A. Sampath Kumar

Pulmonary autograft: Should it be used in young patients with rheumatic disease?

BACKGROUND Although pulmonary autograft is being increasingly used to replace the diseased aortic valve with excellent long-term results, its use in the population with rheumatic disease still needs careful evaluation. PATIENTS AND METHODS From October 1993 through March 1998, 102 patients underwent aortic valve replacement with a pulmonary autograft (Ross procedure). The mean age was 27.9 +/- 4.2 years (range, 0.8-56 years). The cause was rheumatic disease in 75 patients (73%), bicuspid aortic valve in 26 patients (26%), and myxomatous aortoarteritis in 1 patient (1%). The root replacement technique was used in all. In addition, 31 patients had 33 associated procedures: mitral valve repair (n = 15 patients), open mitral commissurotomy (n = 15 patients), tricuspid repair (n = 2 patients), and homograft mitral valve replacement (n = 1 patient). RESULTS Operative mortality was 6.9% (7 patients). Late mortality was 7.8% (8 patients). Follow-up ranged from 1 to 60 months (mean, 25.3 +/- 15.4 months) and was 98% complete. Two patients required reoperation for failed mitral valve repair, and 2 other patients underwent reoperation for failure of both the autograft and mitral valve repair. Echocardiographic assessment showed moderate to severe aortic regurgitation in 13 patients, along with thickening of the autograft. All of these patients had rheumatic disease and were young (<30 years). Ten of these patients had undergone associated mitral valve procedure. Morphologic and histopathologic examination of explanted autografts showed features compatible with rheumatic valvulitis. CONCLUSION Pulmonary autograft is susceptible to rheumatic involvement. Young age (<30 years) and associated mitral valve disease are significant risk factors for autograft failure in patients with rheumatic disease. Use of pulmonary autograft in this subgroup of patients requires a cautious approach.

Phenotypic characterization of cellular components of cardiac myxoma: A light microscopy and immunohistochemistry study

Cardiac myxoma is the most common primary tumor of the heart. A detailed evaluation of cell types in 41 cardiac myxomas by light microscopy and in 30 cases by immunohistochemistry was made. Reactivity to the various antisera were observed in the surface lining cells, the stromal myxoma cells and the cells in the perivascular location. Factor VIII-related antigen (FVIIIR-Ag) and Ulex europaeus agglutinin (UEA-1), both endothelial markers, were positive in 23 cases each. UEA-1 was found to be a more sensitive marker than factor VIII. Desmin and myoglobin were positive in 16 and 24 cases, respectively. Reactivity for cytokeratin was noted in ten cases, one of which showed glandular differentiation. Vimentin and S-100 positivity was obtained in 16 and 14 cases respectively. Thus, cardiac myxoma appears to arise from multipotent cells which have the potential to differentiate along several mesenchymal cells or epithelial cells and may also concurrently exhibit reactivity for both mesenchymal and epithelial markers.

Immunohistochemical characterisation of Aschoff nodules and endomyocardial inflammatory infiltrates in left atrial appendages from patients with chronic rheumatic heart disease

Fifty left atrial appendages collected fresh during closed mitral valvotomy in patients with chronic rheumatic heart disease, were analysed to determine the frequency of Aschoff nodules and characteristics of mononuclear inflammatory infiltration. Fifty-six percent of specimens demonstrated Aschoff nodules with no clinical or laboratory evidence of acute rheumatic activity in the patients undergoing surgery. Endomyocardial infiltration contained predominantly T cells and occasionally B cells. The relative proportions of T helper-inducer, T suppressor-cytotoxic lymphocytes and macrophages were 45.1 +/- 7.6, 23.5 +/- 4.8 and 29.3 +/- 9.6%, respectively. Frequent presence of Aschoff nodules and heavy mononuclear infiltrates in chronic rheumatic heart disease suggests a possibility of subclinical ongoing carditis.

Sewing Needle in the Heart

An unusual case of a sewing needle in the heart is reported for its rarity. The relevant literature is briefly reviewed.

Digital video recording of cardiac surgical procedures

PURPOSE We attempted to find a method of reducing time and effort for recording videos of cardiac surgical procedures. DESCRIPTION A camera mounting arm designed by us provided a properly fixed digital camera location for undisturbed recording. The camera and its remote control unit provided an opportunity for the surgeon to record only the steps of the operation without need for editing. EVALUATION Digital videos produced by this method required no additional time from the surgeon except to record the commentary at leisure. The video recorded was of excellent quality and provided a well-focused recording of the steps of the operation. CONCLUSIONS The technique described for video recording of cardiac surgical procedures provides a time-saving and easy method for good reproduction of surgical procedures.

