Jagdish Khandeparkar

Aneurysms of sinus of Valsalva eroding into the interventricular septum : etiopathology and surgical considerations

OBJECTIVE To evaluate and discuss etiopathology, clinical manifestations and surgical outcome of a rare subset of unruptured aneurysm of the sinus of Valsalva which erodes into the interventricular septum. METHODS Between 1989 and 1995, seven cases of unruptured aneurysm of the sinus of Valsalva eroding into the interventricular septum underwent surgical correction at the King Edward VII Memorial Hospital, Bombay. The origin of all these aneurysms was from the right coronary sinus. The mean age of presentation was 31 years. All patients were male. Calcification of the aneurysm was seen in three. Three patients presented without aortic regurgitation; all had complete heart block. Four patients presented with aortic regurgitation and in addition, two had complete heart block. Preoperative left ventricular function was poor in patients with aortic regurgitation (Ejection fraction range; 30-42%), when compared to those without aortic regurgitation (Ejection fraction range; 48-52%). Of those without aortic regurgitation at initial presentation, one patient developed progressive aortic regurgitation after 3 years requiring surgery. While two other patients were operated at earliest for closure of aneurysm, even in the absence of aortic regurgitation. All those with aortic regurgitation required surgery for aortic valve replacement and closure of aneurysm. Aneurysm was closed by direct suturing of the ostium in two patients and by patch closure in five patients. Permanent pacemaker was implanted in five patients. RESULT There was no operative death. Patients who underwent aortic valve replacement required postoperative ionotropic support. Two patients, who underwent surgery in absence of aortic regurgitation, remain free of aortic regurgitation at the end of 36 and 42 months of follow-up. One of the patients with calcific aneurysmal sac underwent successful re-replacement of the aortic valve for paravalvar leak after a 2 year interval. CONCLUSION Unruptured aneurysm of the sinus of Valsalva eroding into the interventricular septum should be operated at the earliest, which makes surgery simple and prevents development of complications such as aortic regurgitation and heart block.

Intussusception of Left Atrial Appendage through the Mitral Valve

A 4-month-old male infant underwent elective repair of a large subaortic ventricular septal defect. Although it was an uneventful surgical procedure, he required inotropic support during weaning from cardiopulmonary bypass. He presented with sudden-onset low cardiac output syndrome in the immediate postoperative period and could not be revived. Autopsy revealed intussusception of the left atrial appendage projecting through the mitral valve orifice.

Head and Heart: Neuropsychological Reaction and Arterial Line Filtration during Cardiopulmonary Bypass

As part of a prospective study of neuropsychologic reactions after cardiopulmonary bypass and their relation to arterial line filters, 44 patients who underwent elective cardiac operations were randomized into two groups. Group A had a 40-micron nylon screen filter in the arterial line. No arterial filter was used in group B. Neuropsychological examinations of all patients were conducted before and at a mean of 8 days after the operation on a double blind basis by a single trained psychologist. The tests included the Wechsler Memory Scale, the trail-making test, the Hamilton Anxiety Rating Scale, and the Hamilton Rating Scale for Depression. The 2 groups were otherwise similar with respect to preoperative neurologic and intellectual status, anesthetic methods, duration of operation, operative procedures performed, and the time spent in the intensive care unit. Surprisingly, there was a highly significant improvement in all four test scores after surgery. There were no statistically significant differences in the test scores between the two groups but considerable inter-patient performance variability was noted. The arterial line filter did not appear to have an effect on test scores. Routine use of an arterial filter remains questionable.

