Arkalgud Sampath Kumar

Surgical experience with intracardiac myxomas : Long-term follow-up

BACKGROUND Myxomas are the most common benign intracardiac tumors. This report summarizes our 20-year experience with these tumors. METHODS Sixty-six patients (25 male) with a median age of 39 years (range, 6 to 70 years) underwent surgical excision of primary or recurrent intracardiac myxomas during the years 1976 to 1996. Symptom duration ranged from 2 to 8 months. There were 55 left atrial myxomas, 10 right atrial myxomas, and 1 biatrial myxoma. Three of the patients were in one family. The surgical approach comprised complete wide excision. RESULTS There were two early deaths. Late follow-up is 89% (57/64) complete. There was one late death, which was not due to a cardiac cause. Echocardiography at a mean follow-up of 66.9 months (range, 7 to 241 months) showed no recurrence of sporadic myxomas. However, 2 of the 3 patients with familial myxomas had recurrence. CONCLUSIONS Surgical excision of atrial myxoma gives excellent short-term and long-term results leading to eventual cure of nonfamilial myxomas. However, familial myxomas retain a strong tendency to recur even 20 years after excision.

Sinus of Valsalva Aneurysms: 20 Years’ Experience

Abstract Background: Aneurysms of sinus of Valsalva are rare. Here, we analyze retrospectively patients operated on at our center during the last 20 years. Patients and Methods: One hundred four cases of congential aneurysm of sinus of Valsalva were operated upon between January 1977 and April 1996. Only 12 aneurysms were unruptured. The majority (76.9%) arose from the right coronary sinus. The right ventricle was the most common chamber of rupture (58.6%). Ventricular septal defect was associated in 46 patients (44.2%), of which 28 (60.9%) were supracristal. Ventricular septal defect was more common in aneurysms arising from the right coronary sinus (91.3%). Aortic incompetence was found in 45 patients (43.3%). The defect was closed through the aortic root alone in 24 patients (23.1%) and through both the aortic root and the chamber of rupture in the remaining 80 patients. Six patients underwent aortic valve repair, and 21 an aortic valve replacement. Results: There were two hospital deaths (1.92%). Morbidities were few. Follow‐up ranged from 1 to 20 years (mean 8.2 ± 1.1). There was one late noncardiac death, and in the majority, the long‐term follow‐up was uneventful. Conclusion: Surgery for aneurysm of sinus of Valsalva yields gratifying results, and it should be undertaken as soon as the condition is diagnosed.

Aneurysm of Sinus of Valsalva Dissecting Into Interventricular Septum

BACKGROUND Dissection of interventricular septum by aneurysm of the sinus of Valsalva is extremely rare. We present our experience with the management of 10 patients with this condition. METHODS Ten patients with aneurysm of the sinus of Valsalva dissecting into the interventricular septum were managed at All India Institute of Medical Sciences, New Delhi, between May 1987 and September 1996. Conduction abnormalities and aortic insufficiency dominated the clinical picture. Eight patients underwent surgical repair. Two patients refused operation, and only permanent pacemaker implantation was done for complete heart block in both these patients. RESULTS There was no hospital mortality. Follow-up ranged from 1 to 9 years. There was one late death due to carcinoma of the larynx, and 1 patient required reoperation for persistent aortic insufficiency. All other patients who underwent operation are in New York Heart Association functional class I. CONCLUSIONS We recommend surgical repair of this condition to deal with aortic regurgitation and to avoid the potential risk of rupture, thromboembolism, and infective endocarditis. However, surgical repair offers no guarantee against arrhythmias and conduction abnormalities.

Open mitral commissurotomy in the current era: indications, technique, and results

