, J. T. (1974). Thorax, 29,[68][69][70][71][72][73][74]. Jaundice following open-heart surgery. A study was made into the factors influencing the onset of jaundice in 102 patients undergoing valve replacement during cardiopulmonary bypass. Postoperative jaundice appeared to be correlated with double valve replacement, the co-existence of an uncorrected valvular lesion, length of perfusion and myocardial ischaemia times, and also the age of the patient. Factors appearing not to be correlated with the onset of jaundice included preoperative pulmonary artery pressure, cardiac index, parameters of preoperative renal and hepatic function, and the amount of blood used during bypass. The biochemical features of the jaundice seemed to follow a pattern not previously recognized in this context, with sometimes considerably raised bilirubin levels in association with virtually normal levels of transaminases and alkaline phosphatase.Jaundice in the early postoperative period is a well recognized complication of cardiopulmonary bypass, although its causes are not always obvious. Lockey et at. (1967) considered a high central venous pressure and the use of homologous blood as important causes, haemolysis, heart failure, and infection being contributory to it. Mundth, Keller, and Austen (1967), who described three jaundiced patients in low output state postoperatively, suggested that long-standing postoperative pulmonary hypertension and biventricular failure were of aetiological importance. However, Sanderson, Ellison, Benson, and Starr (1967) considered that shock and anoxia were causative factors, but that haemolysis and preoperative cardiacpulmonary and hepatic status bore no relation to the aetiology of postoperative jaundice.Because of these various views, a study of 102 patients undergoing prosthetic cardiac valve replacement was undertaken from January 1971 in an attempt to evaluate possible causative factors in its genesis. An incentive to the study was the relatively high incidence of postoperative jaundice; 21 % of the patients had serum bilirubin levels above 6 mg % with 13 deaths (13%).
Introduction Sinus of Valsalva aneurysm (SOVA) may have associated infective endocarditis in which case single aneurysm may drain into adjacent chamber of heart via multiple openings. We report a rare case of congenital SOVA with associated infective endocarditis where intraoperative transesophageal echocardiogram (TEE) helped in localizing two separate openings in the SOVA draining into right ventricle and an associated perforation in the larger rightward cusp of bicuspid aortic valve (BAV) causing severe aortic regurgitation. Case report A 28-year-old male presented with grade III to IV dyspnea with previous history of infective endocarditis. Preoperative transthoracic echocardiogram (TTE) showed calcified BAV with severe aortic valve regurgitation and stenosis, severe tricuspid regurgitation, and pulmonary artery hypertension along with ruptured SOVA arising from right coronary sinus and draining into the right ventricle. Intraoperative TEE confirmed the TTE findings and in addition showed the presence of two jets arising from the SOVA draining into right ventricle, a subaortic membrane, and a perforation in the aortic cusp opening into left ventricle. The ruptured SOVA was repaired using single patch technique and aortic valve was replaced. The completeness of the repair was checked using TEE to exclude failure of closure of additional opening if any and the patient was discharged from hospital after 7 days of uneventful postoperative course. Conclusion Sinus of Valsalva aneurysm may have multiple openings draining into adjacent chamber, particularly if associated with infective endocarditis. Intraoperative TEE plays a crucial role in identification of multiple opening, involvement of adjacent structure, and assessment of completeness of repair. How to cite this article Kumar B, Munirathinam GK, Sharma P, Puri GD, Singh H. Role of Transesophageal Echocardiography in Rupture of Sinus of Valsalva Aneurysm with Associated Infective Endocarditis. J Perioper Echocardiogr 2016;4(2):59-63.
Forty patients who came to necropsy over a period of five years due to myocardial damage sustained during cardiac valve replacements were studied. The clinical presentation of myocardial damage was assessed in relation to the preoperative cardiac status. The cause and nature of myocardial damage were assessed at necropsy. Evidence of clinical, electrocardiographic and aortographic coronary atheroma was correlated with distribution at necropsy, and the value of selective coronary angiography in perfusing the coronary arteries during cardiopulmonary bypass is stressed. The causes of myocardial damage could be classified as (a) thrombo-embolic, (b) iatrogenic damage to the coronary arteries, and (c) poor or absent coronary perfusion during cardiopulmonary bypass. A case is made for the importance of coronary perfusion during cardiopulmonary bypass.With better understanding of the nutrient requirements of the myocardium, deaths due to myocardial damage sustained during cardiopulmonary bypass are now fortunately infrequent. However, over a period of five years (1965 to 1969) 40 such patients came to necropsy at Sully Hospital, an incidence of about 5% in a yearly output of about 120 valve replacements. The aim of this paper is to study the pathophysiology of myocardial damage in these patients with reference to the incidence of coronary artery disease and to assess the factors adverse to the myocardium during and after cardiopulmonary bypass. In particular, the role of coronary perfusion is outlined, because its use is debatable, and because oxygen requirements and the coronary blood flow demands of the myocardium with non-pulsatile flow and hypothermic perfusate in the beating and fibrillating heart are only now being gradually understood (Sterns, Bonnabeau, and Lillehei, 1966;Vasko, 1967). When coronary atheroma predominates and results in areas of perfusion deficit in the myocardium, the role of coronary perfusion during cardiopulmonary bypass assumes all the more importance. It is in respect of this role that we have looked critically at our coronary perfusion techniques and related them to the myocardial damage sustained in this group of patients.
Cardiopulmonary bypass (CPB) in a patient with glaucoma is a challenge. The glaucomatous eye is at risk during CPB. We report a case of ostium secundum atrial septal defect that was not amenable to device closure. The unique feature in the patient was the presence of congenital glaucoma. She was blind in the left eye, and the visual acuity in the other eye was decreased because of glaucoma. She underwent direct closure of the atrial septal defect under CPB and fibrillatory arrest, with intraoperative monitoring of intraocular pressure. There was no change in visual acuity after 1 year of follow-up.
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