Richard Saldanha

Scimitar Syndrome: Experience with 6 Patients

Scimitar syndrome is a rare congenital anomaly characterized by anomalous pulmonary venous drainage to the inferior vena cava, causing a left-to-right shunt. Six patients with scimitar syndrome were diagnosed in our hospital between 2002 and 2008. There were 4 girls and 2 boys; 4 < 5 kg in weight, 2 < 8 kg in weight. Scimitar syndrome was suspected in 5 cases because of dextroversion, and diagnosed by color Doppler echocardiography in all 6 when a scimitar vein was detected entering the inferior vena cava. Computed tomography confirmed the diagnosis in all patients. Two patients had horseshoe lung, 2 had a unilobar right lung, 1 had a hypoplastic right lung, and 1 had a hypoplastic right lower lobe. Three patients had severe pulmonary arterial hypertension, 2 had moderate pulmonary arterial hypertension, and one had normal pulmonary arterial pressure. All patients had lower respiratory tract infections, volume loss of the right lung, a normal or hyperinflated left lung, dextroversion of the heart, and scimitar arteries from the descending aorta. Pneumonectomy was performed in 3 patients, lobectomy in 1, ligation of anomalous vessels in 1, and 1 died before surgery.

Surgical Closure of Atrial Septal Defect in Children under Two Years of Age

Infants with atrial septal defects are seldom symptomatic and usually require elective surgery between 2 and 4 years of age. However a small minority is symptomatic and management at this age has been controversial. This study evaluated surgical closure of atrial septal defect below 2 years of age. Eighteen infants with a mean age of 13.4 ± 5.7 months were operated on for secundum atrial septal defect from 1994 to 2001. Fourteen patients were symptomatic with failure to thrive in 7 and recurrent respiratory infections in 7, one had increasing cardiomegaly, and 3 were operated on early for social reasons. The defect was isolated in 11 patients (61%) and the other 7 (39%) had minor associated lesions requiring additional procedures such as ductal ligation, direct closure of a tiny ventricular septal defect, and inspection of the mitral valve. There were no early or late deaths. The postoperative course was complicated by pulmonary problems in 4 cases. Of the 16 patients available for follow-up, 14 were asymptomatic and 2 were symptomatically improved. Most showed a dramatic improvement in growth and development. These gratifying results indicate that consideration should be given to early surgical closure of atrial septal defect in symptomatic infants.

Extracardiac Fontan/Kawashima Procedure without Cardiopulmonary Bypass:

Two patients with univentricular physiology underwent successful surgical palliation without the use of cardiopulmonary bypass. A 19-year-old girl had an extracardiac Fontan operation and a 4-year-old boy had a Kawashima-type repair with a bilateral bidirectional Glenn procedure.

Intraoperative anastomotic site detection and assessment of LIMA-to-LAD anastomosis by epicardial ultrasound in off-pump coronary artery bypass grafting--a prospective single-blinded study.

The study was done to detect the optimal site of left anterior descending (LAD) artery for grafting and for the assessment of geometrical and anatomical characteristics of left internal mammary artery (LIMA)-to-LAD artery anastomosis in elective off-pump coronary artery bypass grafting surgery. Fifteen consecutive patients who underwent coronary artery bypass graft (CABG) were included in the study. All the operations were performed by a single surgeon. Epicardial ultrasound probe was placed at the site of grafting for scanning and the site of anastomosis selected. The anticipated target site selected by the surgeon was scanned for patency, size, septal perforator branches, and presence of plaque and calcification. The surgeon identified the LAD artery in 12 patients. In three patients, the LAD artery was not visible. However, with epicardial ultrasound, the LAD artery was identified in all patients. In 6 of 15 patients, the anticipated target anastomotic site was changed to a clear segment either due to the presence of perforators or plaques or calcifications. In all 15 patients, the surgeon scored the anastomosis as good, based on his or her experience independent of the ultrasound image. The anastomotic score by the cardiac anesthesiologist showed 5 anastomoses with satisfactory results and 10 anastomoses with good results. The study demonstrates that epicardial ultrasound scanning with a 10-MHz transducer provides reliable information in choosing the proper anastomotic site and allows proper visualization of LIMA-to-LAD anastomosis. All these measurements are easily obtained without risk of any complications and the method is not time consuming.

Idiopathic ascending aortic pseudoaneurysm in an eleven-year-old girl

An 11-year-old girl presented with shortness of breath. A chest radiograph showed widening of the mediastinum (Figure 1). Computed tomography-angiography revealed a pseudoaneurysm of the ascending aorta (Figure 2). Using hypothermic circulatory arrest, the defect in the aorta (Figure 3) was repaired with a Asian Cardiovascular & Thoracic Annals 2017, Vol. 25(7–8) 561–562 The Author(s) 2017 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492317692469 journals.sagepub.com/home/aan

Ascending-to-descending aortic bypass graft for type B aortic interruption.

A 21-year-old man presented with hypertension. A computed tomography aortogram showed type B aortic interruption (Figure 1). In view of the complexity of the lesion and the presence of a large collateral circulation, an ascending-to-descending aortic bypass graft was performed via a median sternotomy, using hypothermic cardiopulmonary bypass (Figure 2, Figure 3). Asian Cardiovascular & Thoracic Annals 2017, Vol. 25(1) 74–75 The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315592557 aan.sagepub.com

Inadequate harvest of internal mammary artery—beware!

Internal Thoracic Artery (ITA) has been universally accepted as a superior conduit for patients undergoing coronary artery bypass operations. Hence, ITA harvest must be done with utmost care. All the branches of ITA must be clipped to ensure a long term patency. Sometimes, one encounters an ITA densely adherent to the overlying periosteum often prompting the surgeon to leave behind unclipped branches. The surgeon must be aware that there is a 15 % incidence of lateral costal branch in internal thoracic arteries [1], which can sometimes be overlooked. Coronary angiogram in a symptomatic patient, who underwent coronary artery bypass grafting 2 years ago, showed a prominent unclipped lateral costal branch from Left Internal Thoracic Artery (LITA) and string sign of LITA (Fig. 1). This case demonstrates the importance of complete harvest and clipping of all the branches of LITA for its patency.

Recurrent and Large Arteriovenous Malformation with Failed Interventions Managed Surgically in Deep Hypothermic Circulatory Arrest - A Case Report

The first recorded case of an arteriovenous malformation was in the late 16th century. In 1757, William Hunter described an arteriovenous malformation as an abnormal communication between an artery and a vein [1]. Arteriovenous malformations can occur anywhere in the body. They frequently occur as isolated, stable anomalies requiring no specific treatment. Some AVMs may be extensive, multiple,recurrent and progressive causing disfigurement with the potential for life-threatening hemorrhage, thrombosis, painful ischemia or high-output congestive heart failure. These occurrences usually are indications for intervention, which is often technically difficult and unrewarding [6].Surgery in deep hypothermic circulatory arrest has a role in this failed intervention.