Rajesh Sharma

Can late survival of patients with moderate ischemic mitral regurgitation be impacted by intervention on the valve

BACKGROUND Ischemic mitral regurgitation is known to be associated with poor long-term outcome after coronary artery bypass grafting; however, our ability to alter that outcome with intervention on the valve is unclear. The decision to address the valve is most challenging for patients with only moderate mitral regurgitation, particularly with the popularization of off-pump surgery. We therefore reviewed early and late outcomes of patients undergoing revascularization with or without mitral valve surgery. METHODS Patients with moderate mitral regurgitation undergoing revascularization with and without mitral surgery between January 1991 and September 1996 were identified retrospectively. Operative notes were reviewed and patients with structural valve disease excluded. Perioperative events and late outcomes as determined by telephone contact and search of the social security death index (survival data 97% complete) were compared. RESULTS One hundred seventy-six patients with moderate mitral regurgitation underwent revascularization alone (n = 142) or with mitral repair or replacement (n = 34). Those undergoing revascularization alone had a higher serum creatinine, somewhat less mitral regurgitation, and lower New York Heart Association functional class preoperatively. Operative mortality was greater with valve surgery (21% vs 9%, p = 0.047). Actuarial survival of both groups at 5 years was similar (52% vs 58%, p = NS); however, when stratified by preoperative functional class, those with more advanced heart failure preoperatively had superior late survival if their mitral valve was intervened upon. CONCLUSIONS The late survival of patients with ischemic mitral regurgitation undergoing coronary revascularization remains poor; however, intervention on the mitral valve appears to benefit those with symptomatic heart failure.

Prevalence, risk determinants and consequences of atrial fibrillation in rheumatic heart disease: 6 years hospital based-Himachal Pradesh- Rheumatic Fever/Rheumatic Heart Disease (HP-RF/RHD) Registry

Objective To report the prevalence, risk factors and consequences of atrial fibrillation (AF) in patients of rheumatic heart disease (RHD). Methods The Himachal Pradesh- Rheumatic Fever/Rheumatic Heart Disease (HP-RF/RHD) Registry database of 1918 patients was analyzed. AF was diagnosed with 12-lead ECG recording at entry in to the registry. The association of AF with nature and severity of valvular dysfunction was analyzed, adjusted for age, left atrial (LA) dimension and pulmonary arterial hypertension using multivariable logistic regression model and strength of association was reported as odds ratio (OR) with 95% confidence intervals (C. I.). Results The study population consisted of young (40.2 ± 14.3 years), predominantly females (72.3%) from rural area (94.1%). Prevalence of AF was 23.9% (95% C. I. 22.1%–25.8%). The independent determinants AF were age (OR 1.04, 95% C.I. 1.03–1.06), LA size (OR 1.10, 95% C.I. 1.08–1.11). The association of AF with age, New York Heart Association functional class, mitral stenosis severity and tricuspid regurgitation was statistically significant and graded. Mitral regurgitation and aortic valve disease had no significant independent association with AF. The prevalence of heart failure, stroke, peripheral embolism and mortality was significantly higher among patients with AF (p < .01). Conclusion AF is common in RHD patients and is significantly associated with heart failure and systemic thromboembolism. Age, mitral stenosis severity, tricuspid regurgitation and LA size were independently associated with AF.

The bidirectional Glenn shunt for univentricular hearts

In 1958, working on the principle of partial right heart exclusion elucidated by Carlon et al. [1], Dr. Glenn published the superior vena cava (SVC) to right pulmonary artery (RPA) connection [2]. The initial Glenn shunt was an anastomosis between the side of the ligated SVC and the distal end of the transected RPA, and flowed to the ipsilateral lung alone, the contralateral lung being supplied by antegrade flow from the main pulmonary artery (MPA). Today, the bidirectional Glenn shunt (BDG) is performed almost exclusively as an (end of) SVC to superior aspect (side) of ipsilateral pulmonary artery (PA) connection, and therefore, the superior caval return has drainage to both the lungs (i.e., it is bidirectional). The principal indication for a bidirectional superior cavopulmonary shunt today is as staging towards a total cavopulmonary connection after which total exclusion of a deficient/insufficient right ventricle is achieved with complete elimination of mixing between the systemic and pulmonary venous return and normalization of systemic oxygen (O2) saturation. The BDG may be performed with or without the use of cardiopulmonary bypass (CPB). Requirement of a concomitant intracardiac procedure is one of the reasons for use of CPB which may also be used electively. However, it is also possible to perform the BDGwithout CPB; in which case, two angled cannulas connected together are used to drain the venous blood from upstream to the clamp placed on the SVC, to the right atrium with partial heparinization and passive drainage. The BDG can also be performed in a BClamp and Go^ fashion if the anatomy permits and if superiorcaval and ipsilateral PA clamping is tolerated (hemodynamically and with respect to systemic O2 saturation) for the time it takes, which is usually less than 20min.When the BDG is performed using decompressing cannulas but without CPB, the SVC pressure is found to be in the range of 20 mmHg, when done with just clamps and no decompression, up to a mean of 40 mmHg. To date, we have not encountered any complication in the BDGs done with just clamping and neither has there been any neurological /radiological neurological sequelae. A bidirectional Glenn shunt is appropriate first-stage management for a functional or anatomical single ventricle situation (i.e., one not amenable to biventricular repair) and is said to improve candidature for future Fontan conversion.The aim is to achieve superior cavopulmonary diversion along with satisfactory ventricular function and mild or less atrioventricular valve regurgitation (AVVR), without systemic ventricle outlet obstruction, adequate PA size, and no ventricular inflow gradient, so that the requisite pre-Fontan requirements are met to the best extent possible. PreGlenn PA pressures are to be considered along with existent systemic arterial saturation to decide the upper acceptable level as they can be expected to come down once antegrade pulmonary blood flow is reduced or eliminated, and are the same as for a Fontan (< 15-mmHg mean). Suboptimal results may be encountered if the BDG is performed in the setting of elevated PVR. Hence, the lower limit of age for surgery for a BDG has been lowered very cautiously. Today, a BDG is known to have been done even as early as 4–6 weeks after birth [3]. The principal indication for doing a BDG early is as stage II palliation following a Norwood procedure, especially if a systemic artery to pulmonary artery shunt-dependent pulmonary circulation exists. This is because of the known lability of this circulation, combined with the propensity for a small systemic to pulmonary artery shunt to occlude, thereby resulting in interstage attrition. The superior cavopulmonary shunt unloads the single ventricle and, at the same time, provides a more reliable source of pulmonary arterial inflow than the preexistent systemic arterial or systemic ventricle to PA shunt. In the younger ages, routinely doing a BDG below 3 months age is still a matter of debate, but in the absence of the negative prognostic factors for a BDG, the outcomes are, in general, good. Other known incremental risk factors for a BDG are (1) systemic ventricular dysfunction, (2) * Rajesh Sharma rsharmacvs@hotmail.com

