South African flag sign to a giant coronary artery aneurysm

Background

Coronary arteritis leading to aneurysm is one of the unusual presentations of IgG4-related disease. Acute myocardial infarction as a complication of IgG4-related giant coronary artery aneurysm is even rarer.

Case summary

We describe the case of a 56-year-old gentleman who presented to our institute with Canadian Cardiovascular Society (CCS) class III angina. His symptoms were persistent even with high-dose antianginal medications. He had an acute coronary syndrome two weeks back for which he was treated conservatively in a peripheral health centre. His 12-lead electrocardiogram at the time of the event was suggestive of high lateral ST-segment elevation myocardial infarction (South African flag sign). His transthoracic echocardiography showed mild left ventricular dysfunction and a large echogenic mass lateral to the left ventricle. Coronary angiography followed by cardiac computed tomography revealed a giant pseudoaneurysm of the proximal and mid-left anterior descending coronary artery. FDG-PET scan showed significant metabolic activity in the aneurysm wall and mediastinal lymph nodes suggesting active inflammation. IgG4-related coronary arteritis was suspected, and the patient underwent aneurysmectomy and coronary artery bypass (CABG) surgery. The histopathology of the resected segment showed diffuse IgG4-secreting plasma cells confirming the diagnosis.

Discussion

Atherosclerosis is the most common cause of coronary aneurysms in adults. However, cardiologists should be aware of atypical causes like IgG4-related disease that can even present with acute coronary syndrome. Although multimodality imaging is beneficial during early evaluation, histopathological analysis is the cornerstone for the diagnosis of IgG4-related disease. The management involves both immunosuppressive medication and endovascular or surgical repair.

Concomitant Transthyretin Amyloidosis and Severe Aortic Stenosis in Elderly Indian Population: A Pilot Study

BACKGROUND

Prevalence of both degenerative severe aortic stenosis (AS) and transthyretin cardiac amyloidosis (ATTR-CA) increases with age. Dual disease (AS+myocardial ATTR-CA) occurs in significant proportion of patients undergoing surgical aortic valve replacement (SAVR).

OBJECTIVES

This study aimed to determine the prevalence of ATTR-CA in severe AS in the Indian population, identify noninvasive predictors of its diagnosis, and understand its impact on prognosis.

METHODS

Symptomatic severe AS patients aged ≥65 years undergoing SAVR were enrolled. ATTR-CA diagnosis was based on preoperative 99m-technetium pyrophosphate (PYP) scan and intraoperatively obtained basal interventricular septum biopsy for myocardial ATTR-CA, and excised native aortic valve for isolated valvular ATTR-CA. Primary amyloidosis was excluded by serum/urine protein electrophoresis with serum immunofixation.

RESULTS

SAVR was performed in 46 AS patients (age 70 ± 5 years, 70% men). PYP scan was performed for 32 patients, with significant PYP uptake in 3 (n = 3 of 32, 9.4%), suggestive of myocardial ATTR-CA. On histopathological examination, none of the interventricular septum biopsy specimens had amyloid deposits, whereas 33 (71.7%) native aortic valves showed amyloid deposits, of which 19 (57.6%) had transthyretin deposition suggestive of isolated valvular amyloidosis. Noninvasive markers of dual disease included low myocardial contraction fraction (median [interquartile range], 28.8% [23.8% to 39.1%] vs 15.3% [9.3% to 16.1%]; P = 0.006), deceleration time (215 [144 to 236] ms vs 88 [60 to 106] ms; P = 0.009) and global longitudinal strain (-18.7% [-21.1% to -16.9%] vs -14.2% [-17.0% to -9.7%]; P = 0.030). At 1-year follow-up, 2 patients died (4.3%); 1 each in myocardial ATTR-CA negative and positive groups (3.4% vs 33.3%; P = 0.477).

CONCLUSIONS

Dual disease is not uncommon in India. Isolated valvular amyloidosis in severe AS is much more common.

