Probal K. Ghosh

Failure of devices used for closure of atrial septal defects: Mechanisms and management

Various devices for transcatheter ASD closure are undergoing clinical trials. Each new device claims advantages in terms of safety and efficacy over earlier devices. We report three cases in which a new investigational device--the Das angel wings--failed. Emergency operations were necessary for device retrieval and defect closure. The possible mechanisms of the event and the options in management are discussed with a review of literature on all devices.

Cardiac surgery and cold-reactive proteins

Cold agglutinins are commonly found in sera of healthy persons. They rarely become clinically apparent due to their activity at low temperatures. In these patients, cardiovascular operations requiring hypothermia can result in complications such as hemolysis, renal failure, and myocardial damage and can cause unexpected morbidity and mortality. The literature on cold-reactive proteins is reviewed, and methods of diagnosis and management related to cardiac surgery are suggested. Ideally all patients should be routinely tested preoperatively for the antibodies, and appropriate changes in cardiopulmonary bypass and myocardial management plans should be made in positive patients. Preoperative plasmapheresis may be a useful adjunct, especially in patients requiring operation under profound hypothermia and circulatory arrest. Currently, warm heart surgery appears to be the most expedient method. Unexpected detection of agglutination during operation or hemolysis after operation requires a specific treatment plan.

Minimally Invasive Congenital Cardiac Surgery Through Right Anterior Minithoracotomy Approach

BACKGROUNDnMedian sternotomy has been the conventional approach for correction of congenital cardiac defects despite poor cosmetic results at times. Right anterior minithoracotomy was, therefore, assessed as an alternative procedure with a better cosmetic outcome.nnnMETHODSnFrom October 2002 through February 2007, 75 patients underwent correction of congenital cardiac malformations with the use of cardiopulmonary bypass through right anterior minithoracotomy involving a short incision through the fifth intercostal space and the minimally invasive cannulation. Of them, 18 patients were infants, 42 were children, and 15 were adult. The average age was 9.26 +/- 14.1 years (range, 1.2 to 56). The average weight was 19.59 +/- 24.3 kg (range, 8.5 to 118 kg). The corrected defects included atrial septal defect type II, sinus venosus atrial septal defect with partial anomalous pulmonary venous drainage, atrial component of atrioventricular septal defect, perimembranous ventricular septal defects with patent foramen ovale, mitral valve repair (complex), repair of cleft mitral valve, cor triatum atrial septal defect, repair of double-chambered right ventricle and extraction of atrial septal defect closure device. Skin incisions were as long as 5 cm.nnnRESULTSnThere was no operative or late mortality or major morbidity. The mean cardiopulmonary bypass time was 58.67 +/- 35.11 minutes (range, 32 to 263). Sixty-five patients were extubated in the operating room; the remaining 10 patients were extubated within 4 hours. Cosmetic result was very satisfactory in all patients. Two adult patients complained of some right chest musculoskeletal discomfort.nnnCONCLUSIONSnThe right anterior minithoracotomy incision is a safe and effective alternative to a median sternotomy for correction of congenital heart defects. Cosmetic results are highly satisfactory.

Takotsubo Syndrome After Cardiac Surgery

We have not found any reports to date of Takotsubo syndrome after cardiac surgery. Recently described Takotsubo syndrome is characterized by acute reversible left ventricular dysfunction with apical ballooning in the absence of coronary artery disease, and with chest pain and electrocardiographic changes mimicking acute anterior myocardial infarction, but with minimal release of myocardial enzymes. We describe Takotsubo syndrome that developed after elective mitral valve replacement and tricuspid annuloplasty in a 62-year-old woman. On supportive therapy with vasopressors, left ventricular function gradually improved with an ejection fraction returning to 50%. Takotsubo cardiomyopathy should be considered as a possible complication of the cardiac surgery.

Isolated congenital atresia of the left main coronary artery and atherosclerosis

Successful surgical revascularization in an adult with isolated congenital atresia of the left main coronary artery with coexistent two-vessel atherosclerosis is described. This extremely rare anomaly must be differentiated from single right coronary artery and acquired occlusion of the left main coronary artery. Symptomatic myocardial ischemia in patients surviving to adulthood is an indication for surgical revascularization in them.

Risk Factors for Failed “Fast-Tracking” After Cardiac Surgery in Patients Older Than 70 Years

OBJECTIVEnFast-track pathways have been successfully used in low-risk, relatively young patients after all types of surgical procedures including cardiac surgery. An increase in the number of referrals of older patients for cardiac surgery prompted the present study on the use of a fast-track pathway in septuagenarians and octogenarians. Risk factors for the unsuccessful application of the fast-track pathway in these elderly patients were determined.nnnDESIGNnA retrospective observational study.nnnSETTINGnA single tertiary-care, university-affiliated center.nnnPARTICIPANTSnAll 70-year-old or older patients undergoing cardiac surgery between January 1, 2004 and June 30, 2007 were included. Septuagenarians were compared with octogenarians.nnnMEASUREMENTS AND MAIN RESULTSnDuring the 42-month period, 860 cardiac operations were performed on 576 septuagenarians and 284 octogenarians. The fast-track pathway was successful in 54.5% and 37.3%, respectively. On multiple logistic regression analyses, stroke, renal failure, and procedures other than primary isolated coronary artery bypass graft surgery were independently associated with failed early extubation, delayed intensive care unit discharge, and delayed hospital discharge in both groups. Infections and atrial fibrillation were independent risk factors for delayed hospital discharge in both groups and delayed intensive care unit discharge in the octogenarians. In the octogenarians only, congestive heart failure was an independent risk factor for failed early extubation, delayed intensive care unit discharge, and delayed hospital discharge.nnnCONCLUSIONSnA fast-track pathway may be applied in selected septuagenarians and octogenarians. Age alone should not exclude consideration for fast-track management.

