Kwabena Frimpong-Boateng

Experience from a single centre concerning the surgical spectrum and outcome of adolescents and adults with congenitally malformed hearts in West Africa.

BACKGROUND This study was undertaken to review the spectrum and surgical outcome of adolescents and adults with congenitally malformed hearts from January, 1993 to December, 2008. The lack of data on this emerging problem from the West African sub-region prompted this report. PATIENTS AND METHOD This retrospective study is based on 135 adolescents and adults with congenitally malformed hearts. A review of their case notes and operative records was carried out and results analysed. RESULTS Selected patients made up 23% of all congenital cardiac surgeries performed at our institution in the same period. A total of 23 patients (17%) were non-Ghanaian West Africans. There was a female preponderance of 53.3%. The ages ranged from 16 to 70 years (mean 28.6 plus or minus 10.3 years). The mean follow-up was 7.5 plus or minus 4.4 years. Patients were functionally classified (New York Heart Association) as class I (23%), II (58%), and III (19%). In 14 (10.4%) patients, the defects were discovered incidentally. Ventricular septal defects, oval fossa type atrial septal defects, Fallots tetralogy, and patent arterial duct together accounted for 77.8% of the cases. Surgical correction was undertaken in 117 (86.7%) patients; the remainder had palliative procedures. There were six (4.3%) reoperations. The functional class improved to class I or II in 95% of patients within the first postoperative year. The overall hospital mortality was 3% with two late deaths (1.5%). CONCLUSION The study demonstrates the feasibility of surgery for adolescents and adults with congenitally malformed hearts in the sub-region with a good outcome. Majority (77.8%) of patients present with less complex lesions.

Management of intrathoracic oesophageal perforation: analysis of 16 cases.

Intrathoracic oesophageal perforation remains a life-threatening lesion that requires early diagnosis and the appropriate intervention in order to reduce morbidity and mortality. Management depends largely on the cause of the perforation, the integrity of the oesophagus and the time lapse between the perforation and the commencement of treatment. Our aim was to evaluate the management options that were employed in the treatment of patients with oesophageal perforation and the outcome. The records of 16 patients (11 males and 5 females) who had been operated on from 1994–2009 were retrospectively reviewed. Their ages ranged between 2–66 years (mean 36.4). Malignant oesophageal perforations were excluded from the study. The aetiology was iatrogenic in 10 (62.5%), foreign bodies five (31.2%) and spontaneous one (6.2%). Six patients (37.5%) presented within 24 h of their injury and 10 (62.5%) presented after 24 h. Thoracotomy and intrathoracic primary repair was possible in five (31.2%) cases. Oesophagectomy, cervical oesophagostomy and feeding gastrostomy were carried out in 11 (68.8%). Oesophageal substitution was by colon, routed retrosternally. One patient (6.2%) died after oesophagectomy from overwhelming sepsis. Oesophageal perforation is a life-threatening condition. Early diagnosis and the institution of prompt and appropriate treatment ensure good outcome.

Outcome of left heart mechanical valve replacement in West African children - A 15-year retrospective study

BackgroundThe West African sub-region has poor health infrastructure. Mechanical valve replacement in children from such regions raises important postoperative concerns; among these, valve-related morbidity and complications of lifelong anticoagulation are foremost. Little is known about the long-term outcome of mechanical valve replacement in West Africa. We sought to determine the outcome of mechanical valve replacement of the left heart in children from this sub-region.MethodWe conducted a retrospective review of all consecutive left heart valve replacements in children (< 18 years old) from January 1993 - December 2008. The study end-points were mortality, valve-related morbidity, and reoperation.ResultsOne hundred and fourteen patients underwent mitral valve replacement (MVR), aortic valve replacement (AVR) or mitral and aortic valve replacements (MAVR). Their ages ranged from 6-18 years (13.3 ± 3.1 years). All patients were in NYHA class III or IV. Median follow up was 9.1 years. MVR was performed in 91 (79.8%) patients, AVR in 13 (11.4%) and MAVR in 10 (8.8%) patients. Tricuspid valve repair was performed concomitantly in 45 (39.5%) patients.There were 6 (5.3%) early deaths and 6 (5.3%) late deaths. Preoperative left ventricular dysfunction (ejection fraction < 45%) was the most important factor contributing to both early and late mortality. Actuarial survival at 1 and 15 years were 98.1% and 94.0% respectively. Prosthetic valve thrombosis occurred in 5 patients at 0.56% per patient-year. There was 1(0.9%) each of major bleeding event and prosthetic valve endocarditis. Two reoperations were performed at 0.22% per patient-year. Actuarial freedom from reoperation was 99.1% at 1 and 10 years, and 85.1% at 15 years.ConclusionMechanical valve replacement in West African children has excellent outcomes in terms of mortality, valve-related events, and reoperation rate. Preoperative left ventricular dysfunction is the primary determinant of mortality within the first 2 years of valve replacement. The risk of valve-related complications is acceptably low. Anticoagulation is well tolerated with a very low risk of bleeding even in this socioeconomic setting.

