Journal of Cardiovascular Medicine and Surgery

We present a 45 year nonsmoker male presenting to the Cardiology OPD of AIIMS, Bhubaneswar presenting with effort dyspnea NYHA class IV with features of right heart failure with massive edema of both feet diagnosed to be Cor Pulmonale outside, EKG revealed typical epsilon wave in leads V1 to V3 and echo revealed fibrofatty infiltration of RV apex with reduced RV ejection fraction (35%), Cardiac MRI revealed the same and withdrawing all anti PAH drugs the patient was put on antifailure medications presently doing well. Being a rare entity arrythmogenic right ventricular cardiomyopathy (ARVC) stands out a prominent entity in young RV failure.

Enterococcus durans endocarditis is very rare. A few reported cases of infective endocarditis caused by Enterococcus durans exist. Endocarditis with enterococcus durans is a potentially devastating infection and most often requires prolonged intravenous antibiotics with associated risks. We reported the case of aortic valve infective endocarditis caused by Enterococcus durans.

We present a 25 year old boy presenting to Cardiology OPD for routine clinical evaluation before joining as staff nurse in AIIMS, Bhubaneswar, ECG showing non specific ST-T changes across inferoanterior chest leads, Echo revealed abnormally long myxomatous mitral and tricuspid valve without significant valvular regurgitation. Although myxomatous mitral valve is not to uncommon to encounter in young, myxomatous tricuspid valve is a rare entity to be encountered with.

Aims: Effect of Intra luminal Papaverine injection on LIMA flow. Methods and Material: All the patients posted for CABG between January and July 2017, were included in this study. A total of 32 patients (26 male and 6 female ) met the inclusion criteria and were subjected to this study. LIMA pedicle was disconnected distally and blood flow was timed for a minute, collected into a vessel and measured. A soft bulldog clamp was placed proximally and 10 ml of 0.6% Papaverine was injected intra-luminally and a second bulldog clamp was placed distally. After an indwelling time of 1 min, both the bulldog clamps were removed and flow measured for the next 60 seconds. Both flows were measured maintaining similar mean arterial pressures. Results: Mean blood flow before Papaverine injection was 27.18 ml.Mean blood flow after Papaverine injection was 60.81 ml. Mean difference in blood flow was 33.93 ml. Conclusions: Intraluminal injection of Papaverine to LIMA after dissection treats spasm effectively. Papaverine injection injection improves LIMA flow significantly and the difference in flow was found to be statistically significant

Retroperitoneal fibrosis is a rare vascular connective tissue disease of unknown aetiology, typically presenting as inflammation within the retroperitoneum with the resultant mass effect of the pathological processes involved compress the organs in the retroperitoneum: Kidneys, ureter, aorta and pancreas. The disease was first described by John Kelso Ormond in 1948 on a patient who presented with bilateral ureteral obstruction secondary to an inflammatory retroperitoneal process [2,3]. Its incidence is at 1.38 cases per 100,000 [1]. It has a male predominance of between 1.6 to 3 fold [1,7]. There have been associations of retroperitoneal fibrosis with various autoimmune conditions.Immunosuppressive treatment modalities have been effective on its control and management thus indirectly inferring to an autoimmune process as a key factor behind its pathophysiology [4, 5]. Radiological diagnosis through CT remains a gold standard with biopsy being a controversial option of obtaining diagnosis [5, 17-21]. Main stay treatment has been use of glucocorticoids as 1st line, with the disease modifying anti-rheumatic drugs (DMARDS) as a second option where the disease has been found to be steroid resistant [6]. For the scope of this paper, we will describe a case managed at the Karen hospital in Nairobi, Kenya in September 2017.

Aims: Lung complications after cardiopulmonary bypass are well described. Various methods have been adopted by surgeons for lung protection. Lung preservation during cardiopulmonary bypass is controversial. In this study we investigated whether ventilation during cardiopulmonary bypass with low tidal volumes helps in improving oxygenation post operatively. Methods and Material: Two groups of patients were studied here, one group was not ventilated during cardiopulmonary bypass (group A) and the other group was ventilated (group B). A total of 50 patients were studied, out of which 25 were not ventilated (Group A) and 25 were ventilated during cardiopulmonary bypass (Group B). The partial pressure of oxygen in arterial blood, arterial oxygen saturation and hours of ventilation were compared in the two groups at various intervals. Statistical Analysis Used: The Statistical software SPSS 15.0 was used for the analysis of the data and Microsoft Word TM and Excel TM have been used to generate graphs and tables. Results: There was no increase in pO2 or saturations in the ventilated group either at time of extubation [P=0.985] or 24 hours after surgery [P=0.944]. There was no significant difference in the total hours of ventilation between the two groups [P=0.678]. Conclusions: There was no significant difference in the measured parameters between the two groups. There is no improvement in lung function by ventilating with low volume tidal ventilation during cardiopulmonary bypass.

