Vijay Grover

When should you restart anticoagulation in patients who suffer an intracranial bleed who also have a prosthetic valve

A best evidence topic in cardiac surgery was written according to the structured protocol. The question addressed was about the best time to restart anticoagulation in patients with intracranial bleed with a prosthetic valve in situ. This difficult clinical decision has to balance the risk of thromboembolism during the period that the anticoagulation was reversed and later withheld vs the risk of haematoma expansion or rebleed if the anticoagulation was started early. Altogether, more than 80 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. There were two prospective studies and eight retrospective studies. There were no randomized controlled trials on this topic. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Seven studies reported the strategy of reversal of anticoagulation with vitamin K, fresh frozen plasma or prothrombin concentrate. The emphasis was on prompt initial reversal of anticoagulation; however, the best agent for reversal was not defined. Four studies dealt exclusively with intracranial bleed in patients with prosthetic valve in situ. The remaining six studies on intracranial bleed had only a subset of patients with a prosthetic valve in situ. The anticoagulation was restarted with heparin and later switched to oral anticoagulant. Thromboembolic events during the period of reversal and cessation of anticoagulants were low (5%) as was the incidence of rebleed or haematoma expansion (0.5%). We conclude that anticoagulation can safely be withheld for a short period, up to 7-14 days in a patient with intracranial bleed with a very low probability of thromboembolic phenomenon. In patients with prosthetic valves, in situ anticoagulation in the form of heparin can safely be restarted as early as 3 days and switched to oral anticoagulation in the form of warfarin at 7 days without major concerns of bleeding.

Inferior vena caval and right atrial thrombus complicating amoebic liver abscess

We present the result of right atrial thrombectomy in a paediatric patient suffering from a right atrial thrombus due to amoebic liver abscess under total circulatory arrest. A 2-year old boy with amoebic liver abscess complicated by inferior vena cava (IVC) thrombus extending up to the right atrium (RA) was operated on in our institute. During the surgery, the thrombus was removed from the IVC and the RA under deep hypothermic circulatory arrest. After chest closure, open drainage of the abscess was performed. Metronidazole was given postoperatively for 2 weeks. The postoperative period was uneventful. There was rapid convalescence with complete resolution of the abscess. Anticoagulation with warfarin was started on the day following surgery and continued for 6 weeks. There was no recurrence of thrombosis or embolic events in the follow-up period. Extension of thrombus into the right atrium mandates an aggressive surgical approach which may prove life saving. It is crucial in the prevention of pulmonary embolism or Budd-Chiari syndrome, which may have an overall poor outcome.

Inferior vena cava thrombosis in a pediatric patient of amebic liver abscess

Amebic liver abscess (ALA) in pediatric age group is rare. We describe a successful thrombectomy and open drainage of a large left lobe ALA associated with thrombus in the hepatic veins and inferior vena cava extending into the right atrium in a 6-year-old boy.

A unique case of right cervical aortic arch with anomalous left common carotid artery and absent right common carotid artery.

Introduction Cervical aortic arch is a rare anomaly where-in the ascending aorta arises normally from the left ventricle and extends in such a fashion that the aortic arch is situated high in the neck on either side. This anomaly should be suspected in any child exhibiting a pulsatile swelling in the neck. Case commentary An 8 year old child presented with a pulsatile swelling on the right side of the neck since birth. CT angiography revealed right sided cervical aortic arch at C4-C5 level. The left common carotid artery arose from the ascending aorta at D4 with the right external and internal carotid arteries originating separately from the cervical arch. The right and left subclavian arteries arose from the descending aorta at D1 and D4 respectively. Discussion Although most patients with cervical aortic arch are asymptomatic, some have dysphagia from oesophageal compression and respiratory distress from tracheal compression. There are many anatomical variations in cervical aortic arch as mentioned by Haughton. This case is Haughton type A because apart from the presence of right cervical aortic arch, 2 additional oddities in the form of leftward descending aorta and abnormal origin of the left common carotid artery from ascending aorta with absence of right common carotid artery are noted. Conclusion Cervical aortic arch is not a very commonly encountered entity and can be quite vexing for those who are seeing such a case in OPD for the first time. Although cervical aortic arch anomalies have been reported in literature, published reports of new cases will help to increase awareness regarding this anomaly and lead to a swift and efficient diagnosis and management.