Intra-Atrial Y-Graft Fontan for Univentricular Heart With Discontinuous Pulmonary Arteries

The Y-graft Fontan as described today suffers from the disadvantage of being hostage to restrictions imposed upon the design of the limbs of the Y by existent cardiac anatomy. We describe a patient with discontinuous pulmonary arteries following a prior Glenn shunt, who underwent Fontan completion using an intra-atrial Y-limb placement for recruitment of the discontinuous pulmonary artery. Intracardiac placement of the limb(s) of the Y-graft could potentially increase the applicability of this Fontan modification without being constrained by external cardiac anatomy.

Anteroposterior Pulmonary Venous Anatomy: A Hitherto Undescribed Pulmonary Venous Arrangement With Implication for the Senning Operation and a Proposed Method of Dealing With It.

We have encountered a hitherto undescribed anatomical variant of pulmonary vein anatomy in hearts with d-transposition or congenitally corrected transposition of the great arteries. In this variant, the inferior right pulmonary vein lies posterior rather than inferior to the superior right pulmonary vein. This variant of pulmonary vein anatomy may predispose to the development of pulmonary venous pathway obstruction following a Senning operation, since it is difficult to open the pulmonary veins in a way that ensures a wide-open pulmonary venous pathway to the atrioventricular valve of the systemic ventricle. A method of neutralizing this effect is described, with medium-term results.

Anatomical repair of congenitally corrected transposition in the fifth decade of life

Successful repair of congenitally corrected transposition with ventricular septal defect and pulmonary stenosis presenting with heart failure in the fifth decade of life is described. This is the oldest patient to undergo this surgery, as per existing literature.

Biventricular conversion for Fontan failure

Certain cardiac malformations may pose difficulties in achieving a biventricular repair, and univentricular repair may be selected for them if the Fontan criteria are satisfied. However, univentricular palliation is not without its own drawbacks. We present a patient with double outlet of the right ventricle with pulmonic stenosis where the Fontan operation was conducted but where there was early Fontan failure in the short term and she needed conversion to a biventricular physiology.

Hepatoazygos venous shunt for Fontan completion after Kawashima operation

Fontan completion after prior Kawashima repair for single ventricle with interruption of the inferior vena cava can be accomplished by various methods. We describe a patient who underwent the connection of hepatic to hemiazygos vein that we believe would be superior to the conventional cavopulmonary connection in our patient.

One-Stage Midline Unifocalization and Anatomic Correction of Corrected Transposition With Pulmonary Atresia and Absence of Central Pulmonary Arteries

A concomitant double-switch procedure and unifocalization were performed in a child with congenital corrected transposition of the great arteries, ventricular septal defect, pulmonary atresia, absence of central pulmonary arteries and major aortopulmonary collateral arteries. Predischarge echocardiography showed no residual shunts with laminar flow in baffles and outflow tracts. Follow-up computed tomographic angiography revealed good neo-main pulmonary artery confluence with satisfactory pulmonary blood flow.

One-stage repair of tetralogy of Fallot with coarctation of the aorta.

We describe the rare case of a 10-month-old girl who had coarctation of the aorta in association with tetralogy of Fallot. The surgical management and postoperative course is described. This case highlights the rare association of coarctation with tetralogy of Fallot, with a large intracardiac right-to-left shunt. Although an exception to the rule, it challenges the reduced fetal blood flow theory and the smooth muscle cell migration theory as embryological explanations for the development of coarctation.