BACKGROUND The present retrospective study is focused on indications, techniques, and results of open mitral commisurotomy in the current era. METHODS Of the 1,280 patients undergoing open-heart surgical procedures for rheumatic mitral stenosis between January 1990 and July 2000, 276 (21.6%) patients underwent open mitral commissurotomy. Major indications included presence of left atrial thrombus/clot (n = 82, 29.7%), severe subvalvular disease (n = 110, 39.8%), mitral valve calcification (n = 42, 15.2%), mild mitral regurgitation (n = 28, 10.0%), associated aortic valve disease (n = 55, 19.9%), organic tricuspid valve disease (n = 20, 7.2%), and failure or restenosis after closed or balloon mitral valvuloplasty (n = 55, 19.9%). Age of patients ranged from 7 to 67 years (mean, 30.2 +/- 12 years). The majority (76%) were in New York Heart Association class III or IV, and 6.9% were in congestive heart failure. Atrial fibrillation was present in 134 (48.6%) patients. Mitral valve area ranged from 0.3 to 0.7 cm2 (mean, 0.52 +/- 0.12 cm2). Mid-diastolic gradients across the mitral valve ranged from 8 to 34 mm Hg (mean, 14.5 +/- 6.2 mm Hg), and end-diastolic gradients ranged from 8 to 42 mm Hg (mean, 15.2 +/- 5.7 mm Hg). Open mitral commissurotomy was performed using standard cardiopulmonary bypass. Associated aortic valve procedure was performed in 55 patients, and either tricuspid valvotomy or repair was performed in 28 patients. RESULTS There were four early deaths. All these patients had associated aortic valve procedure (Ross procedure in 2 and homograft aortic valve replacement in 2). Three patients developed severe mitral regurgitation in early postoperative period (< or = 30 days) and required reoperation. Predischarge echocardiography showed mitral valve area from 1.4 to 3.5 cm2 (mean, 2.6 +/- 0.6cm2) and moderate mitral regurgitation in 4 patients. Follow-up ranged from 1 to 130 months (mean, 64.5 +/- 28.6 months). There was no late death. There were three reoperations for mitral valve failure, and an additional 2 patients developed severe mitral stenosis (mitral valve area < 1.0 cm2). In operative survivors, freedom from mitral valve failure at 10 years was 87.0% +/- 3.5%. In patients with isolated open mitral commissurotomy, the incidence of thromboembolism was 0.5%/patient-year. CONCLUSIONS Open mitral commissurotomy provides excellent early and long-term results in a selected group of patients.

Results of mitral valve reconstruction in children with rheumatic heart disease

BACKGROUND Between January 1988 and November 1994, we developed techniques of reconstructing diseased mitral valves in patients with rheumatic heart disease. Four hundred thirteen patients underwent mitral valve repair using these techniques. Of these, 125 children and adolescents less than 15 years of age form the study group. METHODS The mean age was 8.9 +/- 4.3 years (range, 5 to 15 years). One hundred seventeen patients (93.6%) had rheumatic heart disease. There were 72 boys (57.6%) and 53 girls (42.4%). All of these patients were symptomatic: New York Heart Association class III or IV. Mitral regurgitation alone was present in 49 patients (39.2%), and combined mitral stenosis and regurgitation were present in 76 patients (60.8%). Surgical techniques included commissurotomy (n = 70; 56%), annuloplasty (n = 122; 97.6%), chordal shortening (n = 46; 36.8%), cusp thinning (n = 27; 5.6%), and associated procedures for tricuspid valve disease (6 patients) and aortic valve disease (2 patients). RESULTS The operative mortality rate was 4.8% (6 patients), and late deaths occurred in 1.6% (2 patients). Follow-up was 378.25 patient-years. In 15 patients, severe mitral regurgitation developed after a mean follow-up of 37.14 +/- 20.47 months (seven reoperations). At 6 years, actuarial and event-free survival rates were 92.1% +/- 3.19% and 75% +/- 8.18%, respectively. One patient (0.15%/patient-year) had transient right hemiparesis. None had anticoagulation-related bleeding. CONCLUSION Mitral valve reconstruction in children and adolescents with rheumatic mitral regurgitation provides satisfactory early results. Progression of disease is the most important risk factor for reoperation. The technique described provided stable repair in the majority of patients.

Anterior Mitral Leaflet Length: Predictor for Mitral Valve Repair in a Rheumatic Population

BACKGROUND The length and mobility of the anterior mitral leaflet (AML) are considered important for mitral valve reparability. In this study, we looked at AML length as a predictor of mitral valve reparability in a rheumatic population. METHODS Between May and November 2008, 44 patients underwent mitral valve repair for pure mitral regurgitation, pure mitral stenosis, and mixed lesions. The mean age was 26.5 ± 10.4 years (range, 9 to 50; median 23.5), and 15 patients were less than 20 years old. There were 28 female patients. The mean body surface area was 1.37 ± 0.13 (range, 0.97 to 1.62). In all patients, we measured AML length at the A2 segment, both by transesophageal echocardiography and intraoperative direct measurement. These measurements were indexed to the body surface area. RESULTS Thirty-five patients had successful repair. Nine patients underwent mitral valve replacement after failed repair. The AML lengths were significantly higher in the successful repair group as compared with the failed repair group (AML length measured by transesophageal echocardiography was 31.4 ± 4.9 mm versus 24.1 ± 2.2 mm, p = 0.001; AML length measured intraoperatively was 30.8 ± 4.4 mm versus 22.3 ± 1.5 mm, p = 0.001). An intraoperatively measured AML length of 26 mm or more predicts reparability with 97.1% sensitivity and 100% specificity. Transesophageal echocardiography can reliably judge AML length and can also predict reparability. Indexed AML lengths are an even stronger predictor of mitral valve reparability, especially in a pediatric population. CONCLUSIONS Indexed AML length is a strong predictor of mitral valve reparability. With a value of 18 mm/m(2) or more, repair can be accomplished in all cases.