Feasibility and Utility of Adenosine Stress Echocardiography in Children Following Post-Arterial Switch Operation: A Comparison with Technetium 99m-Sestamibi Myocardial Perfusion SPECT (MPS)

There is a need for a sensitive, safe, and cost-effective tool for coronary assessment among asymptomatic post-operative children who have undergone arterial switch operation (ASO) for transposition of great arteries (TGA). Adenosine stress echocardiography may be useful in assessing major structures as well for coronary functional assessment. Twenty-six children [median age 6.0 years; IQR 4.9-7.1 years, (22 boys)], who had undergone ASO at a median age of 40 days (IQR 30-75 days), were prospectively included. Left ventricular ejection fraction (LVEF) was calculated in both rest and stress studies (140 µg/kg/min of adenosine IV over 4 min), along with assessment of regional myocardial wall motion. Coronary flow reserve (CFR) was also measured in the left anterior descending artery (LAD). Technetium 99m-MIBI [0.2mCi/kg] was injected after 2 min of adenosine infusion. Adenosine infusion had to be stopped in two children, due to transient atrioventricular (AV) block. The LVEF increased from 55.87 ± 7.27 to 61.20 ± 7.70% (p  < 0.001) with adenosine stress. No significant regional wall motion abnormality was seen in rest or stress. Distal LAD could not be visualized in four patients. Basal and peak coronary flow velocities were 41.51 ± 14.12 and 74.18 ± 6.01 cm/s. Mean CFR was 1.91 ± 0.51. Myocardial perfusion scintigraphy (MPS) was normal in all the patients. Four patients were lost to follow-up and remaining children did not develop any adverse events in the follow-up period of 64.5 ± 7.19 months. Adenosine stress echocardiography is feasible as the initial screening test in the assessment of asymptomatic post-operative children with ASO, at minimal to no inconvenience to the patient. The findings concurred with stress MPS.

Masson's Hemangioma Mimicking As Leaking Aortic Pseudoaneurysm: An Extremely Rare Presentation

Intravascular papillary endothelial hyperplasia or Masson's tumor is a rare reactive disease of vascular origin characterized by exuberant proliferation of endothelial cells. Its importance lies in its ability to mimic a variety of diseases, both benign and malignant. Here, we present a unique case of Masson's tumor arising from the abdominal supraceliac aorta in a 32-year-old man initially misdiagnosed as leaking aortic pseudoaneurysm.

Use of autologous umbilical cord blood transfusion in neonates undergoing surgical correction of congenital cardiac defects: A pilot study

Background

Blood transfusion requirement during neonatal open heart surgeries is universal. Homologous blood transfusion (HBT) in pediatric cardiac surgery is used most commonly for priming of cardiopulmonary bypass (CPB) system and for postoperative transfusion. To avoid the risks associated with HBT in neonates undergoing cardiac surgery, use of autologous umbilical cord blood (AUCB) transfusion has been described. We present our experience with the use of AUCB for neonatal cardiac surgery.

Designs and Methods

Consecutive neonates scheduled to undergo cardiac surgery for various cardiac diseases who had a prenatal diagnosis made on the basis of a fetal echocardiography were included in this prospective observational study. After a vaginal delivery or a cesarean section, UCB was collected from the placenta in a 150-mL bag containing 5 mL of citrate-phosphate-dextrose-adenine-1 solution. The collected bag with 70-75 mL cord blood was stored at 2°C-6°C and tested for blood grouping and infections after proper labeling. The neonate's autologous cord blood was used for postcardiac surgery blood transfusion to replace postoperative blood loss.

Results

AUCB has been used so far at our institute in 10 neonates undergoing cardiac surgery. The donor exposure in age and type of cardiac surgery-matched controls showed that the neonates not receiving autologous cord blood had a donor exposure to 5 donors (2 packed red blood cells [PRBCs], including 1 for CPB prime and 1 for postoperative loss, 1 fresh frozen plasma, 1 cryoprecipitate, and 1 platelet concentrate) compared to 1 donor for the AUCB neonate (1 PRBC for the CPB prime). Postoperative blood loss was similar in both the groups of matched controls and study group. Values of hemoglobin, total leukocyte count, platelet counts, and blood gas parameters were also similar.

Conclusions

Use of AUCB for replacement of postoperative blood loss after neonatal cardiac surgery is feasible and reduces donor exposure to the neonate. Its use, however, requires a prenatal diagnosis of a cardiac defect by fetal echo and adequate logistic and psychological support from involved clinicians and the blood bank.

