 year since the patient is coming for regular follow up. The patient is only on anti coagulants. The patient is maintaining a normal sinus rhythm with no episode of heart failure.

Journal ArticleDOI
TL;DR: Early lung biopsy for a histological diagnosis allows expensive and ineffective treatment to be avoided and can be performed with low risk and high-diagnostic yield for alveolar capillary dysplasia.
Abstract: Alveolar capillary dysplasia with misalignment of pulmonary veins (ACD/MPV) is a rare, fatal, congenital lung disorder involving abnormal development of the capillary vascular system around the alveoli of the lungs, which clinically presents as persistent pulmonary hypertension of the newborn (PPHN) refractory to treatment. It has been linked to the gene FOXF1 on chromosome 16q24.1–q24.2. Histopathological examination by lung biopsy is the gold standard for diagnosis. We present four cases of ACD/MPV who were referred for ECMO support with a diagnosis of PPHN with no apparent congenital anomalies. All the newborns had an overwhelming course, with PPHN and hypoxemia refractory to treatment. The diagnosis of ACD/MPV was established by ante-mortem lung biopsy in all cases. Intensive care treatment was withdrawn post diagnosis, with none of the four surviving. Early lung biopsy for a histological diagnosis allows expensive and ineffective treatment to be avoided. Lung biopsy can be performed with low risk and high-diagnostic yield for alveolar capillary dysplasia.

Journal ArticleDOI
TL;DR: Early pulmonary outcome is similar for patients without preexisting pulmonary dysfunction and undergoing elective multivessel revascularisation by On-Pump Coronary Artery Artery Bypass or OPCAB surgery.
Abstract: Background Coronary Artery Bypass Grafting (CABG) surgery performed on Cardio- Pulmonary Bypass (CPB) may cause pulmonary dysfunction. Off Pump CABG (OPCAB) requires more expertise, but is presumed to reduce pulmonary morbidity as it alleviates the ill effects of CPB. Various studies have conflicting reports of pulmonary dysfunction with both techniques.

Journal ArticleDOI
TL;DR: Early and midterm results of coronary artery bypass surgery in young patients are excellent and actuarial probability of survival at 10 years was estimated to be 91.1 %.
Abstract: Coronary bypass grafting is probably the most extensively studied surgical technique; however, the reported data on its outcome in the younger population are relatively scarce. We present our 10-year experience with young patients undergoing coronary revascularisation. Fifty-one patients, 40 years or younger, underwent coronary bypass surgery in our institution, between January 2003 and December 2012. Relevant preoperative and intraoperative clinical data were retrieved from the patient’s medical records. Follow-up data was obtained by personal or telephonic interview of the patients or relatives. Out of 51 patients (4 females, 47 males), with a mean age of 37.35 ± 3.25 years (range 27–40 years), 47 patients underwent off-pump coronary artery bypass and the rest underwent on-pump beating heart coronary artery bypass. Indication for surgery was triple-vessel disease (TVD) in 24 patients (47 %), double-vessel disease (DVD) in 9 patients (17.7 %) and single-vessel disease (SVD) in 18 patients (35.3 %). A total of 104 grafts (51 with left internal thoracic artery, 10 with radial artery and 43 with saphenous vein) were constructed, with a mean of 2.04 ± 0.94 grafts per patient. There was no in-hospital or 30-day mortality. Mean ICU stay was 2.33 ± 0.76 days and mean hospital stay was 7.2 ± 1.6 days (range 5–13 days). Cumulative follow-up was 256.53 years (mean 5.03 ± 3.19 years); follow-up was 90.2 % complete. Actuarial probability of survival at 10 years was estimated to be 91.1 %. Early and midterm results of coronary artery bypass surgery in young patients are excellent.

