Edwin Ravikumar

Minimal access approach for surgical management of cardiac tumors.

BACKGROUND Following our experience with minimally invasive valve replacement operation, we utilized this technique for surgical management of cardiac tumors. METHODS Between April 1997 and September 1999, 5 consecutive patients with cardiac tumors underwent minimally invasive excision of the tumors. The patients were 4 women and 1 man with an age range of 32 to 50 years. The tumor was located in the left atrium in 4 patients and the right atrium in 1 patient. The common presenting symptoms were dyspnea on exertion (100%), chest pain (60%), palpitation (60%), and transient ischemic attack (20%). Diagnosis was established preoperatively by echocardiography only. RESULTS In 2 patients the approach was right parasternal and the subsequent 3 patients had direct-access partial sternotomy. The myxoma was resected transseptally in all patients. There was no hospital mortality. One patient had postoperative embolic episode leading to left hemiparesis. Follow-up did not reveal any complication related to this technique and all were in New York Heart Association (NYHA) functional class I. CONCLUSIONS Minimal access partial sternotomy is an effective approach that adheres to all the identified surgical principles in successful removal of these tumors. The smaller incision does not compromise the efficacy or safety of the operation, reduces hospital stay, and has a good cosmetic result.

The clinical profile and surgical treatment of tetralogy of Fallot in the adult: results of repair in 200 patients

This report describes our 17-year experience with intracardiac repair in 200 patients older than 14 years with tetralogy of Fallot. Congestive failure, hemoptysis, and cerebral abscess were present in 15, 10, and 3% of patients, respectively. Prior palliative shunts had been performed in 24.5% only. Polycythemia with a hematocrit greater than 60% was noted in 100 patients but was not considered an incremental risk factor (p greater than 0.05). A transannular gusset was utilized in 74% of patients in the last 5 years of the study. Hospital mortality was 1.3% in the last 5 years. Ninety-seven percent of survivors at follow-up are asymptomatic and leading an active life. Recatheterization data from 86 patients revealed excellent or good results in 88%. The incidence of residual ventricular defect was 1% overall, with a zero incidence in the last 12 years. On the basis of this review, we consider that easier and hemodynamically satisfactory repair has been achieved in the adolescent and older patient compared with the child. The ultimate longevity, however, must await the results of long-term functional and serial hemodynamic evaluation.

25-year experience with 456 combined mitral and aortic valve replacement for rheumatic heart disease

BACKGROUND Valvular heart disease in developing countries resulting from rheumatic fever is disabling and if untreated leads to congestive heart failure and death. Valve replacement has remained the procedure of choice for advanced valve disease. METHODS Between 1973 and 1997, 456 patients underwent combined mitral and aortic valve replacement. In light of our favorable earlier experience the Starr-Edwards ball valve prostheses were implanted in 90% and 72.8% of mitral and aortic positions, respectively. Follow-up ranged from 1 to 24 years with a median of 8.5 years. RESULTS The 30-day hospital death rate was 9.2% and late death occurred in 10.1%. A low-intensity anticoagulant regimen was followed to maintain the target prothrombin time at 1.5 times the control value. The actuarial survival at 5, 10, 20, and 24 years was 90.4%, 85.6%, 84.4%, and 82.4% per year, respectively. CONCLUSIONS In view of the acknowledged advantage of superior durability, increased thromboresistance in our patient population, and its cost effectiveness the Starr-Edwards ball valve is the mechanical prosthesis of choice for advanced combined valvular disease. The low-intensity anticoagulant regimen has offered sufficient protection against thromboembolism as well as hemorrhage.

Mechanisms of cardiac perforation leading to tamponade in balloon mitral valvuloplasty

Mechanisms of cardiac perforation in 10 cases of cardiac tamponade encountered in a single-center series of 903 balloon mitral valvuloplasty procedures were elucidated by precise localization of the site of perforation at subsequent surgery. These mechanisms were perforation of the aortic root and adjacent right atrium by sliding up of the transseptal set (2), apical tears by straight-tip balloon catheters driven distally during mitral valve dilatation (3), apical perforations by guidewires introduced through catheters wedged in the apex (2), tear of the posterior right atrial wall by dilatation of the track produced by very low septal punctures (2), and right ventricular perforation by a pacing catheter (1). Multivariate analysis showed cardiac perforation to be significantly related to the total experience at the center (inversely) and to patient age (directly). Left ventricular perforation occurred exclusively in patients > 40 yr of age. Understanding these mechanisms has enabled formulation of effective strategies to prevent cardiac perforation.