Left-sided approach for mitral valve replacement in a case of dextrocardia with situs solitus

Mitral valve surgery in dextrocardia is technically challenging due to its anatomical malposition. Minor modifications are required in the surgical technique to counteract the problems during cannulation and exposure of the mitral valve. We report a case of a patient with dextrocardia, situs solitus, rheumatic heart disease, severe mitral regurgitation, moderate pulmonary artery hypertension, and severe left ventricular dysfunction who underwent mitral valve replacement using a two-stage right atrial cannulation with left-sided left atrial atriotomy, with the surgeon standing on the left side of the patient. Our approach for mitral valve surgery in this clinical setting is simple.

Left atrial appendage myxoma masquerading as left atrial appendage thrombus.

Myxomas are the most common benign tumors of the heart. They can arise from any heart chamber, but have rarely been described as originating from the left atrial appendage. We describe a case of left atrial appendage myxoma mimicking a left atrial appendage thrombus, and presenting with microembolization to the coronaries.

Spontaneous pneumomediastinum: A complication of swine flu.

The occurrence of spontaneous pneumomediastinum in swine flu, or H1N1 influenza A infection, is a rare phenomenon and only few cases have been reported in children. We describe a case of spontaneous pneumomediastinum in adult infected with swine flu.

Mitral Valve Replacement in a Young Pregnant Woman: A Case Report and Review of Literature

Introduction: Cardiac diseases occur in 2-4% of pregnancies and rheumatic mitral disease is the most common acquired heart disease in pregnancy. Cardiac surgery carries significant maternal and fetal complications. Cardiac operation during pregnancy is indicated only when medical management fails. Although emergency cardiac surgery during pregnancy increases fetal mortality, sometime urgent cardiac surgery is inevitable. Cardiac surgery can be performed with relative safety during pregnancy by adopting normothermic, high flow rate circulation and continuous fetal activity monitoring. Case Presentation: We reviewed English literature of a pregnant patient undergoing cardiac surgery during pregnancy. We presented a 25-year-old woman admitted with massive hemoptysis. Discussion: The patient underwent a successful mitral valve replacement during the third trimester. The aim of our study was to propose a practical guideline for similar situations.

Cervical sympathetic chain schwannoma presenting as a carotid body tumor

Nerve sheath tumours arising from the sympathetic chain are extremely rare and are a diagnostic challenge. Schwannomas are benign nerve sheath tumours deriving from Schwann cells that occur in the head and neck region in 25-45% of cases. Cervical lesions originate from spinal nerves, the last four cranial nerve roots, or occasionally from the sympathetic chain. Carotid body tumour (CBT), the most common tumour of the carotid bifurcation, presents as a pulsatile mass. Cervical sympathetic chain (CSC) schwannomas are slow growing lesions and may appear pulsatile due to the displacement of vascular structures by the non-vascular mass and thus may mimic a CBT. We here in discuss a case of 22year old female, who underwent surgical resection of a mass at carotid bifurcation, presuming a CBT, but postoperative histopathological examination revealed it a schwannoma.

Persistent left superior vena cava with absent right superior vena cava-an incidental intraoperative finding

Persistent Left Superior Vena Cava (PLSVC) is a rare venous abnormality. However, it is the most common congenital anomaly of thoracic venous system with a frequency of less than 0.5 % of the general population and up to 10 % of patients with congenital heart disease [1]. In most of such cases, associated right SVC is present. Very rarely right SVC may be absent and this condition is called as Isolated PLSVC. In these cases a persistent left SVC is the sole channel to drains the venous blood of both upper extremities and the head into the heart. Valvular heart disease with absent Right Superior Vena Cava (RSVC) and PLSVC is a very rare condition. We hereby describe this anomaly, which was incidently diagnosed intraoperatively.