Publications by authors named "Vivek Wadhawa"

22 Publications

  • Page 1 of 1

Anesthetic management of right brachiocephalic artery aneurysm causing tracheal compression.

Ann Card Anaesth 2021 Oct-Dec;24(4):498-499

Department of Cardiovascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India.

The airway compression poses a challenge for the anesthesiologist in airway management during aneurysm repair surgery.
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http://dx.doi.org/10.4103/aca.ACA_195_20DOI Listing
November 2021

Mini-Bentall Surgery: The Right Thoracotomy Approach.

J Chest Surg 2021 Dec;54(6):554-557

Department of Cardio Vascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center, B. J. Medical College, Ahmedabad, India.

Surgeons are increasingly using the right mini-thoracotomy approach to perform aortic valve surgery. This approach has shown better results in terms of blood loss and length of hospital stay than the sternotomy approach. For selected patients requiring aortic root and ascending aorta surgery, a right mini-thoracotomy approach may prove beneficial. In our technique, we placed a 5-cm horizontal skin incision in the right second intercostal space. Femoro-femoral cardiopulmonary bypass was established. A valved aortic conduit was used for aortic root replacement. The patient's postoperative course was uneventful, with a short hospital stay. This technique offers a minimally invasive approach to aortic root and ascending aorta surgery with easy adaptability and reduced costs.
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http://dx.doi.org/10.5090/jcs.21.036DOI Listing
December 2021

Case of rheumatic mitral stenosis with bilateral coronary artery fistula to pulmonary artery: A rare entity.

J Cardiovasc Thorac Res 2021 30;13(2):176-178. Epub 2021 Jan 30.

Department of Cardiovascular and Thoracic Surgery, Gujarat, India.

Coronary to pulmonary artery fistula is a rare form of congenital coronary artery anomaly. Majority of coronary arteriovenous fistula detected incidentally on coronary angiography. Although, most of these patients are asymptomatic, larger fistulae can produce symptoms of heart failure. Here we present a rare case of 61-year-old female who presented primarily for mitral valve replacement for severe mitral stenosis. On screening angiography, there were two fistula arising from both right and left coronary artery and draining in to the main pulmonary artery. The patient was operated and mitral valve replacement with closure of the fistula. Patient had an uneventful post-operative period and was discharged on 7 the post-operative day.
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http://dx.doi.org/10.34172/jcvtr.2021.13DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8302896PMC
January 2021

Spontaneous pneumomediastinum and subcutaneous emphysema in patients with COVID-19.

Saudi J Anaesth 2021 Apr-Jun;15(2):93-96. Epub 2021 Apr 1.

Department of Cardio Vascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India.

Background: Coronavirus disease 2019 is an infectious disease caused by severe acute respiratory syndrome virus coronavirus 2 (SARS-COV-2). Many aspects of its pathology and pathogenesis are not well understood.

Material And Methods: We describe a series of spontaneous air leak cases we found in our coronavirus disease 2019 (COVID-19) positive 1086-patient cohort.

Results: Two out of six patients eventually required mechanical ventilation and succumbed to COVID-19. We presume that acute lung injury leading to SARS-CoV-2 with associated acute respiratory distress syndrome predisposes patients to this complication.

Conclusion: This series is presented to highlight the emerging association of COVID-19 with spontaneous air leaks leading to pneumomediastinum, pneumothorax, and subsequent subcutaneous emphysema even in patients who have never received invasive mechanical ventilation and this may be more likely with the institution of high flow nasal cannula.
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http://dx.doi.org/10.4103/sja.sja_939_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8191243PMC
April 2021

Midterm outcome of off-pump CABG for severe LV dysfunction-Does LV size and function predict their midterm outcome?

J Card Surg 2021 Mar 27;36(3):1000-1009. Epub 2021 Jan 27.

Department of CVTS, U. N. Mehta Institute of Cardiology and Research Center (affiliated to BJ Medical College, Ahmedabad), Ahmedabad, Gujarat, India.

Background: The superiority of surgical revascularization in ischemic cardiomyopathy is established beyond doubt, and off-pump CABG (OP-CABG) is a safe way of revascularization in this high-risk subset. Data on the effect of postoperative ventricular function and size on their midterm outcome is scarce.

Materials And Methods: A retrospective study was done on 211 consecutive patients with severe LV dysfunction who underwent OP-CABG from January 2017 to December 2018. Data were collected from the institutional database. Their operative and midterm outcomes were statistically analyzed.

Results: The mean age of the cohort was 58.4 ± 8.3 years. An average number of grafts was 3.1 ± 0.8 (cumulative intended number of grafts-3). Operative mortality was 10.9%. Preoperative NYHA class (p < .0001; OR, 19.72) and postoperative IABP insertion (p < .008; OR, 88.75) were independent predictors of operative mortality. The mean follow-up period was 3.14 ± 0.07 years, was 97.4% complete with cardiac mortality of 5.8%. Postoperative LVEF (p = .002; OR, 0.868) and LV dimensions (systole & diastole) (p = .013, OR = 1.182 and p = .036, OR = 1.184, respectively) were independent predictors of midterm mortality. Midterm major adverse cardiovascular event-free survival of operative survivors was 89%. There was no correlation between postoperative LV dimension and NYHA status(p > .05). Myocardial viability was not associated with early (p = .17) or midterm mortality (p = .676).

