Dronamraju Dilip

Coronary Artery Bypass in Patients with Severe Left Ventricular Dysfunction

We retrospectively reviewed the case records of 82 patients with severe left ventricular dysfunction (ejection fraction < 30%) who underwent coronary artery bypass grafting between March 1993 and February 2000. They were aged 28 to 76 years (mean, 60 years), and 66 of them were male. Significant comorbid factors included hypertension (93%), diabetes mellitus (85%), and hypercholesterolemia (49%). The number of grafts used ranged from 1 to 3. The majority of the patients (91%) belonged to the Canadian Cardiovascular Society angina class III. Coronary angiography revealed single-vessel (in 16% of the patients), double-vessel (52%), and triple-vessel disease (32%), and left main stem disease (18%). Seven patients (9%) died within 48 hours after surgery. The mean duration of hospital stay was 7 ± 2 days. The 75 patients who survived were followed up for 3 months to 7 years. At the 1-year follow-up, 61 of the 68 patients (90%) who were alive moved up from angina class III to class I. Our observations suggest that coronary bypass carries an acceptable mortality risk and may offer a better quality of life in patients with poor ventricular function.

Spirometric Changes following Open-Heart Surgery on Rheumatic Mitral Valves

Evaluation of pulmonary function by spirometry in adult patients undergoing cardiac surgery is a simple test to assess pulmonary reserve that has important implications in the operative morbidity. Pulmonary function was studied preoperatively, before discharge, and at the 3-month follow-up in 22 randomly selected patients who underwent open-heart surgery for rheumatic mitral valve disease (2 reconstructions, 20 replacements). The mean preoperative cardiothoracic ratio was 0.58. Lung function was found to be impaired preoperatively in all 22 patients and the majority suffered from restrictive lung disease. Better preoperative lung function was seen in nonsmokers, patients with a cardiothoracic ratio of less than 0.50, and those with a normal pulmonary artery pressure. After mitral valve surgery, the mean pulmonary artery pressure was 20.6 ± 2.9 mm Hg, the mean mitral valve pressure gradient was 3.6 ± 2.4 mm Hg, and the mean cardiothoracic ratio was 0.52 ± 0.09. A significant deterioration was seen in the predischarge spirometric values of forced vital capacity, forced expiratory volume in one second, peak expiratory flow rate, flow rate at 25% to 75% of expired vital capacity, and maximum volume ventilation. The deterioration was greater in smokers and those who had prolonged cardiopulmonary bypass (more than 80 minutes). No correlation was found with ventilation because all patients were electively ventilated overnight. There was an overall improvement in spirometric parameters at the 3-month follow-up although the values remained lower than predicted. Spirometry was found to be useful for assessing lung function in patients undergoing mitral valve surgery and we recommended it as a routine test.

Hyperbilirubinemia after Cardiopulmonary Bypass: A Prospective Study

Postoperative hyperbilirubinemia is one of the complications of cardiopulmonary bypass. This prospective study was conducted on 77 patients who underwent open-heart surgery, to evaluate the incidence, risk factors, and prognostic significance of postoperative hyperbilirubinemia. Liver function tests were conducted preoperatively, immediately after surgery and on the 1st, 3rd, and 7th postoperative days. The overall incidence of postoperative hyperbilirubinemia was 26%. The incidence was significantly higher in patients who underwent prosthetic valve replacements (31%) than in those without prostheses (22%) and very high in patients undergoing double valve replacement (50%) compared to single valve replacement (27%). Most (90%) of the increase in serum bilirubin was due to a rise in unconjugated bilirubin on the 1st postoperative day. There was no mortality related to postoperative hyperbilirubinemia but it prolonged intensive care stay when it occurred early after surgery and prolonged hospital stay when it occurred later. Preoperative total bilirubin concentration, number of valves to be replaced, and preoperative high right atrial pressure were the factors associated with increased risk of postoperative hyperbilirubinemia by logistic regression analysis.

Profile of Chest Trauma in a Referral Hospital: A Five-Year Experience

From April 1993 to March 1998, 90 patients with chest injuries were retrospectively assessed for the incidence, presentation, and outcome of thoracic trauma. The majority (55.6%) were less than 40 years of age and 83 (92%) were male. The mode and extent of injury, specific intrathoracic organ injuries, associated injuries, flail chest, ventilatory requirements, management, morbidity, and mortality were analyzed. Blunt injuries were seen in 56 (62.2%) and penetrating injuries in 34 (37.7%). Multiple rib fractures with hemopneumothorax was the most frequent presentation with orthopedic and head injuries being most commonly associated. Patients with tachypnea, cyanosis, lung contusion, partial pressure of aterial oxygen less than 60 mm Hg, and those with more than 6 rib fractures most often required ventilation but the majority (54.4%) were treated with a chest drain only. Emergency or delayed thoracotomy was required in 24.4%. The mortality rate was 6.7%, mainly due to respiratory insufficiency. Subcutaneous emphysema requiring releasing incisions accounted for most of the morbidity. Mean hospital stay was 9.5 days. Chest injuries were of major concern in multisystem trauma patients and early planned management is recommended in a mostly vulnerable section of our population in an age of violence and vehicular accidents.

Closed Mitral Valvotomy for Mitral Stenosis in Mirror Image Dextrocardia

A 22-year-old female with mirror image dextrocardia and rheumatic valvular mitral stenosis underwent closed mitral valvotomy using a Tubbs dilator with good results. Despite abnormal position of situs, the surgical approach was simple through right anterolateral thoracotomy, and the operators hands were mirror image to that of levocardia valvotomy in certain steps. Preoperative mitral valve area was 0.8 cm2, and peak and mean diastolic gradients were 21 and 15 mmHg respectively. Postoperatively, valve area improved to 2.16 cm2, and peak and mean diastolic gradients were 8 and 3.1 mmHg, respectively.

Delayed Repair of Popliteal Artery following Blunt Injury

Popliteal artery injury resulting from blunt trauma carries a risk of limb loss. Severe ischemia of prolonged duration is a strong determinant of poor outcome. We report a case of popliteal artery injury in an 18-year-old male who underwent successful repair after a delay of 20 hours.

Aorto-Left Atrial Fistula Complicating Native Aortic Valve Endocarditis

A 21-year-old male with native aortic valve Streptococcus viridans endocarditis was found to have an aorto-left atrial fistula by transthoracic echocardiography. He underwent successful fistula plication and aortic valve replacement.

Ruptured Hydatid Cyst of the Right Ventricular Outflow Tract

A 12-year-old boy who presented with recurrent syncope was diagnosed to have a hydatid cyst of the right ventricular outflow tract. He underwent emergency surgery for cyst rupture but died due to pulmonary embolism and right heart failure.

Temple Pujari's Lung: A New Pneumoconiosis?

A temple pujari (priest), who had long exposure to camphor smoke, developed pulmonary fibrosis. Pneumonectomy of the left lung was performed. We feel that more studies of the lung function of priests working in similar conditions are needed to throw more light on this interesting pathology.