Search

Thrombotic complications following balloon atrial septostomy (BAS) are unusual. We report a patient with thrombus formation at the site of BAS, extending into the inferior vena cava (IVC), following BAS for transposition of great arteries with intact ventricular septum (TGA-IVS). An urgent arterial switch operation (ASO) with removal of the thrombus was performed. [ABSTRACT FROM AUTHOR]

First introduced in 1971, the Fontan procedure is the final common destination for all patients with a functional single ventricle. The procedure itself has evolved tremendously over the last five decades. This review traces this journey and presents the importance, outcomes and future outlook of the procedure in the current era. [ABSTRACT FROM AUTHOR]

Objective: Since the intra-extracardiac Fontan (IECF) was popularized by Jonas in 2008, its claimed advantages over the traditional extracardiac or lateral tunnel Fontan are simplicity, suitability for nearly all subsets, flow characteristics, low risk of sinus node artery injury, and possibly, a lower incidence of arrhythmias. In this paper, we present our early experience with this modification of the Fontan operation. Methods: Between 2009 and 2018, 10 patients underwent IECF on cardiopulmonary bypass (CPB) and cardioplegic arrest at our institute. Analysis of preoperative, intraoperative, and early follow-up results was performed. A polytetrafluoroethylene (PTFE) graft was sutured proximally to the orifice of the inferior vena cava (IVC) and distally to the ipsilateral bidirectional superior cavopulmonary (BSCP) junction. Results: Nine patients had undergone a previous BSCP connection, and one patient had a primary IECF. Diagnoses were double outlet right ventricle (n = 2), unbalanced atrioventricular septal defect with associated atrioventricular valve regurgitation (n = 3), single ventricle with anomalies of cardiac situs (n = 2), and tricuspid atresia with borderline pulmonary arteries (n = 1) or tricuspid atresia with borderline pulmonary artery pressures (n = 2). Median aortic cross-clamp and CPB times were 42 min and 82 min respectively. There were no early or late deaths. Median intensive care stay was 3 days (1 to 23 days). There were no arrhythmias. Mean duration of pleural effusions was 9.5 (median 5.5) days. There were no arrhythmias at a median follow-up of 5 years (range 1 month to 9.3 years). Conclusion: The IECF is simple, particularly at reoperations, in borderline patients and those needing concomitant intracardiac procedures. Early results are promising. These patients need constant surveillance. [ABSTRACT FROM AUTHOR]

Introduction: Even today, the search for the ideal cardiac valve continues. With advantages of having superior flow dynamics, avoidance of anticoagulation, and resistance to infection, homograft has been shown to have an edge over conventional prosthetic and bioprosthetic valves. But they suffer from disadvantages of limited availability and durability. Our center operates one of the oldest functioning valve banks in the country. We present our experience with homograft valve banking with antibiotic and cryopreserved homografts spread over a quarter century. Methods: For donor selection, procurement, sterilization, and preservation, the recommendations of the American Association of Tissue Banks are being followed in accordance with statutory provisions of the Transplantation of Human Organs Act, 1994. Results: During 25-year period (1993–2017), 777 hearts were procured. Age of the donors ranged from 2 to 60 years and hearts were procured within 24 h of death. A total of 1646 homografts (774 pulmonary, 774 aortic, 60 mitral valves, 20 descending thoracic aortae, and 18 monocusps) were harvested. A total of 546 (32%) homografts were rejected for various reasons. Nine hundred sixty-seven (56.7%) homografts were used in different procedures. Of these, 478 were pulmonary homografts, 425 were aortic homografts, 39 mitral homografts, 18 monocusps, and 7 descending thoracic aorta homografts. One hundred fifty-four (16%) homografts were antibiotic preserved and the rest 813 (84%) were cryopreserved. Conclusions: It is possible to run a homograft valve bank with minimum costs. Though, cryopreservation is more expensive, it provides an opportunity to store the valves for an indefinite period and maintain an uninterrupted supply of homografts. [ABSTRACT FROM AUTHOR]

