Case of the Month- Post MI Posterior LV Aneurysm- Endoventricular patch Repair.

Case of the Month- Post MI Posterior LV Aneurysm- Endoventricular patch Repair

 

A sixty year old diabetic male presented to us with a three week history of chest discomfort accompanied by sweating, restlessness and uneasiness.

He was evaluated elsewhere for coronary artery disease but the echo was found to be unremarkable. His chest X- ray revealed left pleural effusion, and he was empirically started on ATT. The patient did not improve and came to us for review/second opinion.

We conducted the following tests:

ECG- t wave inverted infr. Leads                                                                                              

CT Chest Contrast- pericardial collection, postr. Aneurysm.

 CXR- lt pleural effusion

 

 

Echo-

 Posterior LV aneurysm with pericardial effusion.

 Coronary Angio-                Occluded RCA.                      

 Proximal LAD 70-80%.

 

In view of the echo findings and the symptoms, a diagnosis of post MI, aneurysm with contained rupture of the posterior LV wall was made.

A coronary angiography was performed, which revealed significant lesions of LAD and complete occlusion of RCA.

The patient was taken up for emergency surgery. Per-operatively there were dense adhesions in the pericardium. A large 6cmX3cm true aneurysm of the posterior LV wall was found. The patient underwent CABGX2 with LIMA to LAD and SVG to PDA. The aneurysm was excised and defect in the left ventricle repaired with a Dacron patch. (Endoventricular patch). The patients lt pleural fluid was sent for examination and was negative for tuberculosis.

The patient made an uneventful recovery. The post- operative echo shows-  normal lv function, minimal pericardial effusion (post surgery).

Comment-

LV aneurysms complicate 10% of MI’s. Most of them have a chronic course and a good prognosis on medical management. Surgery is indicated when symptoms appear. The usual symptoms are, - angina, Dyspnoea and ventricular arrhythmias causing syncope. On echo an EDV of more than 120ml/m2 is also a relative indication. Rupture is a life threatening condition requiring urgent surgery.

Indications for Surgery.

Documented expansion/large size Angina Congestive heart failure Arrhythmia Rupture Pseudoaneurysm Congenital aneurysm Embolism Documented expansion/large size

 

Surgery consists of CABG (if there is significant CAD on angiography) along with excision of aneurysm and repair of defect in LV with a Dacron patch. The operative mortality is 4-7% with a 80% five year survival.

 

 

 

Punjab's First freestyle Porcine Valve Implant.

Last year we operated on a fifteen year old girl with severe aortic stenosis. She had the rare birth defect of unicuspid aortic valve. Her heart function had come down to 25% and she could barely walk. Her annulus size and ascending aorta were very small. Implanting a regular mechanical valve would have been futile as she would have high residual gradients, also she would have to be on life long anticoagulation.
I therefore implanted a freestyle valve as a complete root replacement technique. This valve is a commercially available pig valve. In a sense it is like transplanting a pig valve in the patient. The advantages are that there are minimal gradients and the heart function recovers promptly. Also the girl need not be on anticoagulation and can have a normal family life. Needless to say the procedure is technically very demanding and time consuming.
At one year follow up the girl is healthy with normal heart function.
The company reps tell me that this is the first time such a valve has been implanted in Punjab!!!



Freestyle Porcine(pig) aortic valve.

Total Arterial Coronary Bypass- Bilateral Mammary Arteries.

Case of the Month- Annulo aortic ectasia- Bentalls Operation.

A 66 year old male referred for evaluation of palpitations and dyspnoea on exertion(class III). ECG was suggestive of left ventricular hypertrophy. Transthoracic echocardiography revealed a tricuspid aortic valve with moderately severe aortic regurgitation. The aortic annulus was dilated (30 mm). There was dilation of the ascending aorta (6.7cm). A  CT aortogram was done (see images below), which showed dilatation of the aortic annulus and the aortic sinuses with aorta tapering to a near normal diameter just before the arch vessels.The images were typical of annulo aortic ectasia. the coronary arteries were normal on angiogram.

Classical pear shaped appearance of aortic root.

The patient underwent a aortic root replacement (modified Bentalls operation)using a size 25 valved conduit.


