Diagnostic Dilemma of Frozen Shoulder in Post CABG Patient: A Case Report

Frozen shoulder, also known as adhesive capsulitis, is a condition featured by stiffness and pain in shoulder joint. In this report, we present a case of 58 years old diabetic male patient with the history of coronary artery bypass grafting (CABG) 06 months back. He presented with persistent right shoulder pain for 05 months. Clinical examinations reveal restriction of the right shoulder joint movement in all directions and wasting of the right supraspinatus, infraspinatus and trapezius muscles. Both active and passive range of motions was restricted with painful right shoulder joint. Pain free abduction range was about 40 degrees in right shoulder. Plain X-ray of right shoulder joint and other relevant investigations show normal findings. Considering the clinical and laboratory findings decision was taken to treat the patient with exercise, pain killer and ultrasound therapy which were found to be optimistic.

A 15 Year's Experience with Minimally Invasive Mitral Valve Replacement in Bangladesh

This study was aimed to compare the long-term outcomes and survival rate among mitral valve replacement using thoracotomy and standard median sternotomy in a single surgeon's practice. Total 250 patients were evaluated; Group I (n=65) patients had anterolateral thoracotomy and Group II (n=185) had standard median sternotomy for valve replacement. Mean age was 25.1±5 years in Group I and 41.8±10.5 years in Group II. Female was predominant in Group I. Total operative time and bypass time was statistically significant in Group I (235.5±25.8 minutes; 84.2±12.75 minutes) in contrast to Group II (203.8±15.5 minutes; 71.5±10.5 minutes). Incision scar was not visible in females in Group I but full incision scar was visible in Group II. Post-operative ICU stay duration was significant high in Group II. Though, wound infection incidence was 0% in Group I; however, 9.73% patient had wound infection in Group II. Only 1.62% patient developed unstable sternum in Group II. Most of the patients from both study group were in regular follow up and 1-year mortality rate was 4.62% and 5.94% in Group I and Group II respectively. Mitral valve replacement through a right anterolateral thoracotomy is easy and safe to perform; while getting maximum benefits for the patients. Besides satisfactory cosmetic outcome especially in female, this approach provides better exposure to mitral apparatus even in patients with small left atrium, cost effectiveness, less duration of hospital stays and absence of the risk for unstable sternum.

Fast Tract Anesthesia Using Isoflurane and Propofol During Off-pump Coronary Artery Bypass Graft Surgery

This study aimed to evaluate myocardial protective effect of isoflurane and propofol as a fast tract anesthesia in off pump coronary artery bypass graft surgery by measuring postoperative cardiac enzyme Troponin-I, and liver enzyme. The study was conducted on 260 patients scheduled to undergo elective off pump coronary artery bypass graft surgery. Patients were randomly allocated to receive either isoflurane or propofol anesthesia and was aimed to extubated within 6 hours. Troponin-I levels were measured preoperatively, at arrival in postoperative intensive care unit, at 12, 24, 48, 72 hours and 4 weeks following surgery. Liver function was also assessed and compared between preoperative and postoperative values. There is no difference in Troponin-I levels between the two studies groups at observed pre and post-operative time intervals. Fast tract anesthesia using isoflurane and propofol provides same myocardial protection during and after OPCABG and overall outcome was excellent.

Cardiofacial Syndrome: A Rare Case Report

Cardiofacial syndrome is associated with facial abnormality with congenital heart disease. Here, we report a case of cardiofacial syndrome having anotia and facial nerve palsy on the right side in combination with infundibular pulmonary stenosis and patent ductus arteriosus which is a rare presentation of cardiofacial syndrome. A 6 years old girl presented to department of Cardiac surgery of Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh with the complaints of shortness of breath on exertion since 2 years of age. Her physical examination revealed right sided anotia and facial nerve palsy associated harsh ejection systolic murmur in upper left parasternal area. Echocardiography showed critical infundibular pulmonary stenosis with a small patent ductus arteriosus. She underwent ligation of patent ductus arteriosus and excision of infundibular muscular bands and discharged to home without any complication. Any child presented with facial abnormality should be checked for any cardiac abnormality for early intervention and better management of the patient.

Pregnancy Outcome with Prosthetic Heart Valve in Bangladesh: A Retrospective Cohort Study

The aim of this retrospective cohort study was to evaluate the occurrence of the maternal and fetal outcome during pregnancy and immediately after delivery in women with prosthetic heart valve, especially with oral anticoagulants therapy that must be weighed against the risk of intracardiac thrombosis. This study was undertaken at Department of Cardiac surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from January 2012 to December 2017. A total of 82 pregnancies with heart valve prosthesis were evaluated in two groups: Group I (n=58) includes pregnancy with mechanical heart valve, while Group II (n=24) includes pregnancy with bioprosthetic valve. The mean age of patients was 25.7±2.5 years and 24.9±5.5 years in Group I and Group II respectively. Approximately 70% pregnancies ended in healthy live births, however about 75% of study population developed maternal complications in Group I, which is significantly higher than Group II. First trimester spontaneous miscarriage was statistically significant between two groups (p value <0.005). Mean birth weight and mean APGAR score was found normal in both study group. Majority of the patients were found in good health status during and after pregnancy. Proper antenatal care and early risk stratification are the fundamental measures to improve the maternal and fetal outcome in a patient with prosthetic heart valve.