Conclusion: OP-CABG can achieve complete revascularization in patients with severe LV dysfunction with good midterm outcomes, albeit with high early operative mortality. Postoperative change in LV dimension and EF are predictors of midterm mortality.
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http://dx.doi.org/10.1111/jocs.15362DOI Listing
March 2021

Total arterial multivessels minimal invasive direct coronary artery bypass grafting via left minithoracotomy.

Gen Thorac Cardiovasc Surg 2021 Jan 25;69(1):8-13. Epub 2020 Jun 25.

Department of Cardio Thoracic and Vascular Surgery, U.N.Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmedabad, 380016, Gujarat, India.

Background: Minimal Invasive Direct Coronary Artery Bypass Surgery (MIDCAB) is becoming popular and an important armamentarium for cardiac surgeons. We aimed to evaluate the result of MIDCAB total arterial revascularization.

Methods: We have evaluated 216 patients who underwent MIDCAB multivessel total arterial revascularization through a left anterolateral mini thoracotomy. LIMA harvested in every patient, RIMA or radial artery used as second conduit. LIMA-RIMA Y or LIMA-RADIAL Y was made to accomplish multivessels total arterial revascularization. Post-operative graft patency was evaluated in all patients by CT coronary angiography at 6 months following discharge.

Results: Mean age of patients was 52.5 ± 9.8 years. Average number of anastomosis performed were 2.34 ± 0.75. Multivessels total arterial CABG was accomplished in all individuals. There was no mortality or deep wound infection. Re-exploration was done in two patients for bleeding. In one patient emergency CPB was required. Average ICU and hospital stay was 1.52 ± 0.77 and 4.92 ± 1.46 days, respectively. Patients were mobilized earlier due to less pain. Wound healing of anterolateral thoracotomy was faster. In the follow up CT angiography 100% of the LIMA grafts were patent.

Conclusions: Multivessels total arterial MIDCAB can be accomplished safely in selected individuals. RIMA can be harvested in long standing diabetic patients with no concern for sternal wound healing. MIDCAB patients experience better cosmetics and early return to daily activities.
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http://dx.doi.org/10.1007/s11748-020-01412-4DOI Listing
January 2021

Early and late mortality and morbidity after post-MI ventricular septal rupture repair: predictors, strategies, and results.

Indian J Thorac Cardiovasc Surg 2019 Jul 6;35(3):437-444. Epub 2019 Apr 6.

Department of Cardiac Anaesthesia, U. N. Mehta Institute of Cardiology and Research Center, BJ Medical College, Ahmedabad, India.

Purpose: There has been a shift in the paradigm of management of post-myocardial infarction ventricular septal rupture (MI VSR), with many authors reporting improved prognosis if the surgery can be "optimally delayed." Timing of the procedure is of critical importance and our management (UPMS), and prognosis scores (UPPS) have proven to be relevant. However, long-term outcomes and their correlation with our scores had not been analyzed. In this study, we present our long-term results of post-MI-VSR repair and their correlation with our prognosis score (UPPS).

Methods: Seventy-one patients with post-MI VSR repair (2009-2017) were retrospectively studied. Patients were managed using standard institute protocols.

Results: The 30-day mortality was 56% ( = 40). During a mean follow-up of 4.91 ± 2.43 years, there were eight late deaths. Actuarial survival of 30-day survivors was 87% at 1 year, 74% at 5 years, and 69% at 10 years. Actuarial freedom from major adverse cardiovascular events (MACE) was 82% at 1 year, 72% at 2 years, and 72% at 8 years. The UPPS score predicts late mortality with sensitivity of 75% and negative predictive value of 84%.

Conclusion: Our prognostic score (UPPS) helps not only in predicting early mortality but also in identifying the patients who are likely to live longer. The management score (UPMS) also provides best timing for the procedure, which is helpful in optimal utilization of resources in the developing world. The accuracy of these scores is reasonable and may be helpful in the decision-making in this difficult subset.
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http://dx.doi.org/10.1007/s12055-019-00792-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525703PMC
July 2019

"RFEF" and mitral regurgitation jet direction: surrogate markers for likelihood of left ventricle reverse remodeling in patients with moderate chronic ischemic mitral regurgitation.

Indian J Thorac Cardiovasc Surg 2019 Apr 18;35(2):158-167. Epub 2018 Oct 18.

Department of Cardiology, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College, Ahmedabad), Ahmedabad, India.

Purpose: Surgical management of moderate chronic ischemic mitral regurgitation (CIMR) is controversial. We propose a simplified classification of moderate CIMR based on regurgitant fraction (RF), ejection fraction (EF), and jet direction (central/eccentric) to predict left ventricle (LV) remodeling and identify patient subsets which need mitral valve (MV) repair along with coronary artery bypass grafting (CABG).

Methods: In this prospective controlled study ( = 210), patients with moderate CIMR were randomized. Group I ( = 106) underwent off-pump CABG alone while group II ( = 104) underwent CABG + MV repair. The product of regurgitation fraction and ejection fraction ("RFEF") was taken as a surrogate for myocardial reserve. The cut-off defined was 0.12; patients with RFEF ≤ 0.12 were categorized as the "bad" and those with RFEF > 0.12 as the "good" subset. The patients were further subdivided on the basis of their mitral regurgitation (MR) jet direction (central/eccentric). The