The relevance of congenital absence of pericardium in minimal access surgery

A 35 year old thinly built hypertensive lady was diagnosed to have a Sinus Venosus Atrial Septal Defect (SVASD) with left to right shunt, Right Anomalous Pulmonary Venous Connection (RPAPVC) to low right superior vena cava and moderate Pulmonary Arterial Hypertension (PAH). The apex was neither seen nor palpable with the indistinct left and retrosternal right heart borders . Her chest x-ray showed a tongue of lung tissue between the prominent aortic knuckle and Main Pulmonary Artery (MPA) (Fig. 1). During the substernal dissection with electrocautery, unexpected diaphragmatic contractions were noticed. Conversion to full sternotomy revealed Congenital Absence of Left Pericardium (CALP) with an anomalously coursing left phrenic nerve arching over the right ventricle and inserting into the diaphragm just medial to themedial border of inferior vena cava. (Figure 2) She underwent repair of RPAPVC and SVASD using pericardial baffle and made an uneventful recovery. The isolated form of the congenital absence of pericardium is rare and some of these may present with nonexertional periodic stabbing chest pain due to a variety of causes [1]. Though the complete defects are rarer than the partial ones, complications are more frequent in the latter due to the strangulation of the heart into the defect and require surgical intervention [2]. Many patients particularly grown up females with atrial septal defect prefer to undergo surgical correction via minimal access surgery such as right thoracotomy or inferior hemisternotomy. A right thoracotomy without establishment of cardiopulmonary bypass could cause severe hemodynamic compromise in unsuspected absent left pericardium. An anterior anomalous course of the left phrenic nerve could compromise the exposure in an inferior hemisternotomy. She was not offered the right thoracotomy approach as there was suspicion of the absence of left pericardium. The presence of Fig 1 Chest Xray showing. a tongue of lung tissue between b prominent knuckle of Aorta and c prominent Main Pulmonary Artery

Ascending Aortic Aneurysm Presenting as Acute Myocardial Infarction in Adulthood

ASCENDING AORTIC ANEURYSM PRESENTING AS ACUTE MYOCARDIAL INFARCTION IN ADULTHOOD A 27-year-old hypertensive female presented with continuous severe chest pain and diaphoresis. Her electrocardiogram showed Q waves in leads II, III, and aVF. The transthoracic echocardiogram revealed minimal inferior wall hypokinesia and raised the possibility of a right ventricular mass. She was treated for the inferior wall myocardial infarction with aspirin, heparin, and intravenous nitroglycerine. She had suffered from intermittent chest pain, dry cough, and low-grade fever for over one year prior to her hospital admission. She had been erroneously diagnosed as suffering from pulmonary tuberculosis and had received 7 months of antituberculous medication. She was hemodynamically stable and her jugular venous pulse was normal. The chest radiograph showed mild cardiomegaly and a prominent ascending aorta. Magnetic resonance imaging carried out one week later showed a 8 × 8 × 10 cm mass suggestive of pseudoaneurysm of the right ventricle with thrombus, which was compressing the superior vena cava, right pulmonary artery, and the right atrium. Coronary angiography revealed extraluminal compression of the proximal right coronary artery. There was no luminal irregularity (Figure 1). The ascending aorta was aneurysmal with a small opening situated 5 cm above the root (Figure 2).

Surgical Treatment of Aneurysms of the Ascending Aorta and Aortic Arch

Surgery for aneurysms of the aorta is a formidable challenge especially when these aneurysms involve the ascending aorta and the transverse arch. We have used the technique of cardiopulmonary bypass, profound hypothermia and total circulatory arrest with marked reduction in neurological complications. Availability of albumin coated and gelatin sealed grafts, as well as blood components, has reduced the associated bleeding problems. Ninety-six patients with aneurysms of the ascending aorta and the transverse arch were operated upon between 1983 and 1993. Patients with aneurysms of the sinus of Valsalva have not been included in this study. Syphilitic pathology was predominant in the group with late presentation of very large aneurysms. The mortality was 17.71% and was largely due to low cardiac output, prolonged ventilatory support, lung infections, and mediastinitis.

A Simplified Technique of Autotransfusion of Shed Mediastinal Blood

We present a simplified technique for autotransfusion of shed mediastinal blood following open heart surgery. We use a hard-shell cardiotomy reservoir as a collection and infusion device. It is a safe and simple technique applicable in any setup, does not require any sophisticated equipment or trained personnel, and is extremely cost effective.