Calcific Mitral valve

I normally do not do repairs if there is calcification in rheumatic valves.
click on the image to see a bigger image

In this 18 year old girl there was some amount of calcification (surprising since she was pretty young) On echo the calcification seemed to be more on the body of the leaflet and I was wondering if I should still repair it. I had repaired 3 patients from the child's village in the past and so the Father was badgering me to attempt a repair as he was convinced about it. In view of the favorable morphology ( I cautioned him about the high probability of replacement) I went with a plan wrt repair. On table I found A3 calcified and some calcification of P3. I also found some atrial wall calcification. I excised the calcific area of P3 and approximated that area. I excised the A3 area which was calcified leaving a sliver of tissue at the margin which was not calcified and patched it with Glutaraldehyde-Protamine-

Heparin bonded Autologous pericardium. The whole AML was prolapsing and I did a combined chordoplasty of the A123 chords using 2 Goretex CV4 sutures. I divided the posterobasal chordae of P3 to increase its mobility.. I implanted a No 38 Goretex Steel ring (which gives a Geometrical area of 3.8cm 2). The first Panel shows the patched area. The second Panel shows the good coaptation with apical saline insufflation. patient has Grade 1 rheumatic AR.Patient also had aa large LA (6.4 cms) and with Afib and I have done a biatrial emaze. You can see the Postope echo still images showing theGood Mitral Doppler velocities and acceptable gradients and mitral vavle area. There was no MR.

Give us today our daily bread

My baking attempt - whole wheat bread spiced with onions,chillies garlic ginger ,basil and peppermint and a small amount of cottage cheese with some olive oil. We rarely make leavened bread at home and this was one of my forays !! I made it into a braid but the blessed thing really swelled up to occupy the whole tray !! It is tasty (though I would have added more chillies !!) It has a thick crust and being made of whole wheat is more like the "rustic" bread twhich I ate in Germany and Croatia - thick crust with a denser core but is tastier than the classical white "Wonder bread' and makes a good dipping bread with a hot soup !!

Click on the Image to enlarge it

1 1/2 cups warm water - actually needed a bit more if you are using whole wheat to allow it to become a workable dough.
3 tablespoons olive oil or peanut oil
1 1/4 tea spoon salt
3 1/2 cups wheat flour (I used whole wheat)
1 tea spoon of baking soda.
1 good packet of active yeast - I used dry yeast which I activated with 1/2 cup warm water and added a teaspoon of sugar.
Mix the activated yeast with the above ingredients and knead it into a dough. Put it into a food processor with a dough hook / blade and allow it to be processed till a "stringy " feel appears.(Good kneading is essential in the processor) Add one spoon garlic paste , one spoon ginger paste, one red onion- finely diced , one handful of coriander - finely chopped, a spoon of chopped basil leaves, one spoon of oregano and if available peppermint leaves. knead and form a tube and divide into 3 parts and braid it in a greased pan. Keep in a warm place for 60 minutes to allow the dough to rise.
Drizzle some olive oil mixed with garlic ginger paste and also chilly powder (if you like it spicy) and grind some pepper over it.
Bake at 190 Deg C for 45 minutes . Wait for 5 minutes to cool and flip it from the pan onto a grid to cool and in the meanwhile coat with a little olive oil.
You can knead into the bread some cottage cheese to make it extra rich. I used Paneer which is home made cottage cheese made by curdling milk and yoghurt and straining it and compacting it with a weight till all the whey runs out but a tub of cottage cheese would do.
Probable interesting additions could be Fennel seeds, Cinnamon,Nutmeg and Star Anise (1 tea spoon each and the last three finely powdered and added to the dough) which would make it more aromatic !!