Aims and Objective: To assess the association of lipoprotein a (Lp a) with coronary artery disease (CAD) in Western Indians. Material and methods: In this single centric, prospective and case control study 200 subjects (100 patients with CAD & 100 healthy volunteer) were enrolled. Fasting blood sample were collected from the antecubital vein of the subjects under sterile conditions. Lipid profile parameters such as total cholesterol (TC), triglyceride (TG), total lipid (TL), low density lipoprotein (LDL), high density lipoprotein (HDL), and very low density lipoprotein cholesterol (VLDL), Lp (a) were measured. Results: The prevalence of cardio-metabolic risk factors was significantly higher in cases as compared to controls (p<0.05). Similarly significantly higher mean lipid levels namely total cholesterol, triglyceride, low density lipoprotein and Lp (a) was observed in CAD patients as compared to their counterparts. Lp (a) levels were well correlated with angiographic severity of the disease and overall incidence of the disease was found to be highest in the greatest quartile of Lp (a). Conclusion: Lp (a) levels are important markers of CAD in Western Indians and could be effectively used to in clinical setting.

Background: Diabetes mellitus has been regarded as an independent risk factor for the progression of coronary artery disease. Even with DES, however patients with diabetes had increased rates of restenosis compared with patients who did not have diabetes. This study aimed to examine individual safety and efficacy endpoints. Methods: A total of 287 patients having chronic stable coronary artery disease or ACS were enrolled. To compare PES and LES in the Diabetic and Non-diabetic population, we separated patients in two groups. Results: In present study, there were 287 patients undergoing PTCA in whom 371 lesions were treated using either PES or LES. Out of 371, 169 lesions were treated with PES and 202 were treated with LES. In those treated with PES, 51 were diabetic while those treated with LES, 66 were diabetic. In present study, among all patients cardiac death, MI, ST, ISR and TLR noted in 2.95%, 4.14%, 2.95%, 5.91% and 4.14% patients respectively in those treated with PES. While those treated with LES cardiac death, MI, ST, ISR and TLR noted in 0.99%, 1.48%, 1.48%, 0.49% and 0.99% patients respectively. ISR and overall MACE observed were statistically significant between two groups. Conclusion: Although diabetes remains a significant predictor of adverse clinical outcomes after percutaneous coronary intervention with DES; in present study there was no statistically significant difference for occurrence of MACE among diabetic and nondiabetic patients. The principle end points of interest occurred with statistically significant lower incidence in patients treated with LES as compared to PES.

Aims: To find the early outcome following dor’s procedure for post infarct LV aneurysm. Settings and Design: This is a retrospective study of left ventricle aneurysm repair done at the Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, since June 2013 to September 2017. Methods and Material: Between June 2013 and September 2017, 23 patients underwent left ventricular aneurysm repair using Dor’s repair. The location of the left ventricular aneurysm was anterior (73.9%), apical (8.7%), posterior (17.4%). The indication for operation was congestive heart failure in all patients. Statistical Analysis Used: Anova and Bonferroni correctionTest was used to analyse the data obtained. Results: Intra-aortic balloon pumping was used postoperatively in 2 cases and 7 patients needed inotropic support for more than 24h. Mean time on the ventilator was 11.7± 3.6 hours and mean stay in the intensive care unit was 49.26 ± 13.7 hours. Overall mortality was 4.3% (one patient). Mean preoperative ejection fraction (EF) after surgery in was 37.9%. EF showed improvement after surgery to 49.23%. Decrease in end-diastolic volume (EDV) was from 111 ml/m2 to 69.19 ml/m2. Decrease in end-systolic volume was from 76.57 ml/ m2 to 45.76 ml/m2. All of these values showed statistically significant improvement. At the end of one month postoperatively, 83% of them were in NYHA class I and 17% were in class II. Conclusions: Dor’s repair is a reproducible surgical option for treatment of post infarction left ventricular aneurysm to restore its volume and geometry. Early results are good in terms of survival and functional improvement.