Ectopic Parathyroid Adenoma: Surgical Correction and its Complication Management

Ectopic parathyroid are most frequently found in the anterior mediastinum, in association with the thymus or the thyroid gland. Ectopic parathyroid glands are a major cause of persistent and recurrent Hyperparathyroidism. We report a case of 65-year-old female was referred from Surgical Endocrine department to the department of Cardiac Surgery on 20 September, 2017 in Bangabandhu Sheikh Mujib Medical University with parathyroid crisis due to an ectopic mediastinal parathyroid adenoma with her serum calcium and PTH markedly increased in short time. Computed tomography of the chest and lower neck showed an ovoid soft tissue density area measuring about 25×20×15mm in the anterior mediastinum. Technetium-99m-sestamibi (MIBI) scintigraphy scan showed positive and detected localized parathyroid adenoma/hyperplasia in superior mediastinum. Ectopic parathyroid adenoma resection was performed via median sternotomy approach. But after 4 hours patient developed the color change of the left arm due to acute left upper limb ischemia of unknown cause for which the patient was rushed to operation theatre suspecting it to be embolic occlusion and managed by both surgical and medical therapy.

Comparison of Two Laboratory Methods of Preservation for Preclinical Preparation of Bovine Aortic Heart Valve Suitable for Human Use

The present experimental study was carried out as an experimental study in the department of Cardiac Surgery at Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from July 2011 to May 2013 to see which preservation techniques give us morphologically and histologically suitable xenograft heart valve for clinical use. We reviewed 20 bovine aortic valves in 2 years. Each of 10 samples was grouped as glutaraldehyde (1.5%) preservation and cryopreservation (-180°C). After collecting each specimen, sterilization of valve was done in low concentration of sterile antibiotic solution (CLPVA). Then 10 dissected valves were immersed each in 250ml of 1.5% glutaraldehyde solution at 4°C. Another 10 dissected valves were placed in a solution of 100ml 10% DMSO and suspended in vapor phase of liquid nitrogen at -180°C. Then after 4 weeks, the valves were examined for naked eye (color change, shrinkage, swelling, pliability, stiffness of leaflet) and histological (endothelial cells, leaflet extracellular matrix preservation, fibroblast preservation, inflammation, necrosis and other pathological conditions on valve leaflet) examination. Statistical analysis showed that morphological changes were not significant in both groups but in histological examination, cryopreservation showed effective preservation of fibroblast and extracellular matrix than glutaraldehyde preservation.

Comparative Study between the Use of Multidose Standard Cardioplegia and Long Acting Del Nido Cardioplegia during Intracardiac Repair for Tetralogy of Fallot in Pediatric Patients

Pediatric myocardium is unique from mature myocardium; thus, the use of adult cardioplegia for pediatric cardiac operations may provide suboptimal myocardial protection. It is found that children undergoing heart surgery show evidence of less myocardial damage when del Nido cardioplegia is used instead of a standard cardioplegic solution. Del Nido cardioplegia solution provides a depolarized hyperkalaemic arrest lasting up to 60 minutes, reduces spontaneous and inducible activity during arrest, and prevents hyper contraction during early reperfusion. In this single blind randomized trial, a total of 60 patients underwent intra cardiac repair for TOF in National Institute of Cardiovascular Diseases, Dhaka, Bangladesh from July 2014 to January 2016 fulfilling inclusion and exclusion criteria. They were randomly assigned in two groups- 30 patients in Del Nido group (Group A) and 30 patients in standard group (Group B). Comparison between groups was done by Chi square test and Student's test. All data were analyzed by SPSS 20.0 for windows. P value less than 0.05 was considered as significant. There was statistically significant difference among the patients in terms of mean total initial cardioplegia volume, mean number of additional dose, mean additional dose amount, mean cross clamp time, mean CPB time (331.67±188.07 vs. 458.67±226.62, p=0.022; 0.13±0.35 vs. 1.27±0.89, p=0.000; 23.33±60.76 vs. 336.83±259.6, p=0.000; 45.10±10.35 vs. 59.23±23.21, p=0.003; 89.30±15.73 vs. 111.10±29.23, p=0.001 respectively). Mean post operative serum troponin I level at arrival in ICU and after 24 hours between two groups were statistically significantly different (55.60±32.91 vs. 83.5±58.99; p=0.024 and 13.01±5.84 vs. 18.16±9.51; p=0.014 respectively). The mean ventilation duration, mean ICU stay were also statistically significant. This study showed that cardiac arrest with Del Nido cardioplegia during intra cardiac repair for TOF was associated with improved myocardial protection over standard cardioplegia in terms of reduced CPB and cross clamp times, lower total volume of cardioplegia.

