Ranjit Deshpande

Unusual tumours of the heart: diagnostic and prognostic implications

Metastases to the heart are extremely uncommon. We describe three unusual cases along with their management. A review of the current literature concerning cardiac secondaries is included.

Home-based preoperative rehabilitation (prehab) to improve physical function and reduce hospital length of stay for frail patients undergoing coronary artery bypass graft and valve surgery

BackgroundEvidence suggests that elective cardiac patients are at risk of functional and psychological deterioration in the time preceding surgery. This poses a risk to successful post-operative rehabilitation. This prospective one-group pre-test, post-test evaluation was designed to assess a clinical Pre-operative Rehabilitation (PREHAB) home-based exercise programme, to optimise pre-operative physical function and frailty in patients awaiting elective Coronary Artery By-Pass Graft (CABG) or Valve Surgery.MethodConsenting patients awaiting cardiac surgery, with wait timexa0≥xa06xa0weeks were referred to a Senior Physiotherapist for baseline assessment. Patients were offered PREHAB in the form of functional home-based exercise that was prescribed from baseline physical outcomes. All patients were followed up via telephone to ensure progression of exercise and any problems associated with it. This continued weekly until the patient attended Surgical Pre-assessment clinic, where all outcome measures were re-assessed.ResultsTwenty two patients, out of a total number of 36 patients seen in the surgical clinic between March 2016 and August 2016, participated in the prehab clinical evaluation. Twenty patients completed their prescribed exercises on a weekly basis prior to surgery. No adverse events or cardiac symptoms were reported as a result of the home exercise intervention. Paired t-Test analyses revealed a significant mean difference in clinical frailty score (CFS) of −0.53xa0±xa00.51 (95% CI [−0.774, −0.279], Pxa0=xa00.0003). Significant mean difference in six-minute walk test (6MWT) distance of 42.5xa0±xa027.8xa0m (95% CI [23.840, 61.251], Pxa0=xa00.0005), 6MWT walking speed of 0.5xa0±xa00.4kmh (95% CI, [0.2433, 0.7567], Pxa0=xa00.001), and short physical performance battery (SPPB) total score of 2.2xa0±xa01.7, (95% CI [3.066, 1.200], Pxa0=xa00.0002) were also observed. The change in 6MWT distance was shown to be significantly associated with hospital length of stay (LOS) (rxa0=xa00.7; Pxa0=xa00.03).ConclusionThis small exploratory evaluation suggests that providing a home-based PREHAB programme for frail patients undergoing CABG or Valve surgery may be able to improve functional ability and reduce hospital length of stay for those patients undergoing cardiac surgery. A frailty score with greater sensitivity may be required to elucidate the influence frailty could have in reducing length of stay. A large randomised controlled study is required to reveal the potential beneficial effects of PREHAB in this patient population.

Delayed cardiac tamponade following posttraumatic diaphragmatic hernia without an intrapericardial component

We describe a case of posttraumatic diaphragmatic laceration with unusual late sequelae of presentation. Ventilatory and gastrointestinal compromises are known complications of such herniae; but delayed cardiac tamponade without an intrapericardial component of such a hernia has not been reported so far.

Factors associated with safe early discharge after transcatheter aortic valve implantation

BACKGROUNDnAs transcatheter aortic valve implantation (TAVI) becomes more straightforward, a larger proportion of patients will be well enough to be discharged early. This study sought to charac-terise the clinical features that allowed patients to be discharged early after TAVI and to evaluate the safety of an early discharge policy.nnnMETHODSnAll patients undergoing TAVI at the above cited center from August 2007 to March 2015 were included in this study. Baseline characteristics, in-hospital outcomes, re-admissions and mortality were compared.nnnRESULTSnThree hundred thirty-seven TAVIs were performed during the study period, and 18 died in-hospital (18/337, 5.3%). Of the remaining patients, 56 were discharged within 3 days of the index procedure (early discharge group 56/319, 17.5%). There was no difference between the early discharge and late discharge group in terms of Valve Academic Research Consortium-2 (VARC-2) criteria out-comes, all-cause re-admission rates and the need for permanent pacemaker implantation. Mortality at 1 year was better among the early discharge group (3.6% vs. 15.6%, p = 0.014); a reflection of baseline clinical differences.nnnCONCLUSIONnEarly discharge of clinically selected TAVI patients is safe and appropriate. Lower logistic EuroSCORE, smaller delta creatinine and not developing any complications are factors associated with early discharge. (Cardiol J 2018; 25, 1: 14-23).

