Shyam Kumar Singh Thingnam

Release of pro-inflammatory mediators during myocardial ischemia/reperfusion in coronary artery bypass graft surgery.

Inflammation has been reported to play an important role in cardiac surgery under cardiopulmonary bypass due to systemic endotoxemia. In order to develop strategies against this injury in future we studied the combined effect of a number of inflammatory mediators in myocardial ischemia/reperfusion. Coronary sinus blood samples of ten patients undergoing coronary artery bypass graft surgery (CABG) were obtained at three time intervals (1) before onset of bypass (2) 30 min after cross clamp, and (3) 10 min after removal of cross clamp. The samples were subjected to evaluate levels of nitric oxide byproducts (nitrite and nitrate and citrulline), inflammatory cytokines (interleukin-2, interferon-γ and interleukin-6), adhesion molecules, (CD62L and CD54), ratio of cell surface markers (CD4/CD8 and TCRαβ/γδ) cell activation markers (CD69 and HLA DR) and second messengers (protein kinase C, inositol 1,4,5 triphosphate and intracellular calcium levels). Ischemia and further reperfusion resulted in significant rise in nitrite and nitrate levels (p < 0.001), interleukin-6 (p < 0.01), CD62L (p < 0.001), CD69 (p < 0.05), protein kinase C (p < 0.001) and intracellular calcium (p < 0.001). A fall in CD4/CD8 ratio was observed on reperfusion. These changes during CABG show that ischemia/reperfusion leads to a release of an array of pro-inflammatory mediators of tissue injury, which could lead to pathophysiological changes. Hence the study suggests the need of some protective therapies against these inflammatory markers.

A possible role of HSP 70 in mediating cardioprotection in patients undergoing CABG

Heat shock protein 70 (HSP70) has been reported to be involved in myocardial self-preservation system. This study shows direct evidence of the effect of HSP70 on lymphocytes during ischemia and reperfusion in CABG (coronary artery bypass graft) surgery. Lymphocytes were separated from the blood obtained from 10 patients undergoing CABG at different time intervals. (i) Baseline samples (drawn before onset of bypass), (ii) ischemic samples (30 min after cross-clamp) and (iii) reperfusion samples (10 min after the cross clamp removal) were incubated with recombinant HSP70 and the cells were harvested after 36 h. The effect of HSP70 was monitored by measuring second messengers such as intracellular calcium, protein kinase C (PKC) and inositol tri phosphate (IP3). In addition CD69 expression was also measured. The results showed a significant decrease in intracellular calcium and CD69 expression in ischemia and further in reperfusion samples as compared to their respective un-triggered controls. PKC and IP3 levels however remained unaffected. The protective effect of HSP70 during ischemia and reperfusion could thus be attributed to decreasing intracellular calcium and CD69 expression. This study could therefore provide a mechanism of cardioprotection afforded by HSP70.

Use of pericardial strip for reinforcement of proximal anastomosis in Bentall's procedure

Bleeding from a proximal suture line is not uncommon following composite graft anastomosis in Bentalls procedure. Passage of valve sutures through the pericardial strip, which is used to encircle the sewing ring of the composite graft, strengthens the repair. The strip can also be sutured to the left ventricular outflow tract in case of bleeding from proximal anastomosis in that particular region.

Closed mitral valvotomy for mitral restenosis: Experience in 113 consecutive cases☆☆☆★★★

The costs of heart operations and the problems related to anticoagulation after prosthetic valve replacement are among the limitations faced by patients in nonindustrialized countries with mitral stenosis caused by chronic rheumatic heart disease. The young age at which these patients are seen also compels the surgeon to preserve the native valve. The least costly and optimal way to achieve this objective is by closed mitral valvotomy. After closed mitral valvotomy, mitral restenosis is commonly encountered. We report here our 10-year experience with operation on 113 consecutive patients with mitral restenosis. Closed transventricular revalvotomy was performed with Tubbs dilator in 105 of 113 patients. Mean age was 343 years, with a male to female ratio of 1:1.5. Most patients were in New York Heart Association functional classes III and IV (74.3% and 19.4%, respectively). Mean interval between first and second valvotomy was 9.4 years, Hospital mortality rate was 2.8%, trivial postoperative mitral regurgitation occurred in 16.1%, and moderately severe regurgitation occurred in 1.9%. Early postoperative systemic embolism occurred in 3.8% of the cases. Moderate to excellent symptomatic improvement was noted in 89.4% of the cases and poor results were seen in 10.2%. Late follow-up of 76 patients ranged from 2 to 10 years (mean 3.8 years), with 39.4% patients in New York Heart Association class I and 50% in class II. Close mitral revalvotomy is thus an economical, simple, and safe palliative procedure that carries good long-term results.