Purpose: Vitamin K antagonists (VKAs), such as warfarin and acenocoumarol, exert their anti-coagulant effect by inhibiting the subunit 1 of vitamin K epoxide reductase complex (VKORC1). CYP2C9 is a hepatic drug-metabolizing enzyme in the CYP450 superfamily and is the primary metabolizing enzyme of warfarin. Three single nucleotide polymorphisms, two in the CYP2C9 gene, namely CYP2C9*2 and CYP2C9*3, and one in the VKORC1 gene (c.− 1639G > A, rs9923231), have been identified to reduce VKA metabolism and enhance their anti-coagulation effect. The purpose of this study is to evaluate the prevalence of CYP2C9 and VKORC1 polymorphism in Indians receiving VKA-based anti-coagulation after valve surgery and to evaluate the usefulness of genetic information in managing VKA-based anti-coagulation. Methods: In the current prospective observational study, 150 patients who underwent heart valve surgery and had stable INR were genotyped for VKORC1 (− 1639 G > A), CYP2C9*2, and CYP2C9*3. The VKA dosage was estimated from published algorithms and compared to the clinically stabilized dosage. Results: Out of 150 patients, 101 (67.33%) were on warfarin and 49 (32.66%) were on acenocoumarol. Majority of the patients, the 83 in warfarin group and the 40 in acenocoumarol group, had a wild CYP2C9 diplotype. The rest had a mutant (CYP2C9*2 or CYP2C9*3) diplotype. Similarly, 67 patients in the warfarin group and 35 patients in the acenocoumarol group had wild type (G/G) of VKORC1 genotype. The rest had a mutant (G/A or A/A) VKORC1 genotype. In the warfarin group, based on the genotype, 51.5% of the patients were extensive or normal metabolizers, and 47.4% of the patients were intermediate metabolizers of VKAs. In the acenocoumarol group, 61.2% of the patients were extensive or normal metabolizers, and 38.8% of the patients were intermediate metabolizers. Individually, alleles of VKORC1 (− 1639 G > A), CYP2C9*2, and CYP2C9*3 had mean dosage reduction effect on VKA dosage, which co-related to the clinically stabilized dosages (P < 0.0001). Among the VKORC1 (− 1639 G > A) cohort, the reduction in warfarin mean weekly dosage was 13.48 mg as compared to the wild-type category (P < 0.0001) and similarly, the reduction in the mean weekly acenocoumarol dose was 6.07 mg (P < 0.03) as compared to the wild type after adjusting for age, gender, and body mass index. Conclusion: Single nucleotide polymorphism in the CYP2C9 gene and in the VKORC1 gene is present in nearly 40% of Indian patients. VKORC1 (− 1639 G > A), CYP2C9*2, and CYP2C9*3 genotypes have significant dosage-lowering effects on VKA-based anti-coagulation therapy. The trend in estimated dosages of VKAs co-related to that of observed the clinically stabilized dosage in the cohort. The pharmacogenomic calculators used in this study tend to overestimate the VKA dosages as compared to clinical dosage due to the limitations in the algorithms and in our study. A new algorithm based on a larger dataset capturing the vast genetic variability across the Indian population and relevant clinical factors could provide better results. [ABSTRACT FROM AUTHOR]

Bulboventricular foramen (BVF) enlargement is often required to enlarge a restrictive interventricular communication in patients with univentricular hearts (UVH) to prevent the development of systemic ventricular outflow tract obstruction (SVOTO). We describe an alternative surgical technique through the transected pulmonary artery without an atriotomy, ventriculotomy or aortotomy that was successfully performed in a patient with double inlet left ventricle (DILV) with malposed great arteries (MPGA) and a restrictive BVF. [ABSTRACT FROM AUTHOR]

In this report, we describe a 3-year-old patient with a functionally univentricular heart (UVH), who had a combination of double outlet right ventricle (DORV) along with an unrouteable interventricular communication (VSD), severe infundibular and pulmonary valvar stenosis, and severe left pulmonary artery (LPA) ostial stenosis. This patient also had an interrupted inferior caval vein (IVC) with bilateral superior caval veins (SVC). We were able to undertake a successful Kawashima procedure with interruption of the antegrade pulmonary blood flow, reconstructing the LPA using a pedicled roll of the left atrial appendage (LAA). [ABSTRACT FROM AUTHOR]

In this review, we discuss various patch materials used for reconstruction of the right ventricular outflow tract. Their relative merits and demerits are discussed. Traditional patches and their results are detailed along with a brief description of newer developments in the field. [ABSTRACT FROM AUTHOR]

Background: Extracardiac Fontan (ECF) is currently the final operation of choice for patients with a univentricular heart. Performing this procedure without cardiopulmonary bypass (CPB) carries potential benefits. In this study, we report the early results of ECF without CPB.Patients and methods: Between 2012 and 2015, 72 consecutive patients underwent Fontan without CPB. Their medical records were examined in detail.Results: Mean age was 11.8 ± 5.2 (range 5 to 23, median 10) years. Intraoperative mean superior vena cava clamp time was 15.19 ± 3.8 min, and the inferior vena cava clamp time was 16.93 ± 3.31 min. There were three early deaths. No patient required conversion from off-CPB to CPB. Mean inotropic score was 4.73 ± 5.9 (range 0 to 25, median 2.5). Mean time to extubation was 9.5 ± 5.82 (range 3 to 29, median 8) hours. Pleural drainage in intensive care unit (ICU) was 551.57 ± 452.77 (median 470) ml, and mean ICU stay was 2.27 ± 3.09 (median 1.5) days. Mean daily pleural drainage after discharge from the ICU was 163.7 ± 88.01 (median 140) ml, and mean time to removal of pleural tubes was 15.76 ± 8.4 (median 14) days. Total hospital stay was 17.03 ± 8.62 (median 15) days. At an early follow-up of 2-40 (median 25) months, all survivors (n = 69) had a patent Fontan circuit with normal ventricular function on echocardiography. There were no late deaths or thromboembolic complications.Conclusions: Off-pump ECF is a low-risk procedure that avoids the harmful effects of CPB. Post-operative course of these patients is predictable with substantial savings in costs. [ABSTRACT FROM AUTHOR]