Fibrosing Mediastinitis and Occlusion of Pulmonary Veins After Radiofrequency Ablation

Pulmonary vein stenosis is a known complication of radiofrequency ablation; its incidence ranges from 8% to 50%. However, complete occlusion of unilateral pulmonary veins is uncommon. We report a case with radiofrequency ablation that was complicated by complete occlusion of pulmonary veins along with fibrosing mediastinitis, which we believe has not been previously reported.

Effective and rapid technique to ensure uniform talc pleurodesis

The use of talc for inducing chemical sclerosis in the pleural cavity dates back to 1935. Insufflation (also known as talc poudrage) and instillation have been the techniques used for administering talc. We describe a surgical technique to insufflate talc in the pleural cavity using an ingenious method at no additional cost that ensures effective, widespread talc dispersion and good results.

100 Multi-disciplinary Clinic: Next Step In “heart Team” Approach For Tavi

Introduction The “Heart team” approach is considered to be the most appropriate method for assessing patients for consideration of Transcatheter Aortic Valve Implantation (TAVI) in severe aortic stenosis. Thus far, the approach has involved the discussion of patients in a multi-disciplinary meeting (MDM) involving interventional cardiologists, imaging specialists, surgeons, anaesthetists and elderly care physicians. The disadvantage of this approach is that the patients are often reviewed remotely by a single specialist. We have developed a unique model of multi-disciplinary clinic (MDC) for assessing patients for TAVI; in this model the patients are reviewed by an interventional cardiologist, cardiac surgeon and anaesthetist in the same clinic. We report the first 8 months data of patients reviewed in this clinic and the outcomes. Methods The TAVI MDC at King’s College hospital has run twice a month since January 2013. Data for all patients who attended this clinic were collected and analysed. For those who attended the clinic more than once, the decision made during the first visit was included for analysis. We compared this with that taken from MDM patient discussions (n = 71) undertaken in the 8 months prior to the inception of the clinic. Results During the study period, 64 appointment slots were made in the clinic. 48 patients (83 ± 6 yrs, 22 female) were reviewed in the clinic 57 times (7 patients seen twice, one patient seen three times). The outcome of clinic decisions for these patients is shown in Figure 1. This was compared with the outcome for patients discussed in the preceding 8 months. (Table 1)TAVI work-up was completed prior to clinic appointment in 15 patients (31.3%) compared to 62 patients (87.3%, p < 0.0001) in the MDM group. A total of 13 patients in the MDC group and 28 patients in the MDM group finally underwent TAVI. In those who finally underwent TAVI, the time interval between clinic/discussion to TAVI was shorter in the MDC group when compared to the MDM group (median 54, IQR 36–88 days vs 130, 64–171 days, p = 0.01). The TAVI ‘turn-down’ rate was also higher when patients were reviewed in MDC when compared to MDM discussion (35.4% vs 16.9%, p = 0.03). Abstract 100 Figure 1 Conclusion This is the first report of the live “Heart team” clinic data. TAVI decline rate was higher when patients were seen earlier in the process by the team, thereby avoiding unnecessary costs of TAVI work-up investigations. Patients underwent TAVI quicker when seen and accepted in the MDC. This model offers the potential for a more effective method of multidisciplinary assessment, but does require significant resource allocation. Abstract 100 Table 1 n (%) MDM clinic(n = 48) MDM discussion(n = 71) P value TAVI Work-up completed prior to clinic/discussion 15 (31) 62 (87.3) <0.0001 No severe AS 3 (6.3) 4 (5.6) 1.0 TAVI declined/not suitable 17 (35.4) 12 (16.9) 0.03 For surgical AVR 5 (10.4) 14 (19.7) 0.2 Accepted (provisionally, for those without work-up) 14 (29.2) 29 (40.8) 0.2 Patient/family to decide after discussion 4 (8.3) NA NA Need further assessment 5 (10.4) 12 (16.9) 0.4 TAVI performed 13 (27.1) 28 (39.4) 0.2

Right pulmonary hilar pedicle injury secondary to blunt chest trauma in a child

Combined tracheobronchial and thoracic vascular injury in children following blunt trauma to the chest is potentially life-threatening and almost certain to be fatal unless managed promptly. We report one such incident where prompt identification and early aggressive surgical management prevented an almost certain fatal outcome in a 5-year-old girl with complete disruption of the right main bronchus just distal to the carina, and a tear in the right pulmonary artery.