Sivakumar Krishnasamy

Effect of sternal closure with biological bone adhesive on pain visual analogue score and serum cytokine

ObjectivesRecently a biocompatible bone adhesive was introduced in addition to the sternal wires to expedite sternal union and improve patient recovery. In this study we aim to objectively assess the biomarker of pain in patient who received the biocompatible bone adhesive.MethodsA total of 62 patients who underwent sternotomy were prospectively randomised to receive either conventional wire closure (CWC); 32 patients or adhesive enhanced closure in addition to sternal wire (AEC); 30 patients. Patients were monitored postoperatively at certain time intervals for incisional pain, serum Interleukin-6 (IL-6) level, analgesia used and postoperative complications. All patients were followed up for 4xa0weeks.ResultsThe post-operative pain scores with coughing were significantly higher in the CWC group at 24xa0hours and 48xa0hours. The postoperative IL 6 levels were significantly higher in the CWC group in comparison with the AEC group at 6xa0hours, 24xa0hours, and 48xa0hours. There were no significant differences in term of additional analgesia used. No adverse events from adhesive bone cement were observed during follow up.ConclusionsAdhesive-enhanced sternal closure resulted in modest reduction of pain confirmed by reduction of pain biomarker. Justification of its routine use requires larger multicentre study.

Metastatic Adenocarcinoma Presenting as Extensive Cavoatrial Tumor Thrombus.

The presence of tumor thrombus in the right atrium is frequently the result of direct intraluminal extension of infra-diaphragmatic malignancy into the inferior vena cava (IVC) or supradiaphragmatic carcinoma into the superior vena cava (SVC). Right atrial tumor thrombus with extension into both SVC and IVC has not been reported in the literature. We present a patient who presented with symptoms of right atrial and SVC obstruction. Imaging revealed presence of a thrombus in the right atrium, extending to the SVC and IVC, with the additional findings of a left adrenal mass and multiple liver lesions. The histopathological examination of the right atrial mass revealed metastatic adenocarcinoma cells. The patient was given a presumptive diagnosis of metastatic adenocarcinoma, most likely adrenal in origin, with multiple hepatic lesions suspicious for metastasis. The clinical outcome of the patient was not favorable; the patient succumbed before the adrenal mass could be confirmed to be the primary tumor. This case highlights that in patients manifesting with extensive cavoatrial thrombus as, the existence of primary carcinoma should be considered especially in the adrenal cortex or in the lung.

Early and midterm outcome of complete Atrioventricular Septal Defect (AVSD) in a single institution

BackgroundSurgical repair of complete atrioventricular septal defect is a well established procedure performed in young children. We sought to determine the rate of survival, reoperation and occurrence of Left Atrioventricular Valve Regurgitation (LAVVR).Patients and methodsThis was a retrospective review of 56 patients with Complete Atrioventricular Septal Defect (CAVSD) recruited from January 2000 till July 2010. Sixty-six percent of these patients had Down’s Syndrome. The median age and weight at surgery was 0.95u2009±u20092.7xa0years and 6.2u2009±u20097.5xa0kg respectively. 2D Echocardiography was used to quantify the degree of LAVVR pre and postoperatively. The technique of repair used was either 2 patch, modified single patch or single patch. The cleft in the LAVV was closed in all cases. Risk factors associated with increased mortality and re-intervention were analyzed.ResultsThe operative mortality was 5.4xa0%. There were 3 patients who developed complete heart block and required Permanent Pace Maker (PPM) implantation whereas 11 patients (20xa0%) developed supraventricular arrhythmia. Twenty-one percent of patients had moderate LAVVR at discharge. Eight patients (14xa0%) required re-operation for LAVV regurgitation at a mean duration of 17u2009±u200929xa0months. The mean ICU stay was 6xa0days. Prolonged ventilation and presence of infection trended towards higher mortality. The presence of moderate or severe LAVVR at discharge was one of the main factors for re-intervention.ConclusionThe surgical repair of Complete Atrioventricular Septal Defect in young children is associated with acceptable mortality and morbidity. Left atrio-ventricular valve regurgitation remains the most common residual defect and significantly associated with re-intervention.

Imaging of an Atypical Pericardial Cyst

Pericardial cysts are uncommon mediastinal lesions that are usually congenital in origin. Patients are usually asymptomatic and the cysts are generally discovered on routine radiography for unrelated purposes. This case illustrates a symptomatic presentation of a haemorrhagic pericardial cyst in which radiographic, echocardiographic and multislice (MRI and CT) imaging were performed. The imaging findings were not typical of pericardial cysts leading to a diagnostic quandary despite the varied imaging techniques. In conclusion, it is important to appreciate that the imaging findings of pericardial cysts can be varied. Radiologists and clinicians alike should be aware of this variability.

A Flowmeter Technique to Exclude Internal Mammary Artery Anastomosis Error in an Arrested Heart

The revision of an internal mammary artery graft anastomosis because of a technical error can be time-consuming and complicated and may lead to complications. Here, we describe the technical details and our early experience of using a standard transit-time flowmeter to exclude technical errors and facilitate rapid decision making for anastomosis revision in an arrested heart during aortic cross-clamping in the absence of ultrasound guidance.