Hypothermic cardiopulmonary bypass without exchange transfusion in sickle-cell patients: a matched-pair analysis

OBJECTIVES Sickle-cell patients undergo cardiopulmonary bypass (CPB) surgery in our institution without perioperative exchange transfusion. We sought to determine whether this protocol increased mortality or important sickle-cell-related complications. METHODS We adopted a 1:1 matched-pair case-control methodology to evaluate the safety of our protocol. Sickle-cell patients who underwent CPB between January 1995 and January 2014 were matched with haemoglobin AA (HbAA) controls according to sex, age, weight and type of cardiac procedure. RESULTS Thirty-three sickle-cell patients (21 HbAS, 7 HbSS and 5 HbSC) underwent CPB surgery using our institutional protocol. Sickle-cell patients and controls were similar according to the matching criteria. Preoperatively, haemoglobin SS (HbSS) and haemoglobin SC (HbSC) patients were anaemic (8.5 ± 1.4 vs 13.5 ± 1.9 g/dl; P <0.01 and 11.0 ± 0.6 vs 12.7 ± 0.9 g/dl; P = 0.01, respectively). Operative procedures included valve repair and replacement (12) as well as repair of congenital cardiac malformations (21). The duration of CPB and lowest CPB temperatures was similar for sickle-cell patients and controls. Systemic hypothermia (23.8-33.5°C), aortic cross-clamping, cold crystalloid antegrade cardioplegia and topical hypothermia were used in sickle-cell patients without complications. There was no acidosis, hypoxia or low cardiac output state. No mortality or important sickle-cell-related complications occurred. Although blood loss was similar between sickle-cell patients and controls, HbSS (unlike HbAS and HbSC) patients required more blood transfusion than controls (30.0 ± 13.3 vs 10.8 ± 14.2 ml/kg; P = 0.02) to counter haemodilution and replace blood loss. In-patient stay was similar for sickle-cell patients and controls. CONCLUSIONS Perioperative exchange transfusion is not essential for a good outcome in sickle-cell patients undergoing CPB. A simple transfusion regimen to replace blood loss is safe in HbSS patients; blood transfusion requirements for HbSC and HbAS patients undergoing CPB are similar to those of matched HbAA controls. The use of systemic hypothermia during CPB does not increase sickle-cell-related complications. Cold crystalloid cardioplegia and topical hypothermia provide safe myocardial protection without the need for more sophisticated measures.

Freedom from thromboembolism despite prolonged inadequate anticoagulation.

Life-long and meticulous control of anticoagulation is mandatory following mechanical valve replacement to prevent thromboembolism. Two patients who underwent mechanical mitral valve replacement with third generation bi-leaflet valves and in whom therapeutic anticoagulation could not be achieved for many months postoperatively form the basis for this report. In the first patient, the target international normalised ratio (INR) of 2.5–3.5 could not be achieved until 53.5 months postoperatively despite good compliance with oral anticoagulation and INR monitoring. In the second patient, the target INR was achieved after 16.9 months of oral anticoagulation treatment and regular INR monitoring. No thromboembolism occurred in either patient; nor did any valve-related event occur. The two patients are in excellent physical health 8 and 5 years, respectively, after the procedure. This unusual phenomenon is reviewed in light of the few reported cases of patients with mechanical heart valves surviving for prolonged periods without anticoagulation.

eComment: Cor triatriatum and cardiac hemolytic anemia.

DOI:€10.1510/icvts.2008.201293A Interact CardioVasc Thorac Surg 2009;9:383- Frank Edwin, Ernest A. Aniteye, Kow Entsua-Mensah and Kwabena Frimpong-BoatengeComment: Cor triatriatum and cardiac hemolytic anemia http://icvts.ctsnetjournals.org/cgi/content/full/9/2/383 located on the World Wide Web at: The online version of this article, along with updated information and services, is

Bilateral tension pneumothorax resulting from a bicycle-to-bicycle collision.

Bilateral tension pneumothorax occurring as a result of recreational activity is exceedingly rare. A 10-year-old boy with no previous respiratory symptoms was involved in a bicycle-to-bicycle collision during play. He was the only one hurt. A few hours later, he was rushed to the general casualty unit of the emergency department of our institution with respiratory distress, diminished bilateral chest excursions and diminished breath sounds. The correct diagnosis was made after a chest radiograph was obtained in the course of resuscitation at the casualty unit. Pleural space needle decompression was suggestive of tension only on the right. Bilateral tube thoracostomies provided effective relief. He was discharged from hospital after a week in excellent health. This case illustrates the need for children to have safety instruction to reduce the risks of recreational bicycling. Chest radiography may be needed to establish the diagnosis of bilateral tension pneumothorax. Needle thoracostomy decompression is not always effective.

Double superior vena cava complicating transvenous pacemaker implantation.

A 62-year-old woman was scheduled for a transvenous pacemaker implantation on account of complete heart block. The left subclavian approach was initially used. The lead was observed to take an anomalous course into the right atrium failing to cross the midline at the angle of Louis; entry into the right ventricle could not be achieved. The right …

A pulmonary azygos lobe encountered during thoracotomy for modified Blalock-Taussig shunt

A 3-year-old boy was scheduled for a modified Blalock-Taussig shunt (MBTS) on account of tetralogy of Fallot. A right posterolateral thoracotomy was used. On entering the chest, a “fourth lung lobe” was found (fig 1) medial to a pleural fold extending from the apex of the right hemithorax …