Comment-Annulo aortic ectasia is a condition in which there is dilatation of the aortic annulus and the aortic sinuses. this leads to stretch on the aortic valve leaflets resulting in variable degrees of aortic regurgitation. This condition is found in patients with Marfans syndrome but aging and hypertension are also the causes. The basic defect is weakness of the medial layer of aorta resulting in dilation which progresses with time. As the size of the aorta increases, the chance of dissection, rupture also increase. The treatment of this condition is surgery. There are well defined guidelines for aortic size when intervention is indicated. If the aortic valve can be preserved, a valve sparing (David I) operation can be performed. In others the aortic valve and the aorta are replaced using a composite graft (Bentalls operation) with reimplantation of the coronary arteries.
Other conditions in which Bentalls procedure is performed are type A aortic dissection with irreparable aortic valve, symptomatic bicuspid aoric valve disease with ascending aortic dilatation. The current aortic size guidelines above which ascending aorta should be replaced  are:

Bicuspid aortic valve- 4.5 cm.
Marfans Syndrome-  5.0 cm
Others------------- 5.5 cm

Composite graft and valve conduit

Modified Bentalls procedure

Amritsars First Aortic Dissection Surgery

Dr Pankaj Goel and the team of surgeons, anesthetist and nurses with the first Aortic Dissection Repair patient.

In March 2008, we created history by performing the first Aortic dissection repair inthe city of Amritsar. The 58 year old patient had an a acute aortic dissection with  leaking aortic valve and underwent a Bentalls operation. At nearly four and half years, the patient is well and enjoying a normal life.

Aortic Dissection- A True Surgical Emergency.

There are a few real cardiac surgical emergencies and Aortic Dissection tops the list. It is an emergency as the death risk is nearly 25% per hour after the onset of symptoms.  Only a few survive beyond 24 hours. The treatment is emergency surgery.

What is Aortic Dissection?- Aorta is the large artery (pipe) that delivers blood form the heart to all the organs of the body. Normal aorta is made up of layers of tissue which are held together by a natural tissue glue. In patients with certain diseases, this glue is weak and the blood tears the inner mambrane of aorta and dissects between the layers creating a false passage. This leads to formation of two passages within aorta- a true lumen and a false lumen.



CT Scan- Tear in Aorta

 

Why is Aortic Dissection Dangerous?- Once the blood leaks into the outer layers of aorta, it is contained only by a very thin layer of tissue. This layer may rupture leading to massive blood loss and sudden death. The dissection may spread to various arteries blocking off the blood supply to vital organs leading to massive heart attacks, stroke, renal failure and gut ischemia. All of these conditons may lead to sudden death.

What are the symptoms of Aortic Dissection?- This condition presents as severe chest pain radiating to the back usually accompanied by sweating and a feeling of impending doom. In many cases it mimics the symptoms of heart attack.

How is Aortic Dissection Diagnosed?- The characterstic symptoms should raise the alarm. The key to save life is to have a high index of suspicion. An echocardiogram can diagnose this condition, a contast CT chest is diagnostic. The important thing is not to waste time and refer the patient to a place where it can be managed surgically.

What is the treatment of Aortic Dissection?- The treatment of this conditon is emergency surgery. Without wasting time, the patient is shifted into the operating room. A transesophageal echo is done to confirm the diagnosis. The patient is put on heart lung machine and the area of the aortsa where the tear started is replaced with an artficial tube graft. The operative risk is about 10%.

Coronary Bypass- Two Mammary Arteries Are Better Than One

The left internal mammary artery (LIMA) has been used for coronary artery bypass grafting (CABG) for the last six decades. It has stood the test of time. The LIMA to left anterior descending artery (LAD)  has a patency rate of 95% at 15 years. It is more than any other graft or stent. In fact, the LIMA to LAD anastomosis is responsible for improved survival after CABG.
With the age of patients coming forward for bypass surgery showing a decline, it is logical to assume that the addition of another arterial graft- Right internal mammary artery(RIMA) should further increase the survival. A series of recent research papers have shown that the addition of RIMA to bypass other left sided arteries of the heart (circumflex system), further improves survival.
The latest issue of Annals of Thoracic Surgery has an article re enforcing the concept that in Bypass surgery two mammary arteries are better than one.

Bilateral Internal Thoracic Artery Grafting Is Associated With Significantly Improved Long-Term Survival, Even Among Diabetic Patients

John D. Puskas, MD^a,_*, Adil Sadiq, MS, MCh^a,Thomas A. Vassiliades, MD^a, Patrick D. Kilgo, MS^b,Omar M. Lattouf, MD, PhD^aa Clinical Research Unit, Division of Cardiothoracic Surgery, Rollins School of Public Health, Emory University, Atlanta, Georgia
^b Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta,
Ann Thorac Surg 2012;94:710-716.