Benevolent Renal Angiomyolipoma with Intra-cardiac Extension-A Challenge in Diagnosis and Management

While intra-caval and intra-cardiac extension of retroperitoneal tumors is extremely rare, it is almost unheard-of in benign tumors. We report the challenges in diagnosis and management of the first case of a renal angiomyolipoma (AML) with intra-ventricular extension in a young man who presented with pain and a lump in the abdomen.

Surgical Repair of Congenital Abdominal Aortic Aneurysm in a 1-year-old Child with Literature Review

Reported here is a case of 1-year-old male child who presented with huge abdominal mass, which on radiological investigation was diagnosed as retroperitoneal pseudoaneurysm of the aorta. On exploration, it was found to be a true aneurysm of infrarenal abdominal aorta with inflow agenesis. Aneurysm was excised, and aorta was reconstructed with 10 mm Dacron graft. Postoperative computed tomography angiography showed patent graft with good distal runoff. Literature review revealed that only 26 cases of congenital abdominal aortic aneurysm had been reported so far. None of them had inflow agenesis which can give false impression of pseudoaneurysm on preoperative evaluation. The case highlights the utility of additional complimentary investigations such as Doppler study in clinching diagnosis and helping plan and execute successful treatment in the difficult diagnostic scenario.

Lactate clearance for initiating and weaning off extracorporeal membrane oxygenation in a child with regressed left ventricle after arterial switch operation

We hereby report a child with transposition of great arteries and regressed ventricle who underwent arterial switch operation (ASO) with the aid of cardiopulmonary bypass and “integrated” extracorporeal membrane oxygenation (ECMO) circuit. The significance of lactate clearance as a guide to initiate and terminate veno-arterial ECMO in a post ASO child with regressed left ventricle is discussed.

Prevalence of carotid artery stenosis in neurologically asymptomatic patients undergoing coronary artery bypass grafting for coronary artery disease: Role of anesthesiologist in preoperative assessment and intraoperative management

Objective(s):

This study aimed to determine the prevalence of carotid artery stenosis (CAS) due to atherosclerosis in neurologically asymptomatic patients undergoing coronary artery bypass grafting (CABG) for coronary artery disease (CAD). It contemplated a greater role for the cardiac anesthesiologist in the perioperative management of such patients with either previously undiagnosed carotid artery disease or towards re-assessment of severity of CAS.

Design:

Prospective, observational clinical study.

Setting:

Operation room of a cardiac surgery centre of a tertiary teaching hospital.

Participants:

A hundred adult patients with New York Heart Association (NYHA) classification I to III presenting electively for CABG.

Interventions:

All patients included in this study were subjected to ultrasonic examination by means of acarotid doppler scan to access for presence of CAS just prior to induction of general anesthesia.

Measurements and Main Results:

Based on parameters measured using carotid doppler, the presence of CAS was defined using standard criteria. The prevalence of CAS was found to be as high as 38% amongst the patients included in our study. The risk factors for CAS were identified to be advanced age, history of smoking, diabetes mellitus, dyslipidaemia and presence of a carotid bruit.

Conclusion:

This study points towards the relatively wide prevalence of carotid artery disease in neurologically asymptomatic patients undergoing CABG for CAD in the elective setting. It highlights the need to routinely incorporate carotid ultrasonography in the armamentarium of the cardiac anesthesiologist as standard of care for all patients presenting for CABG.

Dosage of Epsilon-Aminocaproic Acid to Reduce Postoperative Blood Loss

Postoperative blood loss, blood and blood-product requirements, and complications were compared for 3 commonly used doses of epsilon-aminocaproic acid in 150 patients undergoing first-time coronary artery bypass surgery. The patients were randomly assigned to one of 4 groups. Group 1 (n = 30) served as a control, group 2 (n = 30) received a single dose of 150 mg·kg−1 of epsilon-aminocaproic acid after anesthetic induction, group 3 (n = 30) received a loading dose of 150 mg·kg−1 followed by infusion of 1 g·h−1 for 6 hours, and group 4 (n = 60) received doses of 150 mg·kg−1 at induction, on bypass, and after protamine. No patients, including those who had endarterectomies, experienced any complications attributable to epsilon-aminocaproic acid administration. All patients who received epsilon-aminocaproic acid had significantly less bleeding compared to controls. Groups 3 and 4 had the least blood loss and packed-cell requirements.