Journal ArticleDOI
TL;DR: A case of traumatic transection of the left superficial femoral artery with giant pseudoaneurysm managed successfully by endovascular stent graft is presented.
Abstract: Motor vehicle accidents and falls are the most common causes of blunt injury and are more frequent owing to the ever increasing mobility of modern society. Peripheral vascular injuries account for 90 % of all cases of vascular trauma, most involving the upper extremities in civilian studies and lower extremities in military experience [1]. The penetrating injuries predominate. Continuing refinements in arterial surgery over the ensuing three decades have reduced limb loss in most series to less than 10–15 % [1]. Endovascular techniques have realized great success in treatment of aneurysms of great vessels and have evolved to be of great benefit in management of traumatic aneurysm of peripheral arteries also. Endovascular management of pseudoaneurysm and arterial-venous fistula has been described [2–4]. Transection of an artery is conventionally managed by surgical techniques. Here, we present a case of traumatic transection of the left superficial femoral artery with giant pseudoaneurysm managed successfully by endovascular stent graft.

Journal ArticleDOI
TL;DR: The factors affecting the length of intensive care unit (ICU) stay in patients undergoing isolated on-pump coronary artery bypass (CABG) and effective factors on morbidity, mortality, and survival among patients with prolonged ICU stay were investigated.
Abstract: We aimed to investigate the factors affecting the length of intensive care unit (ICU) stay in patients undergoing isolated on-pump coronary artery bypass (CABG). We also aimed to evaluate effective factors on morbidity, mortality, and survival among patients with prolonged ICU stay. Between January 2002 and December 2009, a total of 1,657 patients underwent isolated on-pump CABG in our clinic. Prolonged ICU stay (>2 days) was present in 532 patient (32.1 %). Diabetes (OR 1.49, P = 0.006), hypertension (OR 1.37, P = 0.029), chronic obstructive pulmonary disease (OR 9.06, P 3 units) (OR 3.23, P = 0.007) were the independent predictive factors of prolonged ICU stay (>2 days). Postoperative mortality rate was 7 % (n = 37) and 2.3 % (n = 26) in patients with length of ICU stay >2 days and length of ICU stay ≤2 days (P 2 days (P < 0.0001). Postoperative mortality was higher in patients with prolonged ICU stay. Mean follow-up was shorter in patients with prolonged ICU stay.

Journal ArticleDOI
TL;DR: All treatment options for managing chronic empyema, including decortication, creation of open-window thoracostomy (OWT), and various types of thoracoplasties for closing the pleural space and BPF, successfully were performed.
Abstract: Surgery for thoracic infections has been defined “the mother of all surgeries” [1], and the surgical management of these conditions requires expertise, experience, and patience on the part of both the surgeon and patient. Chronic empyema can be secondary to delay in diagnosis, ineffective drainage, and presence of bronchopleural fistula (BPF). Surgical procedures for managing this phase include decortication, creation of open-window thoracostomy (OWT), and various types of thoracoplasties for closing the pleural space and BPF, if present [2]. In this case, we performed all of these treatment options successfully. Whenever possible, it would be appropriate to perform a resective surgery to eliminate possible causes of infection, but such actions are rarely possible, in the first instance, in very debilitated patients with active infection [3]. Case report

Journal ArticleDOI
TL;DR: A new case of middle mediastinal schwannomas arising from the vagus nerve or its branches is presented, which is the 26th reported case of this type of tumor since 1943.
Abstract: Neurogenic tumors typically present in the posterior mediastinum originating from the sympathetic chain or intercostal nerve roots. Neurogenic tumors of the middle mediastinum arising from the vagus nerve or its branches are uncommon. However due to their proximity to vital structures in the mediastinum, neurogenic tumors in these locations can pose potential significant problems, as well as undergo malignant degeneration. Complete resection is hence recommended. Since 1943, there have been only 25 reported cases of middle mediastinal schwannomas. We present the 26th reported case.

Journal ArticleDOI
TL;DR: A case of aneurysm of the carotid artery in a 59-year-old female who has undergone a central venous catheterisation through the internal jugular vein and had history of inadvertent carotids artery punctures during jugular veins cannulation is reported.
Abstract: Aneurysm of the carotid artery is rare. We report a case of aneurysm of the carotid artery in a 59-year-old female who has undergone a central venous catheterisation through the internal jugular vein and had history of inadvertent carotid artery punctures during jugular vein cannulation. Patient presented with progressive pulsatile swelling in the neck of 4-month duration, arising immediately after inadvertent punctures. There was no neurological deficit or compressive symptoms due to the neck mass. Patient was subjected to the excision of aneurysm sac and interposition grafting using 8 mm expanded polytetrafluroroethylene (PTFE) graft.

