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.

Case of the Month- LAD Endarterectomy on the Beating Heart.

The goal of coronary bypass surgery is complete revascularisation. This entails bypassing all coronary arteries 1mm or more in diameter with 50% or more obstruction and supplying viable myocardium. In patients with diffuse coronary artery disease this is possible only with the help of endarterctomy. In this technique vessels with less than 1mm lumen or no lumen is opened up by coring out the intima and part of medial layer of the vessel. The long arteriotomy is then patched with the bypass conduit, restoring flow to the native vessel.
Several studies have demonstrated that endarterectomy of the LAD not only relieves symptoms but also increases long term survival.

Case of the Month- Left atrial Myxoma- Commonest Tumor of the Heart.

Left Atrial Myxoma.

Tumors of the heart are rare. The commonest  tumor of the heart is a myxoma which accounts for 40-50% of primary cardiac tumors. Majority of the myxomas(90%) are solitary and pedunculated and nearly 75% occur in the left atrium. Myxomas are lobulated gelatinous in appearance. They are benign in nature but local recurrence has been reported after inadequate resection. majority of the myxomas are sporadic, 10% are familial

Myxomas can produce symptoms either by mechanical obstruction or embolisation. Symptoms of mechanical obstruction include left or right sided heart failure, depending on the site of the tumor. Syncope and dizziness may also occur. Embolic phenomenon may present as stroke, seizures and peripheral embolisation leading to infarction and gangrene.

Echocardiography is the diagnostic investigation of choice. The site and size of the tumor are clearly delineated.

The treatment is surgical excision. The tumor along with its stalk and a rim of surrounding normal tissue is excised. The prognosis is excellent. The recurrence rate is 1-3%, the familial variety  has a recurrence rate of up to 20%.

Excised gelatinous tumor with stalk and margin of interatrial septum.

Carotid Endarterctomy with PTFE patchplasty.

A 54 year old gentleman presented with recurrent right sided TIA's. MR angiography revealed a tight obstruction at the left carotid artery bifurcation. He was taken up for carotid artery stenting but the procedure was unsuccessful and resulted in a peri-procedural right upper limb monopareisis. He was then referred to us for carotid endarterectomy. 

Pre-op MR angio showing tight lt carotid bifurcation stenosis.

Post-operative CT angiogram.

He underwent a left carotid endarterectomy under general anesthesia. A carotid shunt was used and a PTFE patch arterioplasty was performed. He made an uneventful recovery and was discharged the next day. At one month follow up his is recovering well and a CT angiogram shows a widely patent carotid bifurcation with no residual obstruction.

Comment- Despite the advances in carotid stenting, carotid endarterectomy still remains the gold standard for treating carotid artery obstruction. 

Removed ulcerated plaque.

Aortic Arch Aneurysm- Management Using Endovascular Stent grafting.

 A 74 year old gentleman presented with history of hoarseness of voice for last 3 months. He consulted many physicians which led to a CT chest. The CT scan revealed a 2 X 1 cm aneurysm arising from the inner curvature of the arch. the site of the aneurysm was 2cm distal to the origin of the left subclavian artery. On investigation the patient was also diagnosed to have chronic renal failure with a serum creatinine of 2.4. His cardiac evaluation was normal. The site of the aneurysm was ideal for an endovascular procedure. The age and CRFalso pushed the decision towards an endovascular repair.

CT Aortogram Showing saccular aortic arch aneurysm with surrounding hematoma.

CT Aortogram images showing the location of the aneurysm.

Diagram showing stent placement.

The patient underwent a successful aneurysm repair using a Gore thoracic endovascular graft. In ths procedure a covered stent of appropriate size is positioned inside the aorta thus occluding the neck of the aneurysm. The approach is through the femoral artery. He was discharged the next day.

Three months post-op the patients hoarseness has improved remarkably. The CT aortogram shows a well placed stent with complete isolation of the aneurysmal sac.

Post op CT Aortogram

Comment- Aneurysms of the aortic arch are a difficult subset to manage. Conventional surgery requires median sternotomy/thoracotomy with cardio-pulmonary bypass with deep circulatory arrest. The procedure is high risk with prolonged stay in the hospital. In the recent years, endovascular grafting is becoming the procedure of choice for these patients. The patient can be discharged in a day or two and can resume normal activities.

Case of the Month- Hydatid Cyst of the Lung

A 28 year old lady presented with the complaints of persistent cough, low grade fever and malaise for 6 months. On investigation she was found to have a cystic lesion in the right upper lobe of the lung abutting the oblique fissure. She also had a cystic mass in the right lobe of the liver. The radiological findings were consistent with the diagnosis of hydatid disease of the lung and the liver.
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Chest X Ray before surgery.

Chest X Ray at initial presentation.

CT images

She was advised surgery which she refused and was sent home on oral albendazole therapy. She returned after one month a repeat chest x-ray showed that the cyst fluid had drained and it was now empty.

She underwent a right thoracotomy. The cyst was located in the right upperlobe abutting the oblique fissure. After isolating the adjoining areas with sponged soaked in hypertonic saline(scolicidal agent), the cyst was incised. The white ectocyst was removed completely (photograph below). On water testing two areas of bronchial leaks were found. They were secured with polypropylene stitches. The cyst cavity was then obliterated with multiple purse string sutures. The chest was then closed.

Removed ectocyst (germinal membrane).

Comment- hydatid disease or Echinococcosis is a zoonotic infection caused by the tapeworm of the Echinococcus species. In humans E.granulosus is the most common. Humans are accidentaly infected by ingesting food contaminated with embyonated cysts. Theoretically any organ may be involved ,bur liver and lung account for nearly 90% of the cases. The symptoms depend on the site involved and are due to pressure or mass effect and cyst complications. Cyst complications include allergic reactions due to leakage and infection.
Diagnosis is usually made by the classic radiological appearance. The indirect haemagglutination test and ELISA have a sensitivity of  90% in hepatic echinococcosis, 40% in pulmonary echinococcosisand are the initial screening tests of choice.

Antibodies to antigen 5 on IE confirm the diagnosis. The historical Casonis intradermal test is no longer used.
The treatment of this condition is surgical. The cyst is aspirated using high suction. the cavity is sterilised using scolicidal agents. Peri and post op Albendazole/Mebendazole therapy is recommended upto 6 months to prevent recurrence.