Ruptured chordae

Click on the image to enlargen it

Picture shows multiple ruptured chordae in a patient who had endocarditis and was treated for 6 weeks. All chordae to A2 and A3 segment of the mitral valve where ruptured. They were excised , Artificial chordae with Goretex CV4 sutures were made using a loop over loop technique described by Tirone David using one Goretex suture to make ultimately 10 neochordae to suspend the whole of A2 and A3. An annuloplasty was done with a Goretex steel ring and a pseudocleft in the posterior leaflet was closed. Patient has trivial MR on post op echo and incidentally had long QT syndrome which subsided with cessation of preoperative cardorone.LQTS was suspected because the patient fibrillated while opening the pericardium and was defibrillated and while taking purse strings again had resistant fibrillation which necessitated going on CPB and did not defibrillate even after cardiac unloading. Heart was pleged and procedure was done. Patient came of in a slow sinus rhythm with ventricular ectopics which was surpressed with atrial pacing. On shifitng QT was analyzed formally on a 12 lead ECG which showed it was 680 msec and decreased to 330 msec over 5 days after cessation of Carddarone and magnesium supplementation.

Absent pulmonary valve syndrome

Click on the image to enlarge it.

Child withTOF with absent pulmonary valve Panel one shows the dilated RV and Pulmonary artery. Panel 2 shows the dysplastic pulmonary valve and small annulus and the monocusp valve being made using native redundant pulmonary artery tissue. Panel 3 shows the decrease in pulmonary artery size with a limited patch on the PA thus reducing the size of the dilated main PA (The branch PA were just plicated) and the small trans annular patch which was placed to relieve the annular obstruction. Native dysplastic pulmonary valve leaflets were excised

Absent RA appendage ASD and malignant SVT

14 year old girl found to have a secundum ASD. Was posted for surgery. On induction patient developed a hemodynamically unstable SVT not responding to cardioversion/drugs and required emergent sternotomy and CPB for hemodynamic collapse. SVT did not terminate with cardioversion on CPB and with drug loading on CPB (cordorone). On opening the chest the RA appendage was found to be absent, fatty infiltration was seen over the RA and the RA wall was found to be thickened (approx 9 mm) as seen on a biopsy specimen. The heart rate was around 230 and not getting terminated with adenosine or cardioversion on CPB so I presumed it was some sort of flutter but was unable to make out the location on the monitor ECG . The left atrial wall was also thick so I arrested the heart , did a biatrial emaze with specific attention to the Isthmic and coronary sinus burn to eliminate a major flutter cycle.ASD was closed with a Goretex patch.There was a small rudimentary appendage "nubbin" seen within the RA which did not manifest as an appendage externally.
Patient came out with sinus rhythm and has persisted to be in sinus rhythm with no ectopics on 24 hr analysis.
The plan is to withdraw cordorone at 3 months and do a Holter sos EP study then. My electrophysiologist feel that since the burns are good nothing else may be required.
The pctures clearly show the fatty infiltration and actually the fatty extension from the sinus node was extensive and well seen .
Histopath shows fatty infiltration and otherwise nothing else remarkable. (Click on the image to see a larger version)

Tricuspid complete ring implantation

Picture shows a tricuspid indigenous Goretex steel ring ring being implanted. Since the ring is complete the stitches at the base are placed on the base of the septal leaflet rather than on the annulus at the region of the conduction system (between anteroseptal commissure and the coronary sinus orifice. Note that the ring sizers and ring are used in the opposite manner compared to regular mitral sizing and implantation.

ventricular septal defect and pulmonary stenosis

clicl on the image to see a larger version

25 year old male with infundibular pulmonary stenosis (PS) and a ventricular septal defect(VSD). Both the VSD and the PS are seen particularly well in this case. Note the endocardial fibrosis around the infundibular os and the ease at which it could have been mistaken for a VSD. The last frame shows the VSD patch and after infundibular resection with excision of a hypertrophied septal band.The RVOT gradient dropped to 9 mm Hg on echo with laminar flow and the peak RV pressure was 32 mm Hg after resection on direct recording versus a systemic of 102 mm Hg. It is not often that we can get a photographable intracardiac anatomy in this subset !!