Velayoudham Devagourou

Light and electron microscopic features of surgically excised left atrial appendage in rheumatic heart disease patients with atrial fibrillation and sinus rhythm

INTRODUCTION There are few studies comparing the pathology of the remodeled substrate in patients of rheumatic heart disease with atrial fibrillation (AF) and normal sinus rhythm (NSR). METHODS The study group comprised 30 patients with rheumatic heart disease undergoing mitral valve replacement. Excised left atrial appendages of these patients [17 with persistent AF and 13 NSR (control group)] were subjected to light and electron microscopic examination. RESULTS The histopathological findings of the myocardium were characterized by cardiomyocyte hypertrophy (CH), nuclear enlargement (NE), perinuclear clearing (PC), sarcoplasmic vacuolation (SV), fibrosis, and inflammation in the patients with AF and NSR. NE (17/17 vs. 4/13; P=.004), PC (17/17 vs. 4/13; P=.004), SV (17/17 vs. 9/13; P=.06), and fibrosis (15/17 vs. 3/13; P=.001) were all significantly more common in patients with AF. Inflammatory cells were observed in 9/17 patients of AF as compared to 1 in NSR patients (9/17 vs. 1/13; P=.02). CH was common in the patients with AF as compared with those in NSR (17/17 vs. 10/13; P=.103). In AF patients, electron microscopy revealed cardiomyocytes with depletion of the contractile elements (Z-bands), glycogen particle accumulation, and an increase in mitochondria. Cells severely affected by AF showed loss of contractile elements with extensive areas of SV, presence of myelin figures, and mitochondrial aggregates. Majority of AF cases showed extensive fibrosis in the form of collagen bundles in the interstitium. CONCLUSION The left atrial substrate in AF as compared with NSR, in rheumatic heart disease patients, is associated with significant degenerative remodeling and ongoing inflammation that is associated with extensive fibrosis.

Right atrial myxoma with glandular differentiation: A rare entity in pediatric age group

Cardiac myxomas (CMs) account for nearly half of the primary cardiac tumors in the elderly. They arise from sub-endocardial “reserve” or lepidic” cells, which may show divergent differentiation. We describe a CM with glandular differentiation in the right atrium of a 10-year-old child who presented with respiratory distress on exertion, of 2 months duration. On echocardiography, two large interconnected masses measuring 34×30 mm and 20×17 mm were seen to arise from the free wall of the right atrium. Cut surface of the excised mass was myxoid with areas of calcification. On microscopy, there were typical features of a myxoma with prominent glandular differentiation and characteristic immunophenotype. The case is being reported due to its rarity in pediatric age group as well as its glandular differentiation, which must be recognized as a spectrum of histomorphologic diversity and must not be mistaken for a metastatic adenocarcinoma.

Modified Blalock Taussig shunt: Comparison between neonates, infants and older children

OBJECTIVE The aim was to compare various pre-and post-operative parameters and to identify the predictors of mortality in neonates, infants, and older children undergoing Modified Blalock Taussig shunt (MBTS). MATERIALS AND METHODS Medical records of 134 children who underwent MBTS over a period of 2 years through thoracotomy were reviewed. Children were divided into three groups-neonates, infants, and older children. For analysis, various pre-and post-operative variables were recorded, including complications and mortality. RESULTS The increase in PaO 2 and SaO 2 levels after surgery was similar and statistically significant in all the three groups. The requirement of adrenaline, duration of ventilation and mortality was significantly higher in neonates. The overall mortality and infant mortality was 4.5% and 8%, respectively. CONCLUSION Neonates are at increased risk of complications and mortality compared with older children. Age (<30 days), weight (<3 kg), packed red blood cells transfusion >6 ml/kg, mechanical ventilation >24 h and post shunt increase in PaO 2 (P Diff) <25% of baseline PaO 2 are independent predictors of mortality in children undergoing MBTS.

Idiopathic left ventricular outflow tract pseudoaneurysm

Left ventricular outflow tract (LVOT) pseudoaneurysm is a rare occurrence and may produce clinically unpredictable symptoms. A very few cases of LVOT pseudoaneurysm are reported and there has always been a predisposing factor in these reported cases such as history of infective endocarditis, myocardial infarction, prosthetic aortic valve replacement or chest trauma. Our patient did not have the above predisposing conditions. Intra operative transesophageal echocardiography helped patient management and guided the surgical team in securing and isolation of the aneurysmal sac from the LVOT.

Complete Transposition of Great Arteries with Cor Triatriatum: An Unusual Coexistence

The combination of complete transposition of the great arteries and cor triatriatum is extremely rare. We report three infants with this rare combination and discuss the anatomic details apparently unique to the combined lesion.

An Alternative Technique for Rechanneling of Sinus Venosus Atrial Septal Defect With Partial Anomalous Pulmonary Venous Connection Using Autogenous Right Atrial Appendage

We report a new technique for closure of sinus venosus atrial septal defect with high partial anomalous pulmonary venous connection. This technique consisted of preservation of the atriocaval junction, advancement of the posterior rim of the atrial septal defect anterosuperiorly and enlargement of the superior caval vein using right atrial appendage. We found this to be a convenient technique and recommend it for correction of this anomaly.

Pulmonary vein stenosis in a child with ventricular septal defect.