Journal ArticleDOI
TL;DR: Surgical findings were a large ostium primum ASD, cleft anterior mitral leaflet, and a LV–RA shunt on saline testing and an untreated autologous pericardial patch, and patient was weaned off CPB smoothly.
Abstract: A 1-year-old female child, weighing 7.7 kg was admitted to the hospital with history of low birth weight, failure to thrive and recurrent lower respiratory tract infections. On physical examination, there was alopecia, large pointed ears, dysmorphism, ectodermal dyplasia, and motor developmental delay. On auscultation, grade 3/6 early systolic murmur was audible at left upper sternal border. Transthoracic echocardiography showed situs solitus levocardia, concordant atrioventricular-arterial system, partial atrioventricular septal defect (AVSD) characterized by a large ostium primum atrial septal defect (ASD) with left-to-right shunt, cleft anterior mitral leaflet, and trivial mitral regurgitation. There was a tiny left ventricular to right atrium (LV–RA) shunt, pulmonary valvular stenosis, no tricuspid regurgitation, and normal ventricular function. Under general anaesthesia and standard monitoring, aortic and bicaval cannulations were done after systemic heparinisation and cardiopulmonary bypass (CPB) was established. Under moderate hypothermic circulatory arrest, the right atrium was opened. Surgical findings were a large ostium primum ASD, cleft anterior mitral leaflet, and a LV–RA shunt on saline testing. The tricuspid valve had two distinct orifices, the smaller of the two lying posteriorly close to the coronary sinus (Fig. 1). Both components of the tricuspid valve were competent on saline testing. Attempted closure of the mitral cleft resulted in valve stenosis so the cleft was left as such since there was no regurgitation. The ASD was closed with an untreated autologous pericardial patch. Right ventricular outflow tract took Hegar’s dilator size 11, which was appropriate for the age and body surface area, and so pulmonary valvotomy was not required. The accessory valve was left untreated as there was no regurgitation on testing with saline. Patient was weaned off CPB smoothly. Post-CPB epicardial 2D echocardiography showed ASD patch in situ with no residual shunt, no mitral stenosis/regurgitation, no tricuspid regurgitation, and normal ventricular function (Fig. 2)

Journal ArticleDOI
TL;DR: It is concluded that neither of mechanical nor bioprosthetic valves have a greater absolute benefits in surgeries for CHD, and the decision-making for choice of optimal valve should be related to individual factors and condition of the patient.
Abstract: Mechanical and bioprosthetic valves are commonly used for pulmonary valve replacement (PVR) in congenital heart surgery, but they may have a different effect on outcomes. Consequently, optimal choice of the valves in pulmonic position remains controversial. Therefore, the aim of this study was to compare early and long-term surgical outcome and survival of patients after PVR with mechanical and bioprosthetic valves. Sixty-two patients with congenital heart disease (CHD) who underwent PVR were retrospectively reviewed. The patients were divided into two groups—mechanical valve group (MCV) which included 30 patients and bioprosthetic valve group (BPV) which included 32 patients. Medical records of the patients were collected and analyzed to find differences between the outcomes of groups. Thromboembolism, bleeding, and sepsis were more common but not statistically significantly higher in MCV group. On the contrary, right ventricular failure, valve dysfunction, and reoperation were non-significantly higher in BPV group. The survival analysis at 10 years did not show any significant difference between the groups. Moreover, compared with causes of mortality in MCV group, which were right ventricular failure, bleeding, pulmonary embolism, and sepsis, the deaths in BPV group were attributed to endocarditis, arrhythmia, and right ventricular failure. Although bio-prosthetic valves do not require long-time anticoagulants, and mechanical valves have a longer durability, we conclude, based on our results, that neither of mechanical nor bioprosthetic valves have a greater absolute benefits in surgeries for CHD. Hence, we recommend that the decision-making for choice of optimal valve should be related to individual factors and condition of the patient.