Accessory Mitral Valve Tissue: A Case Report and an Updated Review of Literature

Abstractu2002 Accessory mitral valve tissue is an unusual congenital cardiac anomaly and a rare cause responsible for left ventricular outflow tract obstruction. An 18‐year‐old patient was referred to this hospital due to an occasionally noted heart murmur in a medical examination. Echocardiography facilitated the diagnosis of accessory mitral valve tissue. To relieve the left ventricular outflow tract obstruction, an operation including resection of the accessory mitral valve tissue, implantation of artificial chordae tendineae, and mitral valve annuloplasty was performed successfully. Postoperative echocardiography showed a complete relief of the mitral valve leaflets and a wide patent left ventricular outflow tract. However, transient ischemic attack and Horners syndrome complicated the patient early postoperatively. He was administered with a high dose of aspirin, and he recovered shortly. Surgical removal is mandatory insomuch as a definite diagnosis of accessory mitral valve tissue with left ventricular outflow tract obstruction is established. A prophylactic treatment should be applied to the patients with accessory mitral valve tissue in virtue of their susceptibility to neurological events.

Comparison of operative techniques in acute type A aortic dissection performing the distal anastomosis.

Abstractu2003 Objective: The aim of our retrospective study was to evaluate early and midterm clinical outcomes of two surgical techniques: open anastomosis in deep hypothermic circulatory arrest (DHCA) compared to anastomosis with clamped aorta while continuing on extracorporeal circulation (CECC). Methods: Between November 1997 and February 2002, 67 patients were operated for acute type A aortic dissection. Records of 35 patients with isolated replacement of the ascending aorta without intervention on the aortic arch were retrospectively reviewed. The influence of two techniques (DHCA n = 15, CECC n = 20) on clinical outcome and midterm follow up was investigated. Results: There were no statistically significant differences in preoperative data. Female gender in the DHCA group was coincidentally more frequent. Intraoperative management did not result in different early clinical outcome. 30‐day mortality was not statistically different. Mean follow up time was 20.7 ± 11.1 months in the DHCA group and 28.7 ± 14.3 months in the CECC group. One‐year and 3‐year survival estimates in DHCA group were 85%± 7% and 79%± 9%, respectively. In the CECC group similar survivals were 80%± 10% and 73%± 11%, respectively. No statistically significant differences between the two groups were obtained in early or midterm outcome. Conclusion: While there is no difference in clinical outcome in surgical treatment of acute type A aortic dissection with or without circulatory arrest, there are some practical technical advantages if the distal anastomosis is performed in an open manner. Probably the long‐term outcome too is better with this anastomosis technique.

Coronary Ostial Reconstruction: Technical Issues

Coronary ostial reconstruction may be the preferred alternative to reestablish antegrade myocardial revascularization in patients with isolated ostial stenosis. The technical steps of reconstruction are described. The ultrasonic aspirator is a helpful implement in the dissection of the left main and the proximal right coronary arteries. Satisfactory results of coronary ostial reconstruction in the current era seem to fulfill its promise.

Role of an operative score in mitral reconstruction in dominantly stenotic lesions.

OBJECTIVEnThe role of an operative score in selection and results of mitral valve reconstruction in dominantly stenotic mitral lesions was assessed.nnnMETHODSnA total of 136 patients consecutively underwent reconstruction for rheumatic mitral stenosis with or without regurgitation from December 1989 through December 1994. Mitral valve structure was scored for cuspal pliability and thickness, cuspal area loss, chordal length, papillary muscle length, annular dilatation and degree of associated regurgitation and calcification. A score of 0 indicated normal valve while a score of 24 indicated a grossly deformed valve. Age, sex, functional class, cardiac rhythm, mitral valve orifice area, left ventricular and left atrial dimensions, transmitral gradients, pulmonary artery pressures and thoroughness of repair were evaluated.nnnRESULTSnMitral valve architecture was disorganised moderately in 50 (37%) and severely in 69 (52%) patients. Extent of thoroughness in different operative techniques correlated with good (n = 30) or adequate (n = 60) outcome. Mean mitral valve orifice area increased from 0.77 +/- 0.2 to 2.56 +/- 0.6 cm2, peak gradient dropped from 20.3 +/- 6.2 to 8.6 +/- 3.5 torr, mean gradient from 13.5 +/- 4.9 to 4.76 +/- 2.2 torr and end-diastolic gradient from 10.1 +/- 5.0 to 3.2 +/- 1.9 torr. Lack of recognition of anatomical details and of all necessary componental measures constituted the learning curve of different operators.nnnCONCLUSIONSnRecurrent disease, learning curve, inadequate repair and higher operative mitral valve score were the factors for poorer results in the intermediate term follow-up to 64 months. Thoroughness of repair was the most important correlate of outcome and indicative of expertise.