A 1-year-old boy presented with a history of recurrent episodes of upper respiratory tract infection since birth. On the basis of clinical examination, electrocardiography and transthoracic echocardiography, he was diagnosed with perimembranous ventricular septal defect and severe pulmonary hypertension. Intraoperatively, a large perimembranous ventricular septal defect of 12.5mm was seen on transesophageal Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(9) 1130–1131 The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313513600 aan.sagepub.com

Randomized Study Comparing Pre-Operative Glycemic Profile in Pediatric Cardiac Surgical Patients Administered Oral Carbohydrate Solution Preoperatively versus Those Kept Fasting

Objectives: Hypoglycemia is a recognized danger in pediatric patients. Extended period of preoperative fasting in this subset of patients is not well tolerated with metabolic derangements. The oral carbohydrate loading preoperatively can ameliorate many adverse effects. The aim of this study was to compare the glycemic profile in pediatric cardiac surgical patients kept fasting preoperatively with those fed oral clear solutions of carbohydrate half hour prior to induction of anaesthesia. Also we tried to establish a correlation with other factors contributing to preoperative hypoglycemia. Methodology: We planned a randomized controlled study. Group A included patients who were kept fasting according to the ASA guidelines preoperatively and Group B included patients who received 2 ml per kg of body weight of 10% Dextrose water as oral feeds half hour before the expected time of start of anaesthesia. Results: The mean (SD) preoperative BG concentrations were higher in group B (102.5 ±16.97) as compared to group A (64.08 ± 25.37) (p value -0.86 and -0.67) (pvalue Conclusion: Preoperative oral carbohydrate preloading can develop as the easiest and cheapest path to better perioperative blood glucose concentration management in congenital cardiac disease children.

High blood tacrolimus and hyperkalemia in a heart transplant patient

© 2017 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer Medknow The Editor, A 43‐year‐old female patient (weight 54 kg) underwent orthotopic heart transplantation (OHT) for dilated cardiomyopathy. Postoperative recovery was uneventful and her left ventricle (LV) function was 60% on two‐dimensional echocardiography at the time of discharge. She was on immune suppressive therapy with tacrolimus 2 mg/twice daily, mycophenolate mofetil 500 mg/twice daily, and prednisolone 20 mg/twice daily. The other medications were trimethoprim/sulfamethoxazole (80/400)/once daily, voriconazole 200 mg/twice daily, valganciclovir 450 mg/twice daily, insulin, and frusemide 40 mg/once daily. She was readmitted on 68th postoperative day with type 1 respiratory failure. Prophylactic broad spectrum antibiotics (meropenem 1 g/intravenous [iv]/thrice daily and teicoplanin 400 mg/iv/once daily) were started, in addition to the above prophylaxis, after sending blood, urine, and sputum cultures. A complete hemogram, serum electrolytes, kidney function tests, liver function tests, and tacrolimus level were done. She was managed conservatively with noninvasive ventilation, dieresis (injection frusemide 20 mg/iv/twice daily), and bronchodilation (ipratropium bromide and asthalin nebulization/four times daily). Klebsiella pneumonae was isolated on sputum culture, and therapy was initiated with colistin (10 lac IU/iv/thrice daily). Echocardiography showed good LV function (50%) and mild right ventricle dysfunction. Other hematological investigations were unremarkable except for hyperkalemia (Na+ = 128 meq/L, K+ = 6.7). Twice repeated tests also yielded high K+ 7.2 meq/L and 6.9 meq/L. Repeat blood urea nitrogen and creatinine were also normal (45 mg% and 1.0 mg/dl). Electrocardiogram did not show any sign of hyperkalemia. Tacrolimus level was 21.3 ng/dl much higher than the earlier report (10 days before) of 12.3 ng/dl. Tacrolimus was withheld, and treatment started for hyperkalemia with oral sodium polystyrene sulfonate, intravenous frusemide, calcium gluconate, sodium bicarbonate, and glucose‐insulin infusion. Serum potassium (K+) level decreased only up to 6.2 after 48 h [Figure 1]. On 3rd day, oral fludrocortisone 0.1 mg/day was added. On 4th day, the K+ levels came within normal limits and blood tacrolimus levels decreased to 12.7 ng/dl. On 5th day, the serum K+ decreased to 4.5 and fludrocortisone was continued for another 2 days. Tacrolimus was restarted at 1 mg/twice daily; other medications were continued. Sodium and potassium were monitored twice daily for the next 7 days and both remained within normal limits [Figures 1 and 2]. High Blood Tacrolimus and Hyperkalemia in a Heart Transplant Patient Letter to Editor ACA_175_16R2

Sutureless left pulmonary vein augmentation for primary endoluminal pulmonary vein ostial stenosis: role of pulmonary venous Doppler.

Primary PV stenosis results from an abnormal incorporation of the common PV into the left atrium. On echocardiography, it may appear as a discrete shelf, long narrow segment or as a diffuse hypoplasia of the PVs resulting in pulmonary venous hypertension secondary to an impeded pulmonary venous drainage. [2] Seen almost exclusively in young children; it is highly associated with other cardiac defects, primarily septal defects, making it imperative that echocardiographic evaluation of patients with pulmonary hypertension specifically include pulmonary venous profiling. In the sutureless marsupialization technique, any direct stitches over the cut edges of the PVs are avoided as the pericardium around the PVs is directly attached to the left atrium. According to a limited literature, an unimpeded pulmonary venous drainage is best achieved using this technique in comparison to the previous techniques that have used direct anastomosis after resection of stenotic segments or patching of the stenotic veins.[3,4] An 11-month-old girl presented with complaints of recurrent episodes of upper respiratory tract infection since birth. Transthoracic echocardiography revealed a large ostium secundum atrial septal defect (ASD), small subaortic ventricular septal defect and left superior and inferior pulmonary vein (PV) ostial stenosis. Computed tomography angiography was done to confirm the findings, and the child were subsequently planned for closure of septal defects and sutureless leftsided pulmonary venous augmentation.