Objective: The bidirectional Glenn (BDG) procedure is a step in multistage palliation of univentricular heart (UVH). We aimed to report the factors determining the outcomes following BDG.Methods: Two hundred fifteen consecutive patients, 5.29 ± 5 years (range 1 month to 38 years, median 3 years) of age, weighing 13 ± 8.8 kg (range 2.6 to 51 kg, median 10 kg) with variable forms of UVH underwent BDG from 2003 to 2013. Their clinical records were reviewed retrospectively.Results: The most common anatomic diagnoses were tricuspid atresia (n = 87, 40.5%) and double outlet right ventricle (n = 78, 36%). Dextrocardia was present in 21 (9.86%) patients. Median left pulmonary (PA) and right PA diameters were 6 and 7 mm, respectively. One hundred sixty-two (77%) patients received unilateral BDG, and 45 had bilateral BDG. The antegrade pulmonary blood flow was closed in 199 and was left open in 16 patients. Concomitant procedures were reconstruction of pulmonary arteries for non-confluent PA (n = 28), atrial septectomy (n = 15), atrioventricular valve repair (n = 12) and repair of partial anomalous pulmonary venous connection (n = 1). A total of 37% of patients (n = 80) had a mean post-operative saturation of 90 ± 3.2%. There were four (1.86%) early deaths. Mean Glenn pressure was 14.7 ± 3.5 mm Hg, and mean inotropic score and Vasoactive inotropic score (VIS) were 1.64 ± 0.96 and 2.77 ± 2.63, respectively. Mean intensive care unit stay was 24.1 ± 26.4 (range 10-240) h, and mean duration of hospital stay was 7.15 ± 3.2 days. Mean saturation at the time of discharge was 92.4 ± 2.2% and on follow-up was 82 ± 2.16%. Follow-up cardiac catheterization data was available in 123 (60.3%). Sixty-nine (33.8%) patients underwent completion Fontan, and 135 patients were in follow-up or waiting for Fontan completion.Conclusion: BDG procedure can be performed safely with acceptable mortality. Age at presentation, pulmonary artery size and VIS were not related to mortality. Younger patients had similar outcomes but a longer hospital stay. Patients with preserved antegrade pulmonary blood flow had higher saturations. Those undergoing BDG without cardiopulmonary bypass had lower inotropic scores. [ABSTRACT FROM AUTHOR]

Surgical strategies in patients with functionally or anatomically borderline right ventricles include a high-risk biventricular repair, a Fontan procedure, or a one and half ventricle repair (also referred to as the partial biventricular repair). One and half ventricle repair (1.5VR) circumvents the high early mortality of a biventricular repair and also the late morbidity of the Fontan. The two most common indications for a 1.5VR are a small pulmonary ventricle and a dilated poorly functioning pulmonary ventricle. Extension of 1.5VR to patients undergoing anatomical repair for congenitally corrected transposition of great arteries, straddling tricuspid valves, and severe Ebstein’s anomaly has facilitated biventricular repair with decreased mortality. We reviewed the relevant literature on this subject in detail and describe its rationale, indications and its early and late results. [ABSTRACT FROM AUTHOR]

Objectives: The Fontan operation is usually followed by significant pleural effusion. We aimed to study the factors associated with persistent pleural effusion with special reference to serum cortisol levels.Patients and methods: Thirty-eight patients undergoing the Fontan operation between September 2015 and November 2016 were prospectively studied. Parameters studied included age, weight, symptoms, atrio- ventricular valve regurgitation/stenosis/atresia, ventricular function, pulmonary artery pressures, oxygen saturation, aorto-pulmonary, and veno-venous collaterals, type of Fontan, duration of cardiopulmonary bypass, need for inotropes, duration of mechanical ventilation, conduit size, presence or absence of fenestration, and serum cortisol levels. The latter were measured before and after the Fontan operation and the co-relation between pleural effusion and change in serum cortisol levels was studied.Results: Mean age at operation was 13.1 ± 5.6 years (median 13 years). Mean duration and amount of pleural drainage was 15.76 ± 13.2 days (median 11.5 days) and 9.15 ± 4.6 mL/kg/day (median 9 mL/kg/day) respectively. Statistically significant risk factors for prolonged pleural effusion were higher pulmonary artery (PA) pressures (r = 0.328, p = 0.003, odds ratio 1.30), higher inotropic score (r = 0.4, p = 0.01), lower rise in serum cortisol (p = 0.03),elevated superior caval venous pressure (CVP) at 6 h (r = 0.44, p = 0.005) and 12 h (r = 0.4, p = 0.01) and higher duration of mechanical ventilation (r = 0.45, p = 0.005).Conclusions: PA pressures > 15 mmHg, higher inotropic score, higher CVP and lower rise in serum cortisol levels following the Fontan operation were associated with persistent pleural effusion. [ABSTRACT FROM AUTHOR]

We report a 15-year-old female patient with an unusual combination of discreet subaortic membrane, aortopulmonary window, severe aortic insufficiency and rheumatic mitral regurgitation. [ABSTRACT FROM AUTHOR]