Journal ArticleDOI
TL;DR: Removal of radiolucent tracheobronchial FBs in children using rigid bronchoscopy can be performed safely with minimal risks and complications according to type, size, and location of FB.
Abstract: The purpose of this study was to evaluate the role of rigid bronchoscopy in diagnosis and treatment of aspirated radiolucent foreign body (FB) in children. The study was conducted on 150 children with clinical suspicion of radiolucent tracheobronchial FB aspiration, between January 2011 and September 2013. There were 103 (68.7 %) boys and 47 (31.3 %) girls, with a male-to-female ratio of 2.1:1; their age ranged from 4 to 36 months. Removal of aspirated FB was performed under general anesthesia. Patients with favorable outcome were discharged within 24 h. The most common clinical findings were cough (70 %), wheezing (54 %), diminished breath sound (64 %), fever (42 %), and dyspnea (27.3 %) and cyanosis (22.7 %). Rigid bronchoscopy for aspirated tracheobronchial FBs was positive in 95.3 %. The extracted FB was organic (peanuts and fruits) in 95.8 %, and the most common location for FB was the right main bronchus (49.6 %). The most sensitive clinical findings were cough (71.3 %), and the most specific findings were wheezing (85.7 %). Wheezing was a statistically significant predictor of the positive FB (odds ratio = 7.6, CI = 0.89 to 64.9). There was a statistically insignificant difference in demographic and clinical findings between the two positive groups of bronchial and tracheal FBs. The post-procedural complications were encountered in 7.3 % which included pneumonia (3.3 %), hypoxemia (2.7 %), and pneumothorax (1.3 %). The rate of complications was higher and statistically significant with intravenous anesthesia than with inhalation anesthesia (14.5 versus 3.1 %, respectively). Removal of radiolucent tracheobronchial FBs in children using rigid bronchoscopy can be performed safely with minimal risks and complications according to type, size, and location of FB. The index of suspicion is raised by careful history and physical examination.

Journal ArticleDOI
TL;DR: Intraoperative transesophageal echocardiographic examination (TEE) before cardiopulmonary bypass confirmed severe mitral regurgitation and aortic Regurgitation, dilated left atrium (LA) and left ventricle, and no evidence of clot or thrombus in cardiac chambers.
Abstract: Dear Editor, An 18-year-old male patient diagnosed with severe mitral regurgitation and aortic regurgitation was scheduled for aortic valve replacement and mitral valve repair. Intraoperative transesophageal echocardiographic examination (TEE) before cardiopulmonary bypass (CPB) confirmed severe mitral regurgitation and aortic regurgitation, dilated left atrium (LA) and left ventricle, and no evidence of clot or thrombus in cardiac chambers. After surgical repair, an LA clot or mass-like shadow was seen on TEE examination while weaning from bypass. This shadow was just above posterior mitral leaflet in LA (Fig. 1). TEE examination did not show mitral regurgitation, and mean transmitral inflow gradient was 6 mmHg. The shadow was seen in other views also (Fig. 2), but hemodynamics was stable. Before going on bypass again to evaluate this mass, the surgeon inspected the lateral aspect of the left atrium and found that left atrial appendage (LAA) was invaginated into the left atrium giving rise to the echo dense shadow in LA. As LA filling was increased, this LAA inversion gradually disappeared and the LA shadow was no longer visible on TEE (Fig. 3). Transmitral inflow mean gradient decreased to 3 mmHg. Inversion of the left atrial appendage post cardiac surgery mimicking a left atrial mass is an uncommon observation after cardiac surgery [1]. Predisposing factors for inverted left atrial appendage (ILAA) include long, thin atrial appendage with a narrow base, use of LV vent, LA line and inversion of the LA during deairing procedures (Fig. 4) [2]. ILAA was mostly recognised during weaning from cardiopulmonary bypass while the heart was still empty [3]. ILAA has been documented to evert spontaneously as the heart is being filled [3]. Echocardigraphically, ILAA appears as a newly appearing homogenous, mobile mass in the LA without attachments to the LA and may prolapse into the mitral valve (MV). Coumadin ridge can be easily misdiagnosed as left atrial thrombus-like shadow in echocardiography. In the present case, this shadow could be differentiated from coumadin ridge and left atrial appendage in TEE views. Our echocardiographic finding may resemble the images of reverberation previously reported [4]. The change of the transducer angle by at least 120° seems to be helpful for exclusion of such reverberation artefacts [4]. Besides creating confusion in the diagnosis, ILAA has been documented to cause impending necrosis of appendage and mitral valve (MV) obstruction, impaired ventricular filling, and hemodynamic deterioration [1]. In one child, ILAA was felt to be the cause of hemodynamic deterioration 2 days after surgery [4]. Failure to identify such a mass as an inverted left atrial appendage (ILAA) can result in unnecessary interventions [1]. Failure to recognise ILAA, in the differential diagnosis, resulted in unnecessary cardiopulmonary bypass and additional ischemic time [1]. Dimensions of the LAA has been suggested to be important in making spontaneous eversion. Eversion is difficult with longer LAA, larger outpouchings or lobes of the LAA and smaller orifice. The structure, if M. S. Raut (*) :A. Maheshwari Department of Cardiovascular Anesthesiology, Dharam Vira Heart Center, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi 110060, India e-mail: drmonishraut@gmail.com