Ruptured right sinus of Valsalva into main pulmonary artery

A young adult who presented with congestive heart failure was found to have ruptured aneurysm of right sinus of Valsalva. The aneurysm was opening into the main pulmonary artery, which was demonstrated well by transthoracic and transesophageal echocardiography and confirmed by cardiac catheterization. Aneurysm was repaired followed by aortic valve replacement.

Perioperative Follow-Up of Patients With Severe Pulmonary Artery Hypertension Secondary to Left Heart Disease: A Single Center, Prospective, Observational Study.

OBJECTIVE A substantial portion of the Indian cardiac surgery population experiences rheumatic valve disease that progresses to severe pulmonary artery hypertension (PAH) in a few patients. Right ventricular (RV) function, particularly in the perioperative period, has been studied sparsely. The authors describe serial RV function and clinical variables in the perioperative period in patients with severe PAH secondary to left heart disease. DESIGN Prospective, observational study. SETTING University hospital. PARTICIPANTS Patients with PAH. INTERVENTIONS The study comprised consecutive patients referred for open cardiac surgery from January 2012 to June 2013 who also had an estimated right ventricular systolic pressure≥50 mmHg on referral echocardiogram. Composite echocardiographic assessment of right ventricular size and linear/two-dimensional tissue Doppler systolic function and diastolic function analysis were performed at predetermined intervals. Data from right heart catheterization, inotrope use, fluid requirements, mechanical ventilation logs, and intensive care stay also were acquired. MEASUREMENTS AND MAIN RESULTS A complete dataset was obtained in 20 of 22 patients enrolled in the study. Serial comparison of most RV echocardiographic function variables were noted to be abnormal at baseline, deteriorating further in the immediate postoperative period and trending to a partial recovery at discharge from the intensive care unit, particularly for longitudinal assessment of the RV. Fractional area change, although abnormal, was noted to be preserved. Pulmonary artery systolic pressures registered significantly declined after intervention. The clinical course was largely uneventful. CONCLUSION Although linear echocardiographic RV function was grossly abnormal in the perioperative period in this patient subset with PAH, there was apparent disjunction with the clinical course.

A novel surgical technique of repair of posterior wall laceration of thoracic trachea during transhiatal esophagectomy.

Tracheal injury is a rare, dreaded and potentially fatal complication of transhiatal esophagectomy (THE). The close proximity of major airway to esophagus makes it vulnerable to iatrogenic laceration during mediastinal manipulations. Over a period of five years, three patients with injury to membranous trachea during THE, were managed through the cervical incision. There was laceration of membranous trachea ranging from 3.5 to 5 cm in length with minimal loss of tracheal tissue. One of the lacerations was extending up to the right bronchus. All the patients were successfully managed through the cervical incision. The operative repair of trachea lasted for 45-60 min. One patient developed permanent left recurrent laryngeal nerve injury and another had postoperative bronchopneumonia. There was no mortality. Trans-cervical approach is an effective way of repairing thoracic membranous tracheal laceration during THE without any significant increase in the morbidity.

Perioperative echocardiography-derived right ventricle function parameters and early outcomes after tetralogy of Fallot repair in mid-childhood: a single-center, prospective observational study.

Right ventricular (RV) function alterations are invariably present in all patients after tetralogy of Fallot (TOF) repair. Unlike the developed world where most of the patients with TOF are corrected in infancy, average age of presentation and thus surgery for these patients in the developing world may be higher. We aimed to study the correlation between RV function parameters such as tricuspid annular peak systolic excursion (TAPSE), fractional area change (FAC), and tricuspid annular peak systolic velocity (S’) with early outcome variables after intracardiac repair for TOF.

CASE 4—2013 Large Ascending Aortic and Arch Aneurysm: An Unusual Cause of Preoperative Airway Compromise

Graduate Institute of Medical Education India; and †Department of Cardiothoraci Pant Hospital, New Delhi, India. Address reprint requests to Dr Bhupesh Department of Anaesthesia and Intensive of Medical Education and Research, C bhupeshkr@yahoo.com

Interposition of aortic valve leaflets for reinforcement of Bentall proximal anastomosis

Bleeding from the proximal suture line is not uncommon after composite graft anastomosis in the Bentall procedure. The passage of valve sutures through the aortic valve leaflets interposed between the pledgets and the cuff of the composite valved conduit strengthens the repair.