Introduction:In the early days of mitral valve replacement (MVR), there was an increased rate of mortality associated with low cardiac output syndrome (LCOS). Excision of the sub valvular apparatus (SVA) was one of the reasons for LCOS, as MVR at that time included complete excision of mitral leaflets and SVA that is, chordae tendinae and papillary muscles. Left ventricular function and geometry depend on dynamic interaction between left ventricular wall and mitral annulus which is bridged by SVA. Papillary muscle and chordae moderates wall tension during systole and optimize left ventricular distension during diastole. Interruption of ventricular-papillary-annular complex by excision of SVA during MVR thus causes impairment of normal ventricular stress-strain pattern and thus eventually leads to impaired left ventricular function and low cardiac output. In the early sixties Lillehei and his collegues capitalized on the fact and suggested that the high mortality rate associated with MVR could be reduced by preserving the papillary muscles and chorda tendenae. He preserved the posterior leaflet during MVR and noted a decreased incidence of post operative low output syndrome 1 . Short Term Clinical Outcome in Patients with Abstract:Background: Preservation of subvalvular apparatus (SAP) during mitral valve replacement (MVR) was introduced about forty years back, but the outcome of this procedure is not well studied yet. Our study aimed to measure the in-hospital outcome of this procedure in rheumatic patients.
Background: The subvalvular apparatus arrangementcan causeventricular torsion& deformation during cardiac cycle and interruption of papillary annular complex. As a result there was impairment of normal left ventricular strain pattern. [2] In patients with mitral stenosis, the left ventricle is small. Preservation of subvalvular apparatus thus become important in moderation of left ventricular volume in long term in patients with mitral stenosis undergoing mitral valve replacement. Methods: This cross sectional study was performed on the 32 consecutive subjects in department of cardiac surgery and cardiology of BSMMU with rheumatic mitral stenosis undergoing MVR from Jan 2013 to June 2014.Mode of surgery was determined by morphology of subvalvular apparatus which dictated the extent of the preservation. The patients were divided into two groups-Group I-With preservation of subvalvular apparatus &Group II-No preservation-where SVA was completely excised. In 2D and M Mode echocardiographic measurements:Mid-wall circumferential end systolic LV stress as calculated for ellipsoid, LV mass, the mid wall circumferential end systolic LV stress is calculated by mirsky's formula.9,10 Results: Patients with sub valvular apparatus resection (group I) had deterioration with postoperative ejection fraction in compare to group-II. Left ventricular circumferential wall stress analysis showed increased wall stress in group II after MVR. Conclusion: The increased left ventricular wall stress is responsible for poor outcome in nonpreserved group after MVR. The wall stress increases further in midterm follow up which may explain the mechanism of long term poor out come in patients with mitral stenosis.
Coronary artery bypass grafting has always given advantage over medical management in treating ischaemic heart disease when 5 years survival is concerned. But, surgery is usually avoided in patients with ischaemic cardiomyopathy with low ejection fraction due to perioperative mortality .Here, we are presenting a case of first successfully performed CABG in Bangladedesh in a patient with ejection fraction of 19%. A 58 years old diabetic and hypertensive male patient, having history of myocardial infarction was suffering from ischaemic cardiomyopathy. He presented with compressive central chest pain, dyspnoea and fatigue and was in NYHA functional class IV. His coronary angiogram revealed tripple vessel coronary artery disease and there was severe left ventricular systolic dysfunction on Echocardiography. On 11 th June, 2013 he underwent off pump coronary artery bypass graft where 3 grafts were anastomosed on beating heart. There was no peroperative complication and no need for perioperative IABP. Weaning time from ventilation and period of inotropic support were not longer than usual that is required for a patient with normal ejection fraction. Patient's postoperative period was unremarkable. After six months follow up, his ejection fraction had improved to 26% and on nine months follow up his ejection fraction was 35%. The patient is apparently symptom less, resumed his job and leading an almost normal life. Therefore, surgery in a skilled hand can combat perioperative mortality and morbidity and gives better result in patient with low ejection fraction.