We report a 50-day-old infant with infective endocarditis and a large fungal vegetation on the tricuspid valve (TV) obstructing the right ventricular inflow. Emergency excision of the vegetation and TV reconstruction failed. Because of failure to wean off cardiopulmonary bypass support, a rescue bidirectional superior cavopulmonary anastomosis (BDG) was performed. Various management options with appropriateness and efficacy of this procedure are discussed. [ABSTRACT FROM AUTHOR]

Although the safety of paediatric heart surgery has been established, neurologic injuries are still a major source of comorbidity and mortality. The intra-uterine hypoxic milieu coupled with abnormal circulation poses threat to the developing brain. Neurologic injuries vary depending on the level and extent of injury as well as the aetiology, which may be multifactorial. Radiologic signs are late. Various biochemical markers and neuromonitoring modalities enable prediction of neuronal damage. Neuroprotection strategies in these children aim at skilful preoperative assessment, optimal cardiopulmonary bypass strategies, early detection and correction of metabolic parameters. In view of the complex mechanisms and multiple factors involved in neurologic insults, a thorough understanding of pathophysiology and meticulous attention to the details is required to prevent the same. [ABSTRACT FROM AUTHOR]

In patients undergoing open-heart surgery, abnormalities in thyroid hormone levels have been observed even in the absence of primary thyroid disease. These abnormal changes in thyroid hormone level and function have been found to be sufficient to affect myocardial performance and postoperative recovery. In the intensive care unit, postoperatively, it has been found that features such as low cardiac output, left ventricular dysfunction and prolonged ventilator support were associated with hypothyroidism. We reviewed the available literature on the effect of thyroid hormone supplementation in paediatric patients undergoing open-heart surgery under cardiopulmonary bypass and concluded that children after complex congenital cardiac surgery are at risk of developing a clinically significant hypothyroid state in the early postoperative period. In the literature where the effects of supplementation of thyroxine were studied, beneficial effects were observed in terms of reduced mechanical ventilation time, reduced inotropic support and intensive care unit stay, rapid achievement of negative fluid balance and early recovery. Supplementation with thyroid hormones enables a smoother postoperative recovery and is beneficial. The total duration of this therapy is, however, unclear. [ABSTRACT FROM AUTHOR]

Objective: Conventionally, the bidirectional Glenn procedure (BDG) is performed on cardiopulmonary bypass (CPB) using aortobicaval cannulation. This study discusses the procedural details of open anastomosis technique of the BDG and outcomes. Method: Between September 2013 and November 2014, 15 patients (age 49 ± 47.9 months, weight 14.1 ± 10.3 kg) underwent BDG using the open technique (OT). CPB was instituted by aortic cannulation and a single venous cannula in the right atrium. Superior vena cava (SVC) was not cannulated and all the venous return from it was returned via a cardiotomy sucker. This facilitated an open anastomosis. Parameters studied were CPB time, Glenn pressure, SVC clamp time, neurocognitive score, near-infrared spectrometry (NIRS), inotropic score, SpO2, intensive care unit (ICU) stay, hospital stay and immediate complications. Results: Saturation increased from pre-operative 64 to 87 % after operation. Post-operative Glenn pressure was 15 ± 3.8 mmHg. CPB time was 28.6 ± 17.4 min, inotropic score was 8.0 ± 2.5, duration of ventilator support was 8.8 ± 3.6 h, ICU stay was 17.78 ± 3.14 h and hospital stay was 4.4 ± 0.5 days. There was progressive increase of the neurocognitive function post-operatively. NIRS monitoring showed no significant drop in values from base line level in OT group suggesting adequate cerebral perfusion. There were no deaths or major morbidity. Conclusions: BDG can be performed quickly and safely with open anastomosis technique on CPB. [ABSTRACT FROM AUTHOR]

Background: We evaluated midterm results of transatrial repair of TOF with a stress on follow-up studies by echocardiography and exercise testing. Method: Out of a total of 235 patients undergoing transatrial repair of TOF between January 2001 and January 2011 by a single surgical team, 59 patients consented for this study. Mean follow-up was 6.10 ± 1.86 years (median-5.50, range 4.50 years to 12.60 years). Results: One patient had residual VSD and one patient required re-operation for residual right ventricular outflow tract (RVOT) obstruction. Mean RVOT gradient was 13.36 ± 7.99 mmHg. Thirty-three (55.9 %) patients were free of any pulmonary regurgitation. Mean right ventricular myocardial performance index was 0.35 ± 0.06. Tricuspid annular plane systolic excursion and systolic tricuspid lateral annuli velocity (s′) were 16.75 ± 2.57 and 10.82 ± 1.64, respectively, and were suggestive of normal right ventricular systolic function. The mean maximum oxygen uptake (VO2) max was 42.35 ± 6.55 which is higher than previously reported values of patients with repaired TOF. Conclusion: Transatrial repair for TOF offers good mid- to long-term hemodynamics, preserves the right ventricular systolic and diastolic function, and preserves the exercise tolerance capacity. [ABSTRACT FROM AUTHOR]