Surgical Management of a Critical Ischemic Mitral Regurgitation Patient

Functional ischemic mitral regurgitation is strongly associated with poor outcomes in patient with coronary artery disease. The best management for mitral regurgitation at the time of coronary revascularization remains controversial. We report, a case of 58 years-old men admitted to GKNM hospital, Coimbatore, Tamil Nadu, India with chest pain and respiratory distress for last 6 hours during my fellowship training in that hospital. ECG showed acute antero-septal MI. The transthoracic echocardiogram revealed severe left ventricular dysfunction with moderate mitral regurgitation. Coronary angiogram revealed triple vessels disease. We planned for early CABG. But the patient suddenly developed severe respiratory distress with ventricular tachycardia. Patient managed with the support of invasive ventilation and IABP. After that, CABG along with mitral valve repair was done under cardiopulmonary bypass. The patient showed excellent symptomatic improvement during his early post-operative period. Mitral valve repair along with CABG may be a preferable treatment option for patient with Ischemic heart disease with moderate mitral regurgitation.

Coronary Artery Bypass Graft with Endarterectomy and Stent Removal in Patient with Multivessel in Stent Restenosis

In the age of stent deployment after balloon angioplasty. In stent restenosis (ISR) has become a major concern. Various coronary interventional measures and coronary artery bypass graft (CABG) has employed to manage the ISR. Although CABG seems to offer advantages over other coronary intervention methods in patients with multi vessel ISR; lack of appropriate graftable vessels often make the surgery difficult and end up with incomplete revascularization. Coronary endarterectomy with stent removal mitigated some of the limitations of CABG but initial results of this surgical measure were not favorable. Later, with improvement of surgical technique and meticulous anticoagulant therapy along with CABG showed promising result but till date only few cases have been reported. Here, we are reporting a case of 65 years old lady who underwent CABG along with endarterectomy with stent removal after she had developed stent restenosis in three vessels. This diabetic and hypertensive patient presented with chest pain and shortness of breath which was developed within three months of PCI with stent deployment in three vessels. Angiogram done prior to admission in the cardiac surgery department reveals restenosis in all the three stented vessels. CABG was done and three grafts given in LIMA to LAD, RSVG to OM and RCA. Endarterectomy done on LAD and RCA with stent removal from RCA. Postoperative anticoagulant therapy was strictly maintained. Patient's postoperative period remained eventless other than superficial wound infection. With skilled hand capable of handling highly technique demanding surgery and postoperative anticoagulation maintenance; endarterectomy along with CABG seems to be safe solution for multi vessel ISR with diffuse coronary artery disease.

A Rapid and Reliable End-To-End Anastomosis Technique for Emergency Vascular Surgery--A Case Report

A 28 year old male presented to us with 8 hours old open fracture of distal shaft of left femur which was already stabilized with external fixator but had no palpable distal pulse both clinically and on doppler examination. He underwent a primary repair following limited segmental resection. Commonly end-to-end anastomosis techniques following transection of arteries include interrupted and continuous suturing with or without 'parachuting' of the vessel or graft. Here we offer a rapid and reliable technique with following advantages: i) operating system always towards the surgeon, ii) posterior row of suture placed as both ends are well visualized, iii) less chance of catching posterior wall, iv) flushing performed easily before completing anterior row suture. Upto 2nd post operative day anticoagulant used in the form of inj. Heparin 2500 IU subcutaneously 8 hourly and patient was discharged from hospital on 3rd post operative day with presence of good distal pulses both on clinical and Doppler examination. Fourteen days later, on follow up Duplex study showed normal arterial flow without any stenosis or occlusion.

Surgical Closure of Atrial Septal Defect with High Pulmonary Vascular Resistance--A Case Report

We have reported a case of successful pericardial patch closure of atrial septal defect with high pulmonary vascular resistance in a 32 years aged male. Diagnosis was confirmed by Doppler Echocardiography, Cardiac catheterization and lung biopsy. Before starting (orally) bosentan pulmonary arterial pressure was 105 mm Hg and pulmonary vascular resistance was 8 wood's unit. Bosentan was started at a dosage of 125 mg per day (62.5 mg twice a day) for 4 months before operation in this case. Just day before operation pulmonary arterial pressure was 87 mm Hg. Bosentan lowered pulmonary arterial pressure and reversed remodeling of pulmonary arteries and allowed surgical correction. During the post operative course, partial pressure of oxygen was significantly decreased and bilateral radiolucent opacity was present in lower zone of both lungs. All these were managed successfully in postoperative period. This case report has demonstrated that surgical correction of an atrial septal defect is feasible but requires long time pre and post operative treatment with pulmonary vasodilators.