Arindam Choudhury

Tracheal injury causing massive air leak during mitral valve replacement surgery

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Indications, timing and techniques of radical pericardiectomy via modified left anterolateral thoracotomy (ukc's modification) and total pericardiectomy via median sternotomy (holman and willett) without cardiopulmonary bypass

Background: Patients with constrictive pericarditis can be treated by pericardiectomy by either left anterolateral thoracotomy or median sternotomy. The terms “radical,” “total,” “extensive,” “complete,” “subtotal,” “adequate,” “near-total,” and partial pericardiectomy have been used often without much clarity. We describe our experience with a radical pericardiectomy technique via modified left anterolateral thoracotomy and compare the same to total pericardiectomy via median sternotomy. Methods: In this study, 67 (54.9%) patients underwent radical pericardiectomy via modified left anterolateral thoracotomy (Group I), and 55 (45.1%) patients underwent total pericardiectomy via median sternotomy (Group II). Results: The operative mortalities were 2.9% and 7.2% for the radical and total pericardiectomy groups, respectively. The time taken for normalization to Class I/II in Groups I and II was 30 ± 11 and 36 ± 14 days, respectively (P = 0.009). Surgical techniques did not affect the outcome of atrial fibrillation (P = 0. 77). Reoperation was not required for any patient. The radical pericardiectomy was also associated with less postoperative low cardiac output state as compared to patients undergoing total pericardiectomy (P < 0.001). There was no difference in mean duration of hospitalization; however, the radical pericardiectomy group achieved the New York Heart Association I and II Status quicker than the total pericardiectomy group (P = 0. 009). Conclusions: We conclude that using several technical modifications of pericardial excision, it is possible to achieve radical pericardiectomy via modified left anterolateral thoracotomy, particularly removing the constricting pericardium over the anterolateral, diaphragmatic surfaces of left ventricle and the anterior and diaphragmatic surfaces of the right ventricle until the right atrioventricular groove without using cardiopulmonary bypass in the great majority of patients undergoing pericardiectomy for chronic constrictive pericarditis. Although the surgical approach for pericardiectomy is based on surgeons preference, left anterolateral thoracotomy is the preferred and noncontroversial approach in the setting of purulent pericarditis and effusive constrictive pericarditis to prevent sternal infection. We recommend median sternotomy approach with or without cardiopulmonary bypass, in the setting of calcific pericardial patches, pericardial masses, reoperations, and calcific pericardial “cocoon” and for those with predominant right-sided and annular involvement.

Relationship between perioperative left atrial appendage doppler velocity estimates and new-onset atrial fibrillation in patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass

Background: Literature search reveals that postoperative atrial fibrillation (POAF) occurs in 15%–40% of coronary artery bypass graft (CABG) patients. Although several risk models exist for predicting the development of POAF, few have studied left atrial appendage (LAA) velocity. We hypothesize that an association between LAA velocity and development of POAF exists. Design and Methods: Single institution university hospital prospective observational clinical study performed between May 2016 and November 2016 in 96 adult patients undergoing CABG surgery utilizing cardiopulmonary bypass (CPB). Transesophageal echocardiography was performed perioperatively to measure LAA velocity and left atrial (LA) size after anesthetic induction, post-CPB and during the postoperative period before extubation. Students t-test was used for inter-group comparisons. Data are expressed as mean ± (standard deviation). The value of P < 0.05 was considered statistically significant. Results: A total of 95 patients (69 males and 26 females) completed the study and were included in the final analysis. Of these, 21 (22%) (15 males and 5 females) developed POAF. The patient group which developed POAF was compared with the group that did not develop POAF. On comparing mean age of patients in each group (59 years in patients with no POAF and 63.71 years in patients with POAF, P = 0.04). LA volume indexed in POAF group (34.13 ml/m2) compared with that in group with no POAF (34.82 ml/m2) resulted in P = 0.04. Mean LAA velocities (pre-CPB, post-CPB, postoperative Intensive Care Unit) in group with no POAF were 41.06, 56.33, and 60.44 cm/s, respectively, whereas in the other group with POAF the values were 39.68, 55.04, and 58.09 cm/s, respectively. No statistical significance was noted (P > 0.05). Comparison of comorbidities also did not yield any significant results (P > 0.05). Conclusions: Decreasing LAA velocity does not appear to independently predict the development of POAF in patients undergoing CABG surgery with the use of CPB. There is, however, a positive correlation of POAF with age and LA volume.

Inverted left atrial appendage: a complication of de-airing during cardiac surgery

A male patient with a bicuspid aortic valve associated with severe aortic stenosis and a dilated aortic root underwent a Bentall procedure. Apart from the aortic pathology, no other abnormalities were detected by a preoperative transesophageal echocardiography (TEE) examination. After an otherwise uncomplicated surgical procedure, the patient’s heart was deaired using standard maneuvers, including manual cardiac agitation and conventional aspiration of the aortic root vent and left ventricular vent inserted during the operation via the superior pulmonary vein. After the de-airing, a hypoechoic structure suggestive of atrial thrombus was seen in the left atrium (LA) using TEE (Figure A). The surgeon was informed of the unusual finding, and on direct visual inspection of the heart, it was confirmed that the left atrial appendage (LAA) had become intussuscepted and inverted inside the LA. Weaning from cardiopulmonary bypass (CPB) was attempted in order to re-establish normal LA pressures and thus revert the appendage to its normal position. Nevertheless, this attempt was unsuccessful, and application of a Valsalva maneuver also failed. Accordingly, during a brief return to CPB, the tip of the LAA was grasped with Russian tissue forceps and reverted to its normal anatomic position, which was confirmed with a repeat TEE examination (Figure B).

Peri-operative challenges in post myocardial infarction ventricular septal rupture: A case series and review of literature

Ventricular septal rupture (VSR) is a life threatening complication of myocardial infarction (MI). The incidence of post-MIVSR varied from 1% to 3% in the pre-thrombolytic era. There is almost a 10-fold decrease in the reported incidences (0.2-0.3%) of MIVSR today. The mortality in such an event is as high as 50-90%. Prognosis of post-MIVSR depends on prompt echo diagnosis and proactive surgical therapy. The peri-operative challenges during management of such a case can be enormous.