Kotturathu Mammen Cherian

Novel techniques of bidirectional Glenn shunt without cardiopulmonary bypass

BACKGROUND We report novel techniques of performing bidirectional Glenn shunt (BDG) without cardiopulmonary bypass (CPB). METHODS Five cases of single ventricle and pulmonary stenosis (PS) complex were taken up for BDG without CPB. The criteria for case selection were an unrestrictive atrial septal defect (ASD), no atrioventricular (AV) valve regurgitation, and no other intracardiac defects requiring correction. A temporary shunt was established between the superior vena cava (SVC) and contralateral branch pulmonary artery (PA) for venous drainage during SVC clamping for BDG anastomosis in four cases. In case 5, a shunt was put between the SVC and right atrium (RA) for venous drainage, and modified Blalock Taussig shunt and patent ductus arteriosus (PDA) were left open until the completion of the BDG. RESULTS Central venous pressure (CVP) increased to a mean of 22.4 mm Hg during SVC clamping, with improvement of oxygen (O2) saturation from 62.4% to 82.4%. After Glenn shunt, CVP and O2 saturation maintained at 13.2 mm Hg and 87.4%, respectively. Postoperatively, there were no neurological abnormalities and no hospital mortality. CONCLUSIONS Our technique provides an excellent venous drainage with improvement of O2 saturation during SVC clamping. It avoids problems related to CPB and economy. It is easily reproducible, with excellent results in a selected group of patients without compromising the completeness of repair.

Evolving surgical management for ventricular septal defect, pulmonary atresia, and major aortopulmonary collateral arteries

BACKGROUND The purpose of this study was to evaluate the results of various surgical modalities that have been evolving for the treatment of ventricular septal defect, pulmonary atresia, and major aortopulmonary collateral arteries. METHODS From 1993 to May 1997, 14 patients (group 1) were treated with staged unifocalization through thoracotomies and final repair by midsternotomy. From June 1997 to February 1998, 10 patients (group 2) were treated with midsternotomy, single-stage complete unifocalization, and repair. RESULTS In group 1, 14 patients had 21 procedures (1.5 procedures per patient), of which 3 patients (21%) had final correction. There were two deaths (14%). One patient died of blocked shunt. Another patient who had aneurysmal dilation of homograft tubes that were used for unifocalization died after final repair because of low cardiac output. In group 2, 10 patients had ten surgical procedures for complete unifocalization and 9 of 10 (90%) of them achieved final correction. One patient with low cardiac output in whom we did not close the ventricular septal defect died (10%) of suprasystemic right ventricular pressure. CONCLUSION In single-stage complete unifocalization, more patients had final correction. It reduces the number of operations and hospitalization and hence is more cost effective than multistaged procedures.

Median sternotomy single stage complete unifocalization for pulmonary atresia, major aorto-pulmonary collateral arteries and VSD-early experience

