Launch of ECMO Service at Ivy Hospital Amritsar

Mechanical Complications of Myocardial Infarction I - Post Myocardial Infarction VSR

Post MI VSR

The 30 day mortality after heart attack ranges from 2-10%. Mechanical complications after MI i.e ventricular septal rupture, acute papillary muscle rupture and free wall rupture, remain a significant cause of death after heart attack.

Post MI VSR occurs due to gangrene of interventricular septum (Figure1,) leading to rupture and acute left to right shunting. This leads to cardiogenic shock and rapidly progressive liver and kidney failure. If not operated nearly 85% patients die in the next 4-6 weeks. This complication occurs in 1-6% of patients and is responsible for 15-30% of deaths after heart attack.

The diagnosis should be suspected in any patient with acute MI and cardiogenic shock. A holosystolic murmur is heard over praecordium. The diagnosis is confirmed on echocardiography (Figure2).

Specimen showing post MI VSR

Echo showing VSR with shunt across defect.

The treatment of this condition is urgent surgery. IABP is initiated in preparation of surgery. The purpose of the surgery is to debride necrotic septum and close the defect  with a synthetic patch. It creates a water-tight partition and abolishes the left to right shunt. If the patient is stable enough to allow coronary angiography, it is done pre-op and coronary bypasses are also done simultaneously.

Certain selected cases can be closed using devices thus avoiding surgery.

Despite the technical advancements, the surgical mortality remains as high as 25-30% . Patients who recover have a good survival and quality of life..

Case of the Month- Peripheral Arterial Disease- Surgical Management.

Peripheral Arterial Disease (PAD)- As the name suggests,is the disease of the peripheral arteries i.e tubes that supply blood to the arms and the legs. The disease process leads to narrowing of the arteries and this restricts the good flow to the limbs producing symptoms.
Symptoms- pain on walking , relieved on resting (intermittent claudication), rest pain, cold and pale limbs and sores on limbs that do not heal.
A variety of disease can clog the arteries. The common ones are

• Atherosclerosis (cholesterol deposition)
• Buergers disease (related to smoking)
• Bood vessel inflamation(arteritis)
• Injury.

If neglected PAD can lead to gangrene requiring amputation.

Case Report-

A 47 year old gentleman presented with progressive discomfort on walking for last 3 years. He was a heavy smoker and off late the pain was persisting even at rest. On examination he had no peripheral pulses. CT angiogram (figure1) showed severe PAD with blocked superficial femoral artery(artery to lower limb) on both sides. The patient was operated and a bypass was constructed using special synthetic tubes(grafts). These bypasses connect the arteries above and below the block thus restoring blood supply(figure2).
The patient was discharge in two days and is able to walk nearly 3km everyday.

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 Comment-
PAD is common associated with heart disease and diabetes. Smoking is another risk factor. PVD if neglected can lead to gangrene and amputation. Medical, Surgical and endovasular (stent) are treatment options depending on specific case.

Ivy Hospital, Amritsar

As of 21st July 2015, I have moved to IvyHospital, Airport Road, Amritsar. as Director and HOD Cardio-thoracic and Vascular Surgery. Lucky to have the entire team with me. I am working full time here and my contact details remain the same.

Case of the Month- Giant Right Atrium with Rheumatic Heart disease

Case History- A 52 yearly presented with signs of gross CHF. She had ascites, pleural effusions and class IV dyspnea on exertion. Her chest X Ray (below) revealed massive cardiomegaly with a CT ratio 0f 0.95. Echocardiographic diagnosis was rheumatic heart disease with severe mitral stenosis and severe tricuspid stenosis with tricuspid regurgitation. The pulmonary artery pressures were calculated at 75 mmHg (systolic). The right atrium  was giant with a calculated volume of 950ml.

Pre- opChest X Ray

Pre-op CT - giant right atrium.

The operative findings were similar to CT and echo- a hugely enlarged right atrium occupying the chest cavity. She underwent a mitral and tricuspid valve replacement with mechanical valves with reduction pasty of the right atrium. Post-op she required prolonged ventilation for persistent hypercarbia. She was eventually extubated, recovered well and discharged after 20 days.

Peri-op photo- giant right atrium entirely filling the mediastinum .

Comment- Huge enlargement of the right atrium may occur in children as a congenital anomaly. In the adults it is usually associated with pulmonary hypertension. This may be a consequence of rheumatic heart disease with mitral stenosis and tricuspid stenosis/regurgitation. Symptomatic patients need surgery. The operation should correct the primary problem and reduce the size of the atrium.

Combined Correction of Tetralogy of Fallot and CABG in a 74 year Old Man.- Press Release.