Use of dexmedetomidine as an adjunct in the treatment of paradoxical hypertension after surgical repair of coarctation of the aorta in infants

Severe persistent hypertension is seen infrequently in newborns and infants, but we came across two infants who developed severe paradoxical hypertension after successful coarctation repair. Treatment of systemic hypertension following repair of coarctation of the aorta is always challenging particularly in infants. Dexmedetomidine was used successfully as an adjunct to the established anti-hypertensive drugs in the immediate postoperative period in our cases to treat postoperative paradoxical hypertension.

Abernethy syndrome, a rare cause of hypoxemia: A case report

Abernethy syndrome (congenital extrahepatic portosystemic shunt (CEPS II)) as an etiology of hepatopulmonary syndrome (HPS) is uncommon. The severe hypoxemia and its consequences become incapacitating for the patient. Early shunt closure resolves hypoxemia and clinical symptomatology and prevents irreversible changes in pulmonary vasculature.

Midterm outcome of primary arterial switch operation beyond six weeks of life in children with transposition of great arteries and intact ventricular septum

BACKGROUND

We have previously reported our experience in primary arterial switch operation (ASO) in children more than six weeks with transposition of great arteries and intact ventricular septum (TGA/IVS). The upper age limit for performing an ASO in these children is not yet settled and reports regarding outcome of ASO in these children are few. In this prospective observational study, we report the midterm results of children with TGA-IVS older than six weeks undergoing primary ASO.

METHODS

A total of 109 children aged more than 6 weeks with median age of 60 days (range 42-3,000 days), with regressed left ventricle underwent primary ASO. Extracorporeal membrane oxygenation was used in 20% (22 of 109) of them; 90.8% (99 of 109) of children who survived were prospectively followed, with a mean follow-up of 28 months (range 18-84 months).

RESULTS

Two late deaths occurred, and survival in the remainder was estimated to be 98% at seven years. The incidence of aortic regurgitation (AR) was found to have a decreasing trend with freedom from AR approaching 100% by 34 months. The left ventricular shape and function returned to normal within one to three months following surgery. None of these children had any rhythm disturbances or evidence of myocardial ischemia.

CONCLUSIONS

Primary ASO can be safely performed in children with regressed ventricle, irrespective of age with encouraging results. The midterm results of these children are comparable in terms of survival and freedom from complications associated with preserved ventricle.

Aortoesophageal fistula in a child

Aortoesophageal fistulae (AEF) are rare and are associated with very high mortality. Foreign body ingestions remain the commonest cause of AEF seen in children. However in a clinical setting of tuberculosis and massive upper GI bleed, an AEF secondary to tuberculosis should be kept in mind. An early strong clinical suspicion with good quality imaging and endoscopic evaluation and timely aggressive surgical intervention helps offer the best possible management for this life threatening disorder. Our case is a 10-year-old boy who presented to the pediatric emergency with massive bouts of haemetemesis and was investigated and managed by multidisciplinary team effort in the emergency setting.

Extra corporeal membrane oxygenation after pediatric cardiac surgery: a 10 year experience

Indications for extra corporeal membrane oxygenation (ECMO) after pediatric cardiac surgery have been increasing despite the absence of encouraging survival statistics. Modification of ECMO circuit led to the development of integrated ECMO cardiopulmonary bypass (CPB) circuit at the author's institute, for children undergoing repair of transposition of great arteries among other congenital heart diseases (CHD). In this report, they analyzed the outcome of children with CHD, undergoing surgical repair and administered ECMO support in the last 10 years. The outcome was analyzed with reference to the timing of intervention, use of integrated ECMO-CPB circuit, indication for ECMO support, duration of ECMO run and the underlying CHD. The results reveal a significantly improved survival rate with the use of integrated ECMO-CPB circuit and early time of intervention rather than using ECMO as a last resort in the management. The patients with reactive pulmonary artery hypertension respond favorably to ECMO support. In all scenarios, early intervention is the key to survival.

Surgical repair of D-TGA with an aortopulmonary window and ventricular septal defects

D-Transposition of great arteries with an aortopulmonary window is a rare congenital anomaly. We describe a case of D-Transposition of great arteries with an aortopulmonary window and multiple ventricular septal defects in a 5-month boy who underwent successful surgical repair.

