Neerod Kumar Jha

Atresia of coronary sinus ostium with retrograde drainage via persistent left superior vena cava

Atesia of the coronary sinus ostium (ACSO) with retrograde drainage of cardiac veins via the left superior vena cava (LSVC) is a very rare abnormality. This condition is usually asymptomatic during life and a majority of the cases were reported as incidental postmortem findings. If there is retrograde venous drainage via persistent LSVC, this communication cannot be ligated irrespective of its size or the presence of a communicating vein because of resultant cardiac congestion and edema. We report herein a 9-month-old Chinese female who underwent repair of a perimembranous ventricular septal defect, patent ductus arteriosus and secundum atrial septal defect. During the operation, ligation of LSVC resulted in myocardial congestion and distension of the heart. The release of ligature decompressed the heart immediately.

Pulmonary Atresia, VSD in Association with Coronary-Pulmonary Artery Fistula

Congenital coronary-pulmonary artery fistula is rare in patients with pulmonary atresia and ventricular septal defect. The nomenclature, physiological, clinical, and surgical implications of these fistulas are yet to be defined. We report a one-year-old child with pulmonary atresia, ventricular septal defect, and a right coronary-pulmonary artery fistula who also had a diminutive, disconnected left pulmonary artery in addition to aortopulmonary collaterals. The patient underwent corrective surgery. However, the fate of diminutive pulmonary arteries is unknown. The literature was reviewed to explore the clinical or surgical implications of such fistulas for improved understanding and management in the future.

Primary Lymphoepithelioma-Like Carcinoma of Lung

A 57-year-old Caucasian woman presented with nonproductive cough. Computed tomography revealed a peripheral solid mass in the upper lobe of the left lung. She underwent thoracotomy and upper lobectomy. Histology of the excised tumor demonstrated lymphoepithelioma-like carcinoma of the lung, with no associated Epstein-Barr virus activity. Being a rare entity and mostly seen in Asians, very few cases have been described previously.

Role of Lymphocyte Subsets in Pathogenesis of Chronic Rheumatic Heart Disease

Analyses of lymphocyte subsets using flow cytometry were conducted to determine the significance of these cells in the pathogenesis of chronic rheumatic heart disease. Lymphocytes (B cells, T cells, CD4 cells, CD8 suppressor or cytotoxic T cells, activated T cells, and natural killer cells) were measured in blood and left atrial appendage samples of 30 patients with rheumatic heart disease and 10 patients with acyanotic congenital heart disease. Monoclonal fluorescent-labeled antibodies were used to identify various cells by flow cytometry. There was a significant increase in CD4 cells and activated T cells with a significant decrease in B cells in the left atrial appendage tissue of patients with rheumatic heart disease compared to those in the control group. There was no significant difference between the two groups in the distribution pattern of T lymphocytes in peripheral blood. These changes in rheumatic heart disease reflect an abnormal immunoregulatory mechanism with an ongoing enhanced immunological process continuing into the chronic phase of the disease. In our opinion, this persistent T cell response may lead to fresh damage to the myocardium and deformation of the heart valves.

Malignant Fibrous Histiocytoma of the Left Atrium

A 25-year-old female presented with symptoms resembling those of critical mitral stenosis. Echocardiography revealed a left atrial mass without a stalk, which was suspected to be a left atrial myxoma. An irregular soft friable mass was found at surgery. It measured 10 × 8 cm, with finger-like extensions and occupied almost the entire left atrial cavity, extending into the three tributaries of the right pulmonary vein. Histopathology of the excised tumor including electron microscopy showed a pleomorphic cytology interlaced with bundles, areas of necrosis, and occasional bizarre tumor giant cells. Characteristic histiocytes containing lysosomes identified the tumor as malignant fibrous histiocytoma. A postoperative course of radiotherapy with a dose of 4,000 cGy/20 fractions was applied to the mediastinum. At follow-up 4 months later the patient was asymptomatic. This case is reported because of the extreme rarity of left atrial malignant fibrous histiocytoma.

Post-Enteric Mycotic Aneurysm of Abdominal Aorta with Total Disruption

We report an extremely rare case of suprarenal mycotic aneurysm of the abdominal aorta below the origin of the superior mesenteric artery, secondary to Salmonella infection in a 3-year-old boy, which was associated with total disruption of the aortic wall. This case was successfully managed surgically with debridement and interposition of a double velour Dacron graft in the involved segment of aorta. A high degree of suspicion, angiographic evaluation supported by noninvasive investigations, and a planned surgical approach are required for a successful outcome.

Large Congenital Ventricular Septal Defect: Surgical Closure at Sixty Years

Large congenital ventricular septal defects have an unfavorable natural history and survival to 60 years of age with a large left-to-right shunt is very uncommon; surgical closure of such a defect in the elderly is even rarer. We report the case of a 60-year-old female who presented with a large left-to-right shunt across a congenital subaortic ventricular septal defect and underwent successful surgical closure.

Inferior Vena Caval Bullet Embolism

We report a case of bullet penetration into the left iliac vein, with embolus into the inferior vena cava and migration up to the junction of the inferior vena cava and the right atrium. The bullet was subsequently extracted through laparotomy from the infrarenal segment of the inferior vena cava, just above its bifurcation.

Cardiac Tumors: Surgical Experience in Thirty-Nine Cases

Over a period of 18 years, 39 cases of cardiac tumors were operated upon in the Department of Cardiothoracic Surgery at the Postgraduate Institute of Medical Education and Research, Chandigarh. These included 34 (87%) patients with benign tumors and 5 (13%) patients with primary malignant tumors. All the benign tumors were myxomas, of which 31 (91.2%) were in the left atrium and 3 (8.8%) in right atrium. Primary malignant tumors comprised 2 rhabdomyosarcomas, 1 angiosarcoma, 1 lymphoma and 1 case of pleomorphic malignant fibrous histiocytoma. The diagnosis was established by echocardiography, angiocardiography and computed tomography. In one case the diagnosis was made at autopsy. All myxomas, except tricuspid valve myxoma, were removed completely through right atrial or biatrial approach with the use of cardiopulmonary bypass. Four cases of primary malignant tumors were non-resectable. Near total resection of a malignant fibrous histiocytoma arising from the right middle pulmonary vein and left atrial junction was achieved. There were 2 operative deaths (5.1 %). The follow-up ranged from 3 months to 10 years with a mean of 5.7 years. There was 1 recurrence (2.9%) in the benign group. In the malignant group, 3 cases (60%) died within 5 to 8 months of surgery due to further local and metastatic spread of the tumor. The case of malignant fibrous histiocytoma was treated with postoperative radiotherapy to the right mediastinum and is doing well at follow-up 3 months after surgery.