Creation of a defect in the atrial septum is a well-established palliation for complex congenital cyanotic heart disease. It allows mixing of blood from both the sides and improves systemic saturation and ensures better palliation. We describe a new approach of atrial septectomy through left atrial appendage. This patient also underwent a left-sided bidirectional superior cavopulmonary anastomosis. [ABSTRACT FROM AUTHOR]

Background: Role of Computed Tomography Angiography (CTA) in patients with Bicuspid Aortic Valve (BAV) undergoing Aortic Valve Replacement (AVR) needs assessment. Patients and Methods: After echocardiography, 54 patients with BAV were referred for AVR. CTA was performed routinely. Pre-operative characteristics, echocardiographic and CTA findings, and details of surgery were obtained. Results: The study population had 54 subjects (48 males). Median age was 35.5 years (range 7 to 78 years), and median weight was 57.5 Kg (range 14 to 83 kg). On echocardiography, aortic sinus diameter ranged from 13 to 38 mm (median 28 mm). In none of the patients, ascending aorta was reported to be dilated. On CT angiography, the sinus diameter ranged from 16 to 46 mm (median 35 mm). Sinus diameter was ≥40 mm in 13 patients. The sinus diameter on echocardiography was within the range of 0 to 2 mm of CT angiographic estimates in 31 patients, within 2.1 to 5 mm in 22 patients, and more than 5 mm in one patient. The ascending aortic diameter ranged from 19 to 70 mm (median 43 mm). In 26 patients, ascending aortic diameter was ≥45 mm. In 12 patients, the proximal arch diameter was ≥40 mm. In two patients, the distal ascending aorta and proximal arch were aneurysmally dilated (48 mm and 57 mm). In 12 patients, the ascending aorta was dilated (≥ 45 mm) without any sinus dilatation. In one patient, the distal ascending aorta and proximal arch were aneurysmally dilated (57 mm) without any proximal dilatation. Based on CT angiographic findings, 25 patients (46.3 %) underwent additional aortic replacement in the form of Bentall's procedure ( n = 7), Bentall's + Hemiarch replacement ( n = 6), aortoplasty ( n = 5), Wheat procedure ( n = 6) and Wheat procedure + Hemiarch replacement ( n = 1). Conclusion: CT angiography is justified as a routine pre-operative evaluation tool in all patients with BAV who are undergoing open heart surgery for significant aortic valve dysfunction. [ABSTRACT FROM AUTHOR]

Extracardiac Fontan is currently the preferred final palliation for patients with a univentricular heart. The operation is commonly performed on Cardiopulmonary bypass on a beating heart. In this review, we discuss a protocol for successfully performing this operation without cardiopulmonary bypass. The advantages and pitfalls of this technique are briefly discussed. [ABSTRACT FROM AUTHOR]

During the last two decades, there has been a phenomenal rise in the number of patients undergoing early primary repair for congenital heart defects. Repair of these intracardiac defects usually requires open heart surgery that necessitates cardiopulmonary bypass, aortic cross clamping and administered cardiac arrest. To achieve this goal, cardioplegia is administered at predetermined intervals to ensure a quiescent heart and protection of the myocardium from ischaemia at the same time. Cardioplegia administration is usually done in conjunction with hypothermia to decrease the metabolic demands of the arrested heart as hypothermia alone is inferior to the combination of hypothermia and cardioplegia in providing adequate myocardial protection. The types and methods of cardioplegia in use today are as diverse as individual surgeons; and most institutions have over time developed their own preferred myocardial protection techniques that have proven to be safe and effective. Most of the available literature and concepts in pediatric myocardial protection today have been borrowed from observations in adults and ex- vivo and in-vivo animal models. The extrapolation of these concepts to pediatric myocardium is inappropriate as immature myocardium is not simply a 'small adult heart'. It has unique differences and susceptibilities. This review provides a synopsis of pediatric myocardial protection including types, mechanisms, composition and comparative features of pediatric cardioplegia solutions currently in use all over the world. As of now, there is no evidence favoring one technique or strategy over the other. Pediatric myocardial protection protocols in general are currently experience based. [ABSTRACT FROM AUTHOR]