Tetralogy of Fallot in teenagers and adults: surgical experience and follow-up

OBJECTIVE

The aim of this study was to review short- and long-term outcomes following total correction in patients with tetralogy of Fallot that presented during adulthood.

METHODS

It was a retrospective analysis of 284 patients (aged 14-50 years, mean 19.4 +/- 2.5 years) with tetralogy of Fallot who underwent total correction at our institution between January 1991 and December 2001. Thirty patients were subjected to postoperative first-pass radionuclide angiocardiography scans. A Hindi version of the standard World Health Organization quality of life proforma was mailed to 120 patients operated on during the first half of the study period.

RESULTS

Altogether, 45 (15.8%) patients had palliative shunts, and 32 (11%) had preoperative coil embolization. The transatrial/transpulmonary artery approach was used in 62 (22%) patients, the transventricular approach in 86 (30%) patients, and a combined approach in 136 (48%) patients. A transannular pericardial patch was used in 200 (70%) patients. A total of 61 (21%) patients had nonfatal complications. There were 28 hospital deaths. Follow-up ranged from 1 month to 10 years (mean 4.6 +/- 2.3 years). There were 7 (2.5%) late deaths and 6 (2.1%) reoperations. Altogether, 94% of patients were in New Yk Heart Association (NYHA) class I. Radionuclide angiocardiography showed normal right ventricular and left ventricular function in 18 (60%) and 22 (73%) patients, respectively. All of the 66 respondents perceived an improved quality of life. The actuarial survival and freedom from reoperation at 10 years were 82.88% +/- 3.80% and 92.82% +/- 3.40%, respectively.

CONCLUSION

Total correction in this subset of patients offers the best option for long-term symptom-free survival.

Application of stem cell technology for coronary artery disease at the All India Institute of Medical Sciences, New Delhi, India

Stem cell technology is rapidly gaining popularity as a way to improve the prognosis of patients with coronary artery disease and heart failure. In this review, we systematically analyze the basis, methods, and results of stem cell technology for coronary artery disease at the All India Institute of Medical Sciences, New Delhi, India.

Comparison of analgesic efficacy of fentanyl and sufentanil for chest tube removal after cardiac surgery

Chest tube removal in the postcardiac surgical patients is a painful and distressful event. Fentanyl and sufentanil have not been used for pain control during chest tube removal in the postoperative period. We compared efficacy offentanyl and sufentanil in controlling pain due to chest tube removal. One hundred and forty one adult patients undergoing cardiac surgery were recruited in a prospective, randomized, double blind, placebo controlled study. Patients were randomized to receive either 2 microg/Kg fentanyl IV or 0.2 microg/Kg sufentanil IV or 2 ml isotonic normal saline, 10 min before removing chest tubes. Pain intensity was assessed by measuring visual analog scale pain score 10 minutes before removing chest tubes and 5 min and 20 min after removing chest tubes. Level of sedation, heart rate, arterial pressure, oxygen saturation, and respiratory rate were recorded by a blinded observer at the same time intervals. Mean pain intensity scores 10 minutes before removal of chest tubes infentanyl, sufentanil and control groups were 23.88+/-5.2, 25.10+/-5.39 and 23.64+/-6.10 respectively. The pain scores 5 minutes after chest tube removal were reduced to 20.11+/-6.9 (p<0.05) in the fentanyl group and 13.60+/-6.60 (p<0.05) in the sufentanil group, whereas in control group pain scores increased to 27.97+/-8.39 (p<O.05). The pain scores in sufentanil group were significantly lower compared with fentanyl or control group. Sedation scores remained low in all groups and patients remained alert and none of the patients showed any adverse effects of opioids. Heart rate, arterial pressure and respiratory rate had least variations in sufentanil group than fentanyl or control group.

Mitral Stenosis After Duran Ring Annuloplasty for Non-rheumatic Mitral Regurgitation—A Foreign Body Response?

We report two cases of mitral stenosis after Duran ring annuloplasty for myxomatous mitral regurgitation. Simple explantation of the ring provided relief of mitral stenosis.

