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

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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 !!

How to remove a Myxoma (Trans right atrial)

This is a picture panorama showing how to remove a myxoma transatrially.
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How to do an OMV

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This case had significant mitral stenosis and Grade II MR an LA clot and a history of CVA.. The patient underwent a mitral valve repair which required significant mitral commissurotomy, posterobasal chordal release, pseudocleft closure that resulted in perfect competence on both apical saline insufflation and epicardial echocardiography. The patient had clot removal and and an emaze done.
I have photographed the main steps viz
Valve analysis
Traction sutures on leaflets and crossing them to enhance the definition of the commissures.
Marking the end of the commissure and the mitral veil with a stab with a 11 No Blade.
Hooking of the subvalvar with a Mixter and division of the fused commissure with a 15 No blade and proceeding to divided inferiorly into the subvalvar while cautiously "sharing" subvalvar structures bilaterally to both AML and PML.
The process is repeated on the opposite side.
In this case post commissurotomy the residual leak was judged to be from a pseudocleft between P2 and P3 which was closed (Usually is not required with pure MS).

This picture set shows how to treat pericardium. Click on the image to see a bigger image.

So you are considering getting your valve repair done

As I said , valve repair is the preferred modality for treatment of leaking mitral valves. Unfortunately a lot of these are replaced. For example in the US only 30 % of valves are actually repaired and most are replaced. Valve repair takes an additional skill set and more analysis of the valve. Unfortunately, it also involves a bit of art in addition to science and a conviction to spend a bit of extra time if you want to do it. Thus many surgeons prefer to take an easier path and replace valves. I would suggest that you discuss with your surgeon and cardiologist the possibility of valve repair .

Mitral valve repair

Hi, I am a cardiac surgeon and am making a blog for the first time. I am interested in mitral valve repairs
Mitral valve repairs are done for valves that are damaged and are judged amenable to repair. This is superior to valve replacement as it allows preservation of the patients own valve and has been associated with better survival, less complications and better long term results.