Calcific Mitral valve

I normally do not do repairs if there is calcification in rheumatic valves.
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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 !!

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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 !!