Subaortic membrane excision: Mid-term results

BACKGROUND

Subaortic membrane (SAM) is a form of fixed subaortic obstruction in which a fibrous membrane is located below the aortic valve.

AIM

To determine the role of surgical treatment for patients with a discrete SAM.

PATIENTS AND METHODS

The hospital records of 45 patients (age range: 2-23 years; median 8 years) undergoing surgery for SAM between 1990 and 1998 at the All India Institute of Medical Sciences, New Delhi, India, were analysed. Preoperative echocardiographically calculated gradients across the left ventricular outflow tract ranged from 50 to 154 mmHg (mean: 86.5 +/- 33.2 mmHg). Nine patients had trivial aortic regurgitation (AR), 10 had mild AR and five had moderate-severe AR. The left ventricular ejection fraction (LVEF) ranged from 20 to 68% (mean 48 +/- 15%). Nineteen patients had significant left ventricular dysfunction (LVEF <50%). Transaortic resection of SAM was done in all patients along with excision of a wedge-shaped segment of septal muscle underlying the membrane.

RESULTS

There were no early or late postoperative deaths. On follow up (up to 113 months), only four patients had gradients >30 mmHg. LVEF improved to 45-70% (mean 58 +/- 7.7%). AR reduced to mild in four patients and trivial in four patients, and did not progress further.

CONCLUSION

Resection of SAM carries long-term benefits. Routine septal myectomy appears to be associated with a low risk of recurrence.

Epsilon aminocaproic acid in paediatric cardiac surgery to reduce postoperative blood loss

We have studied the efficacy of epsilon aminocaproic acid in reducing postoperative blood loss in infants and children with congenital cyanotic cardiac anomalies undergoing corrective operative procedures. This prospective study was carried out on 170 infants and children randomly divided into two equal groups. Group A acted as the control group and received normal saline as placebo while group B patients received epsilon aminocaproic acid (100 mg/kg body wt) intravenously slowly soon after anaesthetic induction followed by 100 mg/kg in the cardiopulmonary bypass pump at the time of starting of cardiopulmonary bypass and 100 mg/kg after weaning from bypass over a period of 3 h. In group A the time for sternal closure after separation from bypass and administration of protamine was 75.18 +/- 5.5 min and in group B 50.7 +/- 5.2, (P < 0.001). Blood loss at 24 h in group A was 42.6 +/- 6.9 ml/kg/24 h and in group B 23.7 +/- 5.8 ml/kg/24 h, (P < 0.001). The need for packed red cells in group A was 21.8 +/- 7.1 ml/kg/24 h and in group B 10.7 +/- 7.8 ml/kg/24 h, (P < 0.001). The need for platelet concentrate in group A was 22.0 +/- 6.7 ml/kg/24 h and group B 6.2 +/- 3.2 ml/kg/24 h, (P < 0.001). Fibrin degradation products (split) in group A was 8.2 +/- 0.8 micrograms/ml, and group B 3.8 +/- 1.3 micrograms/ml, (P < 0.001). Reexploration rate was also considerably reduced in group B, 5 of 85 (6%) compared to group A, 13 of 85 (15%), (P < 0.001). It was found that epsilon aminocaproic acid is effective in reducing postoperative blood loss, packed red cells and plasma product requirements in paediatric patients undergoing corrective surgical procedures for congenital cyanotic heart diseases.

Blood Conservation in Open-Heart Surgery

At the All India Institute of Medical Sciences, in a 6-week period between October and November 1995, 57 patients with preoperative hemoglobin levels of more than 10 g/100mL were included in a blood conservation protocol. Autologous blood trans-fusion, total body hemodilution to a minimum hematocrit of 20%, and retransfusion of pump blood, along with meticulous intraoperative hemostasis, were performed. Forty-eight, patients (84%) did not require transfusion of homologous blood or blood products. The remaining 9 patients (including 2 who underwent reoperation, 2 who had reexploration, and 2 with preoperative renal failure) received blood or blood products when their hemoglobin fell below 8 g/100mL. No patient had postoperative hemodynamic instability or delayed recovery. All patients were discharged on oral hematinics. Blood conservation techniques are safe and easy to implement. When used in combination, they provide satisfactory results, avoid transfusion-related problems, and conserve blood supplies.