Effect of preoperative administration of allopurinol in patients undergoing surgery for valvular heart diseases

OBJECTIVE To assess the effects of preoperative administration of allopurinol in patients undergoing open-heart surgery (OHS) for valvular heart diseases. METHODS In this prospective randomised double-blind study, 50 consecutive patients undergoing OHS for valvular heart disease were randomised into two groups of 25 patients each: (a) control group received placebo and (b) test group received allopurinol prior to surgery. Serum troponin T and creatine phosphokinase-MB (CPK-MB) isoenzymes were measured prior to the induction of anaesthesia, at the time of aortic cross-clamp release and 24h following termination of cardiopulmonary bypass. Postoperatively assessed parameters were inotropic score, rhythm, and duration of mechanical ventilation and occurrence of a low cardiac output state. RESULTS Significant differences were observed with respect to inotropic score: median 5 ((0-25) vs 0 (0-25) p=0.027) and mean 6.44+/-6.145 versus 3.4+/-5.54, mean duration of mechanical ventilation (11.1+/-4.9 vs 7.5+/-2.5 h, p=0.002, hospital stay (6.35+/-1.43 vs 5.04+/-0.611, p=0.001) and maintenance of normal sinus rhythm (NSR) (18 vs 25, p=0.004) between the control groups versus the test group, respectively. There were no significant differences in the levels and trends of troponin T and CPK-MB between the two groups. CONCLUSION The administration of allopurinol prior to OHS for valvular heart diseases is associated with increased conversion and maintenance to normal sinus rhythm, reduced inotropic score and a reduction in the duration of mechanical ventilation and hospital stay. There was, however, no significant difference in the blood levels of CPK-MB and troponin T and a large sample size is required to assess this further.

Redo Mitral Valve Surgery—A Long-Term Experience

Abstract  Background: Our experience with reoperative mitral valve (MV) surgery over a 27‐year period is presented here. Methods: From January 1975 to June 2002, 11,908 operations were performed for MV disease. Out of these 744 were reoperations. The mean age at primary operation was 23.6 ± 10.1 years (range 2 to 53 years) and at reoperation was 36.0 ± 11.0 years (range 6 to 65 years) with a mean interval of 11.5 ± 2.5 years. Mitral valve replacement (MVR) was performed following previous closed mitral valvotomy (CMV) in 408 patients, open mitral commissurotomy (OMC) in 21 patients, and MV repair in 58 patients, MVR in 80 patients, homograft mitral valve replacement (HMVR) in 11 patients. The reasons for reoperation were mainly progression of lesions. Valve thrombosis and endocarditis were indications for reoperation following MVR. Twenty‐eight patients underwent redo CMV, 53 patients underwent OMC, and 14 patients underwent MV Repair. Results: Early mortality was 5.64% (n = 42). Hemorrhage and low cardiac output were the major causes. Follow‐up was 124.8 ± 30.5 months (2 to 300 months). Follow‐up was 88%. There were no late deaths in the valve repair group. There were three episodes of thromboembolism in this group (0.3% per patient‐year). In the valve replacement group there were six late deaths; three due to valve thrombosis, one due to infective endocarditis, and two due to anticoagulant‐related hemorrhage. There were 13 episodes of thromboembolism in this group (0.6% per patient‐year). Conclusion: Redo MV surgery is safe and can be undertaken with acceptable mortality and morbidity.

Reducing the costs of surgical correction of congenitally malformed hearts in developing countries.

A large number of patients in developing countries require surgical correction of congenitally malformed hearts. Unfortunately, only a limited number of centres offer these patients surgery at an affordable cost. In this review, we discuss the problems in managing these patients, with an emphasis on reduction of costs, so that the maximum number of patients can benefit. It is apparent that containing costs requires a multipronged approach, which begins with timely referral, and continues with early surgical correction and adequate postoperative care carried out in a scientific manner. Indigenization, innovation, training of manpower, and building a team, are essential to cut the costs, and to improve the quality of care.

Early Experience with Homograft Valve Banking

Homograft cardiac valves have been shown to have several advantages over conventional prosthetic valves. From October 1993 through November 1996, 273 homografts (262 valved and 11 non-valved) were used in various procedures at the All India Institute of Medical Sciences, New Delhi, India. The recommendations of the American Association of Tissue Banks were followed for procurement, harvesting, and storage of the valves. One hundred and ninety-six hearts were procured yielding a total of 439 homograft valves; 192 were pulmonary homografts, 187 were aortic homografts, and 60 were mitral homografts. Eighty-five homografts were used in the Ross procedure, 64 were used in homograft replacement of the aortic valve, 28 were used in replacement of the mitral valve, 85 were used in various operations for heart disease as valved conduits, and 11 homografts were used as either non-valved conduits or for patch repair. One hundred and thirty-five homografts (31%) were discarded for various reasons. Our early experience of valve banking is discussed.