Journal ArticleDOI
TL;DR: A patient with a left ventricular hemangioma arising from the interventricular septum is presented, unable to diagnose the tumor as a hemANGioma preoperatively eventhough coronary angiogram andMRI was done.
Abstract: Cardiac hemangiomas are very rare benign tumours that present at all ages with the incidence of 2 % [1]. Mcallister and Fenoglio in a review of 533 primary tumours and cysts of the heart and pericardium found only 15 % hemangiomas. The first case of cardiac hemangioma was described in 1893 [8]. Only less than 100 cases of cardiac hemangiomas have been reported in literature till now [2–4]. These benign vascular tumors are usually solitary but can be associated with extracardiac, cutaneous and gastrointestinal hemangiomas. Symptoms include atypical chest pain, dyspnea, pericardial effusion, congestive cardiac failure, thromboembolism, arrhythmias and sudden death [5,6]. These tumours are managed by excision but some hemangiomas may regress without treatment [7]. We present here a patient with a left ventricular hemangioma arising from the interventricular septum. It was an unusal hemangioma because the well circumscribed tumour which was visualized in the echocardiogram and Magnetic Resonance Imaging (MRI) of the heart preoperatively, appeared as a collapsed flat whitish structure whose borders were very difficult to identify in the arrested heart intraoperatively. We were unable to diagnose the tumor as a hemangioma preoperatively eventhough coronary angiogram andMRI was done.

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TL;DR: A 23-year-old male presented with dyspnoea, cyanosis and clubbing and diagnosed to have the right ventricular outflow tract obstruction, patent foramen ovale, severe aortic regurgitation and ascending aorta aneurysm, and a successful intracardiac repair with aortsic root replacement was performed.
Abstract: A 23-year-old male presented with dyspnoea, cyanosis and clubbing and diagnosed to have the right ventricular outflow tract obstruction, patent foramen ovale, severe aortic regurgitation and ascending aortic aneurysm. The diagnosis was achieved by transthoracic echocardiography, cardiac catheterization and contrast-enhanced computed tomography. A successful intracardiac repair with aortic root replacement was performed. Postoperative course was uneventful. Postoperative and 3-month follow-up echocardiogram revealed no gradient across right ventricular outflow tract with mild pulmonary regurgitation and normally functioning prosthetic aortic valve. Histological examination of the aorta revealed cystic medial necrosis of aneurysmal sac wall.

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TL;DR: A 55-year-old male patient presented with complaints of increasing severity of breathlessness and occasional chest pain of 3-months duration and was referred for surgery.
Abstract: A 55-year-old male patient presented with complaints of increasing severity of breathlessness and occasional chest pain of 3-months duration. Electrocardiogram showed features of right ventricular hypertrophy with no signs of myocardial ischemia. Echocardiogram revealed presence of small atrial septal defect with left to right shunt and features of moderate pulmonary hypertension. Patient was referred for computed tomography (CT) coronary angiography for evaluation of coronary arteries. CT coronary angiography showed both coronary arteries arising from right sinus of valsalva through a common ostium. The left coronary artery was seen coursing posterior to aorta in retroaortic course and dividing into left anterior descending and left circumflex artery (Figs. 1a, and 2a, b). Right coronary artery showed normal course and branching pattern. No evidence of any coronary artery stenosis noted. Associated small atrial septal defect was seen (Fig. 1b) with dilated pulmonary arteries, suggestive of pulmonary hypertension. The patient was referred for surgery.