Coexistent mitral valve disease with left-to-right shunt at the atrial level: Clinical profile, hemodynamics, and surgical considerations in 67 consecutive patients

Between January, 1963, and June, 1985, 67 patients underwent corrective surgery for this complex anomaly. Symptoms and signs of atrial septal defect were dominant in the majority of subjects. History of rheumatic fever (46%), paroxysmal nocturnal dyspnea (33%), presence of an opening snap, mitral diastolic murmur, or pansystolic murmur provided clinical clues to document associated mitral valve disease. Open mitral valvotomy was accomplished in 39 subjects, while in the remainder (28 subjects) the valve required replacement. Partial anomalous venous connection was encountered in 12 subjects. Recognition and attention to the associated tricuspid incompetence is a high priority, and 21 subjects underwent concomitant annuloplasty. The overall hospital mortality was 13.4%, with no deaths in the last 22 consecutive patients. The period of follow-up ranged from 1 year to 22 years, with a mean +/- SD of 9.34 +/- 6.61 years. We believe, with other authors, that since the hemodynamic and therapeutic considerations are very similar, both the stenotic and regurgitant lesions should be included in the same syndrome.

Tetralogy of Fallot: Intracardiac Repair in 840 Subjects

Since 1967. when the first intracardiac repair was performed in this centre, until 1991, 840 symptomatic subjects with tetralogy of Fallot have undergone corrective surgery. Cardiac catheterization and angiocardiography were carried out in all patients. Cardinal findings on the clinical status of these subjects are outlined. A substantial number of patients (244; 29.0%) were >15 years of age. Historically, a transannular pericardial gusset has been utilized in 578 (68.8%). and in 423 (93.0%) during the past decade. The incidence of residual interventricular septal defects has been 0.68% and occurrence of complete heart block after surgery 0.4%. Death occurred in 86 patients (10.2%) within 30 days of operation and later in 40 subjects (4.8%). Long-term results have been excellent with good haemodynamic status In >90% of subjects in the follow-up period. Associated features including absent pulmonary valve, absent left pulmonary artery, and previous palliative shunts did not alter the outcome: however, a raised haematocrit (>0.65) was associated with an increased mortality rate.

Long-Term Prednisolone Therapy in Children with Idiopathic Pulmonary Hemosiderosis

Idiopathic pulmonary hemosiderosis (IPH) is a rare disease of unknown etiology characterized by the triad of iron deficiency anaemia, hemoptysis, and pulmonary infiltrates.1 Effective therapy remains elusive although oral iron therapy;1,2 corticosteroids,1,2 tranexamic acid,1 desferrioxamine,1 diet free of cows milk,3 and nebulized saline,2 plasmapheresis,1 splenectomy,2 and chloro-quine4 have all been tried. Long-term steroid treatment has not been recommended.2 We describe our experience with three recent cases of IPH treated with prednisolone.

Minimally Invasive Approach for Left Atrial Myxoma

A 32-year-old female with left atrial myxoma who was in New York Heart Association functional class IV, underwent a minimally invasive excision of the tumor through a right parasternal approach. Early follow-up demonstrated that this technique was effective and had the benefits of low cost, rapid recovery, decreased hospital stay, and a good cosmetic result.

A Quarter Century Experience with Mitral Valve Replacement

Between January 1967 and August 1994 Starr-Edwards (Baxter Healthcare Corporation, Santa Ana, CA, USA) ball valve prostheses (model 6120) were implanted in 1129 patients whose ages ranged from 9 to 65 years (mean 29.5 ± 11.08 years). One hundred and ninety-three patients had a concomitant tricuspid valve repair and 36 underwent closure of an atrial septal defect. A closed mitral valvotomy had been carried out previously in 15%. The hospital (30-day) mortality rate was 10.9% (123/1129), which declined to 6.9% (32/461) in the last decade. The patients were administered warfarin to counter thrombogenesis and were regularly monitored with prothrombin time values. Over the last 10 years, aspirin was used as the sole anticoagulant in a cohort of 63 patients. Follow-up was achieved in 87% of cases; the follow-up period ranged from 1 to 25 years with a total follow-up of 8579.69 patient-years. Late death occurred in 132 patients. Anticoagulant-related hemorrhage occurred at a rate of 0.31 per 100 patient-years. Prosthetic valve endocarditis occurred at a linearized rate of 0.05 per 100 patient-years. The incidence of thromboembolic events was 0.5 per 100 patient-years. There was no incidence of structural valve dysfunction or prosthetic valve thrombosis. Forty young women subsequently delivered 47 healthy children. The long-term overall survival rate was 76.1% ± 3.17% at 20 years and 70.4% ± 4.31% at 25 years. These results confirm the long-term durability and superior thromboresistance of the Starr-Edwards ball valve. We conclude that this prosthesis is the device of choice for patients undergoing mitral valve replacement in Third World countries.

Empyema caused by an unusual retained pleural foreign body

We report a rare case of post-traumatic chronic empyema in an 18-year-old boy, caused by a piece of wood retained in the pleura. This unusual foreign body initially remained undetected on account of its radiolucency and was discovered during rib-resection for open drainage.