Objectives: This study was aimed at assessing whether bypass assisted beating heart surgery reduces pump time, ventilation, and hospital stay, avoids myocardial ischemic and reperfusion injury, gives better long term results over classical cold cardioplegic arrest, for mitral valve replacement in rheumatic mitral valve disease with moderate left ventricular dysfunction. Materials and Methods: 60 patients with rheumatic mitral valve disease with moderate left ventricular dysfunction (Ejection fraction (%) 36.73±4.06), divided into equal and comparable groups, underwent classical mitral valve replacement with St. Jude bileafelet mechanical valve. Group 1 had pumped assisted beating heart surgery and Group 2 had cold cardioplegic arrest. All ventilated, with minimal inotropic support and discharged by 3-10 days. Cardiac enzymes were assessed 6 & 12 hours post declamping. Follow up done by 2D echocardiography on post-operative day 3, 6 months and 1 year. Data was statically evaluated by using Microsoft Excel 2013 version, with values represented as mean±SD. Continuous variables compared with paired student’s t-test. Result: One patient died, due to anticoagulant non-compliance. There was elevation of cardiac enzymes in Group 2, normal in Group 1. Ejection fraction at day 3 and 6 months for Group 1 (47.8±3.25, 53.43±2.6) and Group 2 (39.4±3.1, 40.1±3.5). No further improvement at 1 year. Left ventricular dimensions (mm) at 6 months and 1 year for Group 1 (39.8±2.76/24.6±1.49, 37.8±2.1/24.3±1.32) compared to Group 2 (44.5±5/27.9±4, 42.4±4/27.4±3.7). Ventilation period (hours) and hospital stay (days) for Group 1 (2.95±1.1, 4.1±0.6) compared to Group 2 (7.52±0.9, 8.5±0.8). Conclusion: Mitral valve replacement in rheumatic mitral valve disease with moderate left ventricular dysfunction, bypass assisted beating heart surgery, reduces pump time, ventilation, hospital stay, avoids myocardial ischemic and reperfusion injury and gives better long term results.

Background: Socio-economic status isknown to possess an inverse relationship with cardiovascular disease risk. Aims: We aimed to investigate the prevalence of cardiovascular disease risk factors in children and adolescents of Western India and examine its association with the socio-economic status of the population. Materials and Methods: In this cross sectional, observational study, 3543 children and adolescents of 4-18 years of age were enrolled. Blood pressure (BP), body mass index (BMI) and anthropometric parameters were recorded according to the standardized protocols. Details of socio-economic status (SES), physical activity and stress were obtained from a questionnaire for each individual. Based on the SES, study population was divided into– group I (low-middle SES) and group II (high SES). Results: Overall, the prevalence of prehypertension, hypertension, sedentary life style and type A personality was 14.6%, 33.9%, 58.2%, 53.7% respectively. Obesity was observed in 13.4% and 22.3% of the individuals were malnourished. Prevalence of hypertension (35.21 vs 28.53%), obesity (7.44% vs 2.1%), high waist circumference (WC-58.82±20.34 vs 53.78±15.74) andhigh mid-arm circumference (MAC-21.87±5.3 vs 20.11±5.77) weresignificantly higher in group II as compared to group Ipopulation. Conclusion: The study observation suggests deadly coexistence of hypertension, obesity, sedentary life style and stress in Gujarati Asian Indian children and adolescents. These risk factor prevalence was more in population from high socio-economic class.These observations would contribute in development of appropriate preventive public health policy to efficiently manage these health and social issues early in life.

Background: Mini-invasive pediatric cardiac surgery has been slow to gain pace due to limited surgical exposure and long learning curve. We started performing transverse sternal split (TSS) to improve surgical exposure with advantage of mini incision in tetralogy of Fallot (TOF) and here we have reviewed our short and mid -term results. Methods: Retrospectivereview of patientsof TOF (n=23) operated using TSS (Group 1) from January-2015 to Dec- 2016 was performed. Patients were compared with matched patients operated using midline sternotomy (Group 2). Further,TSS group wasdivided into two sub-groups: Group 1A-patients operated in 2015 (n=11) & Group 1B-patients operated in 2016(n=12). Pre-operative, intraoperative and post-operative datawere collected and analyzed. Results: There was no significant difference in mortality, residual defects and morbidity between TSS and sternotomy group. Mean preparation (p<0.001), cross clamp (p=0.001), CPB (p<0.001), and surgery time (p<0.001) were significantly higher in TSS group than sternotomy group. However, mean duration of ventilation, ICU and hospital stay were significantly lower (p<0.05) in TSS group. Whileanalyzing TSS sub-groups, mean preparation, cross clamp, CPB and surgery time were significantly lower (p<0.05) in group 1B as compared to group 1A, however all remained higher than sternotomy group. Cosmetic result was satisfactory without sterna dehiscence in TSS group and all were in NYHA-Iat mean follow-up of 17.6±7.4 months. Conclusions: The TSS is good alternative to a midlinesternotomy for TOF repair in selected patients with satisfactory cosmetic results without compromising the surgical exposure or quality of repair. With increase in expertise, operative duration can be decreased although it remains higher than midline sternotomy.