Keywords: Atrial septal defect; on-pump; beating heartOnline: 11 Feb 2010DOI: http://dx.doi.org/10.3329/bmrcb.v35i3.4083Bangladesh Med Res Counc Bull 2009; 35: 113-116
Carotid Endarterectomy (CEA) performed in combination with coronary artery bypass grafting (CABG) have also increased steadily since Bernhard and colleague's initial report in 1972. Coexistence of symptomatic coronary artery disease and significant carotid artery stenosis ranges from 3.4% to 22%. The incidence of postoperative stroke after CABG ranges from 0.7% to 5%. Coronary revascularization in a patient with internal carotid artery stenosis more than 50% is associated with a postoperative stroke rate of 6%, which increases significantly to more than 16% when stenosis is more than 90%. To reduce the potential risk for postoperative stroke after CABG in patients with significant or symptomatic carotid artery stenosis, many surgeons have advocated combined CABG with unilateral carotid endarterectomy. However, clinical experience with the concomitant approach is conflicting. On the basis of the long-term results, it is estimated that simultaneous carotid endarterectomy and myocardial revascularization in conjunction with cardiopulmonary bypass is a method safe enough to prefer its routine use with acceptable low operative risk and satisfactory long-term morbidity. The overall 30-day mortality of combined CABG with bilateral carotid endarterectomy was 6.1% and that was unrelated to primary cardiac or cerebrovascular events. Favorable outcome also supports the justification for performing concomitant coronary artery bypass grafting with bilateral carotid endarterectomies in selected patients.
Background: Chronic lower limb ischemia is a dreadful disease and may present with intermittent claudication, rest pain and ischemic gangrene. Apart from life style modification and treating risk factors either angioplasty and stenting or surgical bypass are the mainstay of treatment. For infrainguinal bypasses reversed saphenous venous grafts are the conduits of choice because it is autologous , and have good patency rate. Endarterectomy is used in vessels of large caliber and may be added to bypass procedure.Objective: To study the outcome of surgical revascularization of the lower limb for chronic ischemia using reversed saphenous venous grafts.Methods: Thirty five cases of lower limb bypass surgery using reversed saphenous vein grafts were done for critical chronic lower limb ischemia from January, 2004 to December, 2008 and were analyzed for clinical success. The clinical success was defined as freedom from symptoms, avoidance of further revascularization, surgical or interventional or freedom from further amputation. The bypass procedures were femoro-popliteal, femoro-distal, femoral endarterectomy plus bypass, profundoplasty plus bypass. Data were collected, analyzed and results were recorded before discharge from the hospital, at 3 months, at 6 months and thereafter yearly follow up for up to 3 years.Results: The age range was 55 to 72 years (mean 62.34± 05.98 SD), 30 cases were male, 5 cases were female, all male patients were chronic smokers, 28 cases were diabetic, and 26 cases were hypertensive. Altogether 48 procedures were done, femoro-popliteal bypass were done in 30 cases, femoro-distal bypass were done in 7 cases (distal anastomotic sites were anterior tibial, posterior tibial or arteria dorsalis pedis), 9 cases had common femoral endarterectomy after which femoro-popliteal bypass were done, profundoplasty with femoro-popliteal bypass were done in 2 cases, 10 patient had to undergo either toe or transmetatarsal amputation. Three cases were subjected to below knee amputation at 2 to 3 years follow up due to recurrent ischemic rest pain with patchy gangrene. These were patients with femoral endarterectomy cases. The patency rate of grafts at 3 years was 65% for femoro-popliteal, 60% for femoro-distal, 57% for femoral endarterectomy with bypass and 58% for profundoplasty with bypass procedure.Conclusion: The graft patency rate and limb salvage rate for infrainguinal bypass procedure using reversed saphenous vein graft were quite satisfactory. Cessation of smoking, anti platelet and lipid lowering drug therapy, daily brisk walking for one hour and lifestyle modification improved the claudication distance and saved the limb and life in the study population. DOI: 10.3329/uhj.v6i2.7251University Heart Journal Vol. 6, No. 2, July 2010 pp.82-85
Mr. X, a smoker, normotensive, nondiabetic male patient of 24 years of age, presented with acute severe pain of the left upper extremity for 2 days. He had discoloration of the thumb and index finger for which he consulted a quack doctor who made an incision over the blackened area to drain subcutaneous collection and gave antibiotic and analgesics. There was no bleeding from the site of incision and regular dressing could not improve his condition. After waiting for 15 days without any improvement, he reported to a private clinic in Dhaka. Thorough physical examination and investigation revealed subclavian artery thrombosis due to cervical rib. The thoracic outlet syndrome was relieved by sclaneous muscle division and excision of the cervical rib, subclavian artery thrombectomy was possible through transbrachial route even after more than 2 weeks.
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