Aortic Valve Replacement with Biological Substitute

Abstract In the quest for an ideal aortic valve substitute, homografts and autografts are well‐established options. We reviewed our results with homografts and autografts for aortic valve replacement during the last 5 years. From March 1992 through July 1997,189 patients (138 male and 51 female), age 8 months to 68 years (mean 31.0 2 4.2 years), underwent aortic valve replacement with a human biological substitute. Of these, 93 patients received a cryopreserved or antibiotic‐preserved aortic/pulmonary homograft, whereas 96 patients underwent a Ross procedure. Etiology was rheumatic in 143 (75.6%) patients, bicuspid aortic valve in 40 (21.2%, Marfans disease in 5 (2.6%), and myxomatous aortitis in 1 (0.5%). Among the homograft group, a scalloped subcoronary implantation technique was used in 54 patients, whereas 32 patients underwent root replacement. Five patients required aortic root and ascending aortia replacement for annuloaortic ectasia. In all patients undergoing the Ross procedure, a root replacement technique was used. Operative mortality was 7.4% (14 patients). Late mortality was 5.3% (10 patients). Follow‐up ranged from 1 to 46 months postoperatively. In patients with homograft aortic valve replacement, 76 patients (91.5%) had trivial to mild aortic regurgitation, while 7 patients (8.4%) had important aortic regurgitation. In patients with the Ross procedure, 78 patients (89.6%) had trivial to mild regurgitation. Moderate to severe aortic regurgitation was present in 9 patients (10.3%). all of whom had rheumatic heart disease and were young (< 30 years at surgery). We conclude that homografts and autografts provide an excellent substitute for the diseased aortic valve. Young age (< 30 years) with rheumatic etiology is a major risk factor for early progressive aortic regurgitation in patients undergoing the Ross procedure.(J Card Surg 1998;13:1–8)

Quadrivalvular heart disease

A case of chronic rheumatic heart disease with quadrivalvular involvement is presented. Pulmonary valve involvement was diagnosed only at surgery. The rarity of this disorder and problems regarding diagnosis and management are highlighted.

Immunohistochemical and histochemical profile of Aschoff bodies in rheumatic carditis in excised left atrial appendages: an immunoperoxidase study in fresh and paraffin-embedded tissue

We have evaluated the nature of Aschoff cells within Aschoff bodies seen in 35 of 100 excised left atrial appendages from cases of rheumatic mitral stenosis who underwent closed mitral valvotomy. These were tested using a panel of monoclonal and polyclonal antisera by the indirect immunoperoxidase staining for leucocyte common antigen, macrophage, desmin, vimentin, alpha-1-antitrypsin, alpha-1-antichymotrypsin, lysozyme, acid phosphatase and nonspecific esterase. The Aschoff cell gave strong reactivity with monoclonal antisera to vimentin, macrophage and variable reaction with polyclonal antisera known to recognise macrophages/histiocytes in tissues, namely alpha-1-antitrypsin, alpha-1-antichymotrypsin and lysozyme. These were also strongly positive for acid phosphatase and nonspecific esterase. The Aschoff cell lacked affinity for desmin and only an occasional cell in 4 out of 20 and 6 out of 35 cases showed a weak reaction with myoglobin and leucocyte common antigen, respectively. Intense consistent reactivity with several histiocytic markers affirms the genesis of these cells from macrophages/histiocytes and not muscle cells; a controversy which must be laid to rest!

Criterions for selection of patients for, and results of, a new technique for construction of the modified Blalock-Taussig shunt

BACKGROUND We describe alternative surgical techniques for construction of systemic-to-pulmonary arterial shunts, and propose criterions for their application in selected patients. PATIENTS AND METHODS We constructed a variety of modified systemic-to-pulmonary arterial shunts, using polytetrafluoroethylene grafts, in 92 selected patients with cyanotic congenital heart disease and anomalies of the aortic arch and systemic veins. Their age ranged from 7 days to 3.6 years, with a mean of 7.08 months. We performed 88 operations through a thoracotomy. Of this cohort, 60 patients underwent a second-stage operation, with 15 receiving a superior cavopulmonary connection, 16 a total cavopulmonary connection, and 29 proceeding to biventricular repair after a mean interval of 15.6 months. We have 21 patients awaiting their second or final stage of palliation. RESULTS There were five early (5.4%) and six late deaths (6.8%), two of which were related to construction of the shunts. At a mean follow-up of 45.29 months, the increase in diameter of pulmonary trunk and its right and left branches was uniform and significant (p value less than 0.001). Pulmonary arterial distortion requiring correction at the time of second-stage operation was observed in 5 patients (6.1%). Adequate overall palliation was achieved in 98% of the cohort at 8 months, 91% at 12 months, and 58% at 18 months. CONCLUSIONS Patients with a right- or left-sided aortic arch and right-sided descending thoracic aorta, those with anomalies of systemic venous drainage masking the origin of great arterial branches, and those with disproportionately small subclavian arteries, constitute the ideal candidates for our suggested modification of the construction of a modified Blalock-Taussig shunt. The palliation provided by these shunts was satisfactory, with predictable growth of pulmonary arteries, insignificant distortion in the great majority, and easy take-down.

Pathological aspects of explanted homograft mitral valve

BACKGROUND Homograft mitral valve replacement is an alternative therapeutic approach to prosthetic or bioprosthetic valve replacement. The present paper documents the pathological changes of explanted homograft mitral valve. METHODS We examined six explanted homograft mitral valves, which were taken out 6 weeks to 60 months following valve replacement procedure. Gross examination of the specimens was done, and representative sections were evaluated using haematoxylin-eosin, Massons trichrome, Verhoeffs van Gieson and von Kossa stains. RESULTS On gross examination, the valves showed leaflet calcification and chordal rupture at the tip of the papillary muscles in three cases each. Microscopically, the valve leaflets appeared as aneucleated structures with loss of endocardial lining and lack of nuclear details. The collagenous skeleton was largely preserved. The papillary muscles underwent coagulative necrosis and lacked significant inflammatory infiltrate. One case had a few macrophages at the periphery of myonecrosis, while two cases revealed focal foreign body giant cell reaction. Foci of dystrophic calcification within the areas of myonecrosis were present in three cases. CONCLUSION Homograft mitral valve undergoes degenerative changes in the recipient, some of which can be attributed to ischaemia.