Introduction: Patients with untreated Persistent Truncus Arteriosus (PTA) usually do not survive or develop irreversible pulmonary vascular obstructive disease beyond infancy. The present study reports the anatomic and hemodynamic data, and results of surgery in patients undergoing surgical repair of PTA beyond 1 year of age. Patients and Methods: Between January 2000 and March 2012, 9 patients aged 1 year or more underwent complete surgical repair of PTA. The median age was 3 years (range, 1 year to 12 years). Median weight was 9 kg (range, 4.7 kg to 30 kg). Seven patients had type I PTA and two patients had type II PTA. Five patients had mild and two patients had moderate truncal valve regurgitation. The mean pre-operative oxygen saturation was 87 % (SD ± 5.07); mean indexed pulmonary vascular resistance was 9.1 units.m (range, 4.5 units.m to 12.3 units.m). The right ventricular to pulmonary artery continuity was created by aortic homograft ( n = 3), pulmonary homograft ( n = 2) or valved bovine xenograft ( n = 4). In one patient, the ventricular septal defect was closed with unidirectional valved patch. Follow up was complete for all patients. Results: There were two in-hospital deaths: one each due to sepsis and intractable pulmonary hypertension. Mean follow up duration was 39 months (range, 3 months to 138 months). There were no late deaths. One patient underwent conduit replacement secondary to aneurysmal dilatation of the conduit with clots leading to conduit obstruction 1 month after the initial operation. None of the patients underwent an additional procedure for truncal regurgitation, which at follow up was trivial in 4 and mild in 3 patients. All patients had good biventricular function and pulmonary hypertension subsided in all. All survivors have systemic saturation in excess of 95 %. Conclusion: A few naturally selected patients with PTA are still suitable candidates for surgical repair after infancy and the early and mid-term outcomes are satisfactory. [ABSTRACT FROM AUTHOR]

Anomalous origin of the left coronary artery from the pulmonary artery is an infrequent and lethal anomaly which can be alleviated surgically. However, its timely diagnosis is important. The management of such patients is challenging for cardiac surgeons and anesthesiologists as they are vulnerable to myocardial ischemia from coronary steal, left ventricular dysfunction, dysrhythmias and pulmonary hypertension. In this report, we present an adult patient who underwent successful surgery for this anomaly. Clinical presentation, diagnosis and anesthetic management of such patients is discussed. [ABSTRACT FROM AUTHOR]

Intense medical and economic pressures have led to the concept of fast track cardiac surgery in which clinical services are streamlined and early discharge to home is encouraged. This aims at optimizing the perioperative management to reduce patient morbidity, to enhance recovery, reduce hospital stay and to reduce costs. 100 Patients undergoing cardiac surgery between October 2008 and March 2009 were included in this study. Operative procedures included pediatric as well as adult cardiac procedures. Two patients were readmitted with superficial sternal wound infection within 1 week of discharge and were managed conservatively with oral antibiotics and daily dressing. Fast tracking is feasible in patients undergoing cardiac surgery. Short acting anesthetics and cardio-pulmonary bypass with mild hypothermia helps in achieving early extubation and thus early discharge. [ABSTRACT FROM AUTHOR]

Aortic valve reconstruction (AoR) using single strip of autologous glutaraldehyde treated pericardium is a substitute for aortic valve replacement. We present our early results with the use of this technique. Between November 2006 and December 2008, we successfully performed AoR with stentless glutaraldehyde treated autologous pericardial valve in 34 patients. The mitral valve was repaired in 26 of these patients. Trans-thoracic echocardiography (TTE) was performed in all patients prior to discharge and thereafter at 3 monthly intervals. Valve deterioration, thrombo-embolic complications, hemorrhage or infective complications were noted during follow-up. There was one operative death. After mean follow-up of 16.3±8.6 months (range 4 to 29 months) low moderate to moderate AR was reported in 9 patients on TTE. AR free survival was 72.2±7.9% at a median follow-up of 14.2 months. None of the patient had any thrombo-embolic complications. None of the patients had any significant AS. Aortic Valve reconstruction using glutaraldehyde treated autologous pericardium is feasible in young patients with acceptable results. [ABSTRACT FROM AUTHOR]

Mitral Valve (MV) repair has gained preference over MV replacement in the past few decades. This randomized trial compares our technique of C-shaped Teflon ring annuloplasty with Carpentier’s ring for annuloplasty in rheumatic mitral valve disease. Fifty adult patients with rheumatic mitral valve disease with predominant mitral regurgitation were randomized to 25 in each group (group A and group B). All Patients were evaluated pre-operatively by trans-thoracic echocardiography. In group A MV repair was performed using Teflon Felt (TF)annuloplasty while in group B Carpentier’s ring (CE) annuloplasty was performed. Patients were followed up for MR, MS or any other adverse event. There were no early or late deaths. The MR free survival in TF group was 72.3±10.5% (median follow-up 13.2 months) vs. 90.3±6.6% (median follow-up 15.5 months) in CE ring group (p value=0.230). There were no thrombo-embolic or bleeding complications noted in any of the patients. The results of annuloplasty with use of Teflon felt are comparable to CE ring in early followup. [ABSTRACT FROM AUTHOR]

The bidirectional superior cavopulmonary anastomosis is an important intermediate palliation in patients with a structurally or functionally univentricular heart. There is an increasing trend to perform this anastomosis without cardiopulmonary bypass. In this review, we present our preferred technique of performing this operation in a safe, simple, inexpensive and reproducible manner. [ABSTRACT FROM AUTHOR]