OBJECTIVE It is a prospective study to assess the results of median sternotomy, single stage complete unifocalization and repair for ventricular septal defect (VSD), pulmonary atresia and major aorto pulmonary collateral arteries (MAPCAs). METHODS From June 97 to August 98, 20 patients were treated with single stage complete unifocalization and repair. Their ages ranged from 6 months to 11 years. Through median sternotomy, all MAPCAs were dissected and looped. On cardiopulmonary bypass, MAPCAs were anastomosed to native pulmonary arteries (PAs) or to MAPCAs. VSD was closed if possible and RV to PA continuity was established with a homograft conduit. If complete repair was not suitable, central shunt was done from ascending aorta to reconstructed PA with a polytetrafluroethylene graft. The patients were divided into three groups according to the arborization pattern in the lungs. Group 1 had well formed native PAs with MAPCAs, group 2 had hypoplastic PAs with MAPCAs and group 3 had only MAPCAs. RESULTS Twenty patients had 21 procedures. All MAPCAs were unifocalized with tissue-to-tissue anastomosis for future growth, except one in whom polytetrafluroethylene tube graft was used to attain the confluence. In group 1, all seven patients had complete unifocalization and repair. In group 2, four patients had RV to PA conduit and two patients had central shunt. In group 3, three patients had complete repair, three patients had RV to PA conduit and one patient had central shunt. There were three deaths, two in group 2 and one in group 3. The first patient died due to a wrong decision to close the VSD, the second patient died due to missed large MAPCA in preoperative angio and the third patient was a 7-year-old boy who died with irreversible pulmonary vascular changes due to unprotected MAPCAs. CONCLUSIONS To conclude, complete repair/RV-PA conduit/central shunt should be done according to the size of the total pulmonary vasculature in patients with group 1, 2 and 3 with protected PAs/MAPCAs and in hypoplastic or absent PAs with unprotected MAPCAs (less than 1 year) and protected MAPCAs. We are yet to determine the surgical procedure to be performed in hypoplastic/absent PAs with unprotected MAPCAs more than 1 year. It is very essential to delineate all the MAPCAs up to the level of the diaphragm preoperatively.

Use of direct laryngoscope for better exposure in minimally invasive saphenous vein harvesting

A direct laryngoscope-assisted technique of saphenous vein harvesting by tunnelling method is described. This technique provides better exposure through small incisions, thus reducing the chances of trauma to the vein due to excessive handling. The equipment used is inexpensive and readily available.

Enlargement of Small Aortic Annulus by Modified Manouguian's Technique

From January 1981 to June 1994, 17 patients underwent aortic annulus enlargement by a modified Manouguians technique. A small aortic root associated with stenotic lesions was the main indication. The ages of the patients ranged from 5 to 55 years (mean, 21 ± 14 years). There were 10 males and 7 females. Four had concomitant mitral valve replacement, 2 had open mitral valvotomy, 1 underwent ventricular septal defect closure, excision of a subaortic membrane, and ascending aortic replacement. The aortic roots were enlarged to between 20 to 30 mm. A Dacron patch was used in 16 patients and glutaraldehyde-treated autologous pericardium was used in 1. Two patients (12%) died in the postoperative period, 1 due to hemorrhage and the other due to septicemia. Mitral regurgitation (grade 1) was seen in 1 patient postoperatively but there was no further deterioration on serial evaluation. Four patients were lost to follow-up. Of the 11 followed up over a period of 10 years, 7 were in New York Heart Association functional class I and 4 were in class II.

Modified supra-arterial myotomy for intermittent coronary obstruction by myocardial bridges

Coronary artery narrowing secondary to myocardial bridging, with consequent clinical manifestation, is a known but uncommon entity. A modified supra-arterial myotomy in a case of myocardial bridge causing medication-refractory angina is described.

Left Atrial Myxoma Presenting as Acute Inferior Wall Infarction—A Case Report

Abstract  Acute myocardial infarction is a rare form of presentation in patients with left atrial myxoma. With wider availability of echocardiography, more and more patients with atrial myxomas will be diagnosed. This report describes a patient with left atrial myxoma who presented features of acute myocardial infarction and had surgical removal of LA myxoma

Spontaneous double vessel coronary artery dissection : A case report and surgical management

Spontaneous coronary artery dissection is an uncommon clinical entity, its presentation and management similar to atherosclerotic coronary artery disease. We report on a young adult male who presented with myocardial infarction due to simultaneous dissection of left anterior descending and right coronary artery. He was treated with bilateral interal mammary artery grafts.

Osseus metaplasia with functioning marrow in a calcified aortic valve.

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Pseudoaneurysm of homograft placed in right ventricular outflow tract.

Pseudoaneurysm of the right ventricular outflow tract after homograft placement is an infrequent complication after intracardiac repair for tetralogy of Fallot. We report two cases of pseudoaneurysm of right ventricular outflow tract after homograft placement for surgical repair of tetralogy of Fallot with pulmonary atresia.