Catalytic microwave pyrolysis of oil palm fiber (OPF) for the biochar production

Microwave pyrolysis of oil palm fiber (OPF) with three types of Na-based catalysts was experimentally investigated to produce biochar. Sodium hydroxide (NaOH), sodium chloride (NaCl), and sodium carbonate (Na2CO3) with purity 99.9% were selected for this investigation. Microwave muffle reactor (Model: HAMiab-C1500) with a microwave power controller including a microwave generator was used to perform the microwave pyrolysis. OPF particles were used after removing foreign materials, impurities, and dust. Microwave power ranges from 400 to 900xa0W, temperature ranges from 450 to 700xa0°C, and N2 flow rates ranges from 200 to -1200xa0cm3/min were used along with all three Na-based catalysts for this investigation. Lower microwave power, temperature, and N2 flow rate have been found favorable for higher yield of biochar. NaOH is to be found as the more suitable catalyst than NaCl and Na2CO3 to produce biochar. A maximum biochar yield (51.42xa0wt%) has been found by using the catalysts NaOH at N2 flow rate of 200xa0cm3/min. One sample of the biochar (maximum yield without catalysts) was selected for further characterization via thermo gravimetric analysis (TGA), scanning electron microscopy (SEM), BET surface area, Fourier transform infrared spectroscopy (FTIR), and ultimate and proximate analysis. SEM and BET surface area analysis showed the presence of some pores in the biochar. High percentage of carbon (60.24xa0wt%) was also recorded in the sample biochar. The pores and high percentage of carbon of biochar have significant impact on soil fertilization by increasing the carbon sequestration in the soil. It assists to slow down the decomposition rate of nutrients from soil and therefore enhances the soil quality.

Strategy for ventricular septal defect closure after prior gastric pull-through

A 9-year-old boy was referred with a perimembranous ventricular septal defect. At birth, he had undergone a right thoracotomy with ligation of a tracheoesophageal fistula, cervical esophagostomy, and feeding gastrostomy. At 2 years of age, he had gastric tube reconstruction with a pull-through retrosternally, anterior to the heart, and an end-to-end esophagogastric anastomosis. Via a right anterolateral thoracotomy through the previous scar, the entire gastric tube was mobilized away from the sternum to facilitate a median sternotomy. With the patient supine, a median sternotomy was performed without difficulty, and the ventricular septal defect was closed under cardiopulmonary bypass.

Cavopulmonary anastomosis without concomitant valvoplasty in patients with single ventricle physiology

BackgroundAtrioventricular Valve Regurgitation (AVVR) is a risk factor for increased mortality in patients with single ventricular physiology. We postulate that by offloading the blood volume from the single ventricle, AVVR would improve without valvuloplasty.ObjectiveWe aimed to determine risk factors associated with AVVR and whether a Bidirectional Cavopulmonary Anastomosis (BCPA) alone would improve AVVR without valvuloplasty in our cohort of patients.Material and methodsA retrospective review of 213 consecutive patients who underwent BCPA between January 2000 to August 2010 was conducted. Eighty patients with AVVR without valvuloplasty were analyzed. Eighty-nine patients required palliation prior to the BCPA. The median age and weight at surgery were 3xa0years +/−4.4 and 11.2xa0kg +/−11.4 respectively. 2D Echocardiography was used to quantify the degree of AVVR pre and postoperatively. Significant (moderate and severe) AVVR before BCPA was noted in 29 out of 213 patients (13.6xa0%). The risk factors associated with AVVR i.e. type of cardiac diagnosis, systemic ventricle, palliation prior to BCPA and age at BCPA were analyzed.Result and conclusionThe overall mortality was 5.2xa0%. The operative mortality was significantly lower in patients operated between 2006 and 2010 as compared to between 2000 and 2005 (0.9xa0% versus 7.1xa0%) (pu2009=u20090.024). AVVR was significantly higher in patients who had right ventricle as systemic ventricle (pu2009=u20090.032) and unbalanced atrioventricular canal (pu2009<u20090.05). In the immediate postoperative period, presence of moderate AVVR improved (pu2009<u20090.05) from 21.3 to 8.8xa0%. However at mean follow up of 3.7+/−2.8xa0years, 12.5xa0% patients presented with moderate AVVR. In conclusion, the BCPA significantly offloaded the single ventricle and improved AVVR in patients with moderate regurgitation. However, improvement did not sustain at longer duration of follow up.

Early postoperative hemodynamics and clinical outcomes of patients receiving freedom solo aortic calve replacement; the Asian Experience

Aim: Freedom SOLO (FS) valve (Sorin Group, Saluggia, Italy) is a stentless aortic valve bioprosthesis that use a single running suture line implanted in supra-annular position. Current study aims to assess the early postoperative hemodynamics and clinical outcomes of patients receiving FS aortic valve replacement (AVR). Methodology: 4 patients (2 male; 2 female; mean age 49.25 ± 23.78 years; range: from 25 to 73) who underwent AVR with FS valve in a single center were enrolled in the study. 2 patients underwent AVR for aortic stenosis and 2 patients for aortic regurgitation. Clinical and biological outcomes were recorded. Echocardiographic parameters were compared between preoperative and 5 months postoperative observation. Results: There was no early mortality reported. Late death was reported in one patient which was non valve related. There were 2 patients who developed early postoperative complication but it was not attributed to the valve itself. The mean transvalvular pressure gradient was 26.50 ± 11.90 mmHg preoperatively and 15.25 ± 10.11 mmHg postoperatively. The mean aortic valve area (AVA) for patients having stenosis improved from 0.74 ± 0.23 cm2 preoperatively to 1.50 ± 0.57 cm2 postoperatively. Preoperatively, the mean left ventricular ejection fraction (LVEF) was 65.75 ± 6.29 % and postoperatively 61.25+_11.84 %. The mean cross-clamp time (CCT) for isolated valve replacement was 80.5 ± 21.92 minutes and 147.00 ± 26.87 minutes. The mean lowest postoperative platelet count recorded was 24.50 ± 6.19 (x109/L). The mean platelet count at discharge was 128.75 ±10.11 (x109/L). Conclusion: The result demonstrated good short-term clinical and hemodynamic outcomes in patients underwent FS aortic valve replacement. However, the study also showed the occurrence of severe thrombocytopenia after FS valve implantation.