To identify the incidence, characteristics and risk factors of nosocomial infections (NIs) in infants and children undergoing open heart surgery, a prospective observational study. One hundred consecutive infants and children < 2 yrs of age undergoing open heart surgery (OHS) between March 2007 and December 2007 were included in the study. Samples for blood, endotracheal and urine culture were drawn daily during intensive care unit (ICU) stay. Cultures from endotracheal tube, central venous catheter, arterial cannula, chest tube, urinary catheter and other invasive lines were also obtained. Centers for Disease Control and Prevention criteria were used for defining NIs. A number of possible risk factors predisposing to NI were analyzed. 32% patients developed NI. The NI rate was 49%. Common NIs were bloodstream infection (19%), respiratory tract infection (17%), catheter site infection (7%) and urinary tract infection (6%). Common pathogens were Acinetobacter (22.5%), Pseudomonas aeruginosa (20.4%), Klebsiella pneumoniae (16.3%) and Staphylococcus aureus (12.2%). Major risk factors for NI were length of ICU stay ( p < 0.001), duration of intubation ( p < 0.001), reintubation ( p < 0.001), duration of central venous catheterization ( p = 0.001), preoperative congestive heart failure ( p = 0.002), tracheostomy ( p = 0.003), duration of preoperative stay ( p = 0.01), blood transfusion ( p = 0.01), preoperative balloon atrial septostomy ( p = 0.02), duration of surgery ( p = 0.03), surgical complexity score ( p = 0.03) and hypothermia ( p = 0.03). The mortality rate was 11% with significant association between NI and death ( p = 0.002). NIs develop frequently in infants and children after OHS. This study may serve as a reference point for further development and implementation of interventions aimed at reducing NI rates and improving patient outcome. [ABSTRACT FROM AUTHOR]

Modified Blalock-Taussig shunt is an important initial palliation in a selected subset of patients. This randomized controlled study was conducted to evaluate and compare PTFE and homograft saphenous vein as a conduit for this purpose. Thirty patients were prospectively randomized to receive either a Polytetrafluoroethylene (PTFE) or an antibiotic preserved homograft saphenous vein as conduit. Early results were analysed and compared. Mean graft size was 3.93 mm±0.53 and 4.2 mm±0.53 in the PTFE and vein group respectively. There were 3 hospital deaths in the vein group and none in the PTFE group. There were 2 early and no late shunt thromboses in PTFE group while 1 early and 2 late thrombosis occurred in vein group. These differences were statistically insignificant. The incidence of post-operative bleeding, peri-graft seroma and operative time was less in vein then PTFE group. Palliation on follow-up was comparable in both groups. This study failed to demonstrate any benefit of homograft saphenous vein over PTFE graft in terms of thrombotic complications and mortality. There was however less bleeding and peri-graft seroma formation in the Saphenous vein (SVG) group. Further studies with greater number of patients and longer follow-up are required to demonstrate the superiority of either of these conduits. [ABSTRACT FROM AUTHOR]

Supravalvular aortic stenosis (SVAS) is the rarest form of left ventricular outflow tract (LVOT) obstruction and there is no agreement on the optimal management strategy for these patients Between April 1993 and January 2006, 13 patients with discreet SVAS underwent surgical repair at the All India Institute of Medical Sciences, New Delhi. Age ranged from 2–24 years (mean 8.9±7.2, median 7 years). Williams syndrome was present in four (31%). One patient had associated bicuspid aortic valve with evidence of mild aortic valve stenosis, two patients had moderate aortic regurgitation Surgical procedures consisted of Doty’s extended aortoplasty (n=11), McGoon repair (n=1) and Brom’s three patch aortoplasty (n=1). These patients were followed up to assess progressive LVOT gradients. Pre-operative LVOT gradients ranged from 80–186 mmHg (mean 119.4±34.8, median 106 mmHg) and reduced to 10–40 mmHg (mean 19.2±8.6, median 20 mmHg) after surgery. There was one early death due to infective endocarditis. At a median follow-up of 57 months, gradients across the LVOT progressed to 10–130 mmHg (37.3 ±31.6, median 30 mmHg). In seven (58%), the gradients were 30 mmHg or more at 5 years of follow up. One patient developed valvular aortic stenosis. Actuarial freedom from significant gradients across the LVOT was 66.7 ± 15.7% at 5 years. Although the initial results of our surgical strategy were acceptable, more than 50% of these patients developed significant gradients. Recurrent LVOT obstruction is an ongoing issue even after satisfactory initial repair of SVAS. [ABSTRACT FROM AUTHOR]

There is limited experience with bioprosthetic heart valve implantation in India and results and follow-up are not available. This study aims to assess the suitability of the bioprostheses in the Indian population and impact on their quality of life. Between January 2000 and December 2006, 457 patients underwent bioprosthetic valve replacement. Their age ranged from 20–77 years with a mean age of 55.5±9.3 years. A total of 559 bioprosthesis were implanted: of these 200 (43%) were mitral valve replacements (MVR), 154 (33.7%) aortic valve replacements (AVR), 102 (22.3%) double valve replacements (DVR) and one(0.2 %) tricuspid valve replacement (TVR). There were 11 (2.4%) early and 3 late deaths (0.7%). Post-operative gradients were low. Actuarial survival at 60 months was 95.1±2.2%. The actuarial event free survival was 87.9±5.7% at 60 months. Advantages were freedom from thromboembolism (97.6%), infective endocarditis (98%), haemorrhage (99.7%), Paravalvular leak (99.3%), valve dysfunction (100%) and re-operation (100%). Assessment of quality of life using the standard World Health Organization questionnaire for quality of life yielded satisfactory results. Bioprosthesis are particularly suited for older age patients in our country and are associated with a good quality of life. However long-term results on valve function are awaited. [ABSTRACT FROM AUTHOR]

This is a retrospective analysis of 94 patients who underwent aortic valve replacement for predominant aortic stenosis between January 1998 and December 2004. Age ranged from 16 to 70 years (mean 43.2±13.2 years). 73 were male (77.7%). Etiology was rheumatic in 71 (75.5%) and degenerative in 23 (24.5%) patients. On transthoracic echocardiography, the diameter of the aortic annulus ranged from 19 mm to 36mm (mean 28.5±3.0 mm) and the peak systolic gradients ranged from 54 mm to 174 mm of Hg (mean of 109.8±28.8 mmHg). Aortic regurgitation was absent or mild in 76 patients (80.8%) and moderate in rest. A mechanical valve was implanted in 66 patients (70.2%) and a tissue valve in 28 patients (29.8%). Valves of size 23 mm or more were implanted in 75 patients (80%). A valve of 25 mm or larger was implanted in 55 patients (54.3%). There were no early deaths. Two patients required permanent pacemaker implantation for complete heart block in the immediate postoperative period. Prosthetic valve thrombosis in one patient was relieved by thrombolysis. Anticoagulant related hemorrhage was seen in two patients. One patient underwent homograft aortic valve replacement for prosthetic valve endocarditis nine months after surgery. Isolated aortic valve replacement in patients with predominant aortic stenosis can be performed safely by implanting an adequately large sized prosthesis, without root enlargement in a large majority of patients. [ABSTRACT FROM AUTHOR]

There is no available data on normal coronary artery size in the Indian population. We attempted to establish a database for normal dimensions of the coronary artery segments during life by using quantitative coronary angiography and compared these with Western estimates of coronary artery size. Between december 2003 and June 2004, 94 patients who underwent quantitative coronary angiography for evaluation of symptoms of ischemic heart disease and were found to have no coronary artery disease form the sample size. The dimensions of branches in the left coronary system in our patients were less and those of the distal circumflex, and the proximal and distal left anterior descending coronary arteries were significantly greater than those of Indian Asians living in the United Kingdom and the native Caucasians but the dimensions of the right coronary artery were significantly greater in our patients. Coronary artery dimensions for at least some branches of the left coronary system are similar to that reported in the West and the dimensions of the right coronary are greater. These findings contradict the general perception that Indians have smaller coronary arteries. [ABSTRACT FROM AUTHOR]

To assess the impact of a protocol for reduction of sternal wound complications following open heart surgery. We compared two groups of patients. Group A consisted of 117 patients operated between January 2001 through May 2001. There were 80 males, age ranged from 10–74 years (mean 37.6 years). Surgical procedures included coronary artery bypass surgery (CABG), Valve Surgery and Atrial Septal Defect Closure (ASD). A protocol for surgical technique was introduced from June 2001 and continued through December 2002 (group B). The changes consisted of an interlocking sternotomy, minimal use of electrocautery, irrigation of the pericardial cavity with copious amount of saline with gentamycin, avoiding steel wires for sternal closure and strict supervision of procedures in the operation theatre and intensive care units. Group B-513 patients (332 males) underwent similar surgical procedures June 2001 and December 2002. Age ranged from 5 to 70 years (mean 36.3 years). The incidence of superificial infections, and sternal dehiscence were compared. There was significant reduction in all complications (p=0.0001) as also in superficial infections and sternal dehiscence. Risk factors for infection could not be identified statistically because of the small number of patients with complications in each group. However, age>60 years, Diabetes mellitus & CABG were associated with sternal dehiscence in both groups. With meticulous attention to details sternal wound complications can be reduced significantly. Maintenance of a consistently low complication rate requires strict surveillance. [ABSTRACT FROM AUTHOR]

In medical schools worldwide, the traditional clinical approach is based on the law of parsimony. Physicians in daily clinical practice attempt to fulfill this very simplified yet complex concept of unifying the diagnosis in a given clinical scenario. However, failures are not uncommon. This report presents a case of tetralogy of Fallot who presented with heart failure at young age of 18 months. This is the first description of coexisting tubercular chronic constrictive pericarditis and tetralogy of Fallot. This case is reported for its unique association of two relatively uncommon clinical entities. The logistic dictum of Hickam in similar circumstances is discussed. [ABSTRACT FROM AUTHOR]

A 4½-month-old patient who underwent mitral valve replacement for congenital mitral stenosis using a pulmonary autograft is reported. Failure of the autograft resulted in pulmonary hypertension, leading to pulmonary regurgitation in the reconstructed right ventricular outflow tract, then tricuspid regurgitation, refractory right heart failure, and death. Caution should be exercised in applying this procedure with children, particularly those at risk for pulmonary hypertension. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Coronary Implantation Using the Autologous Flap Extension Technique in Complicated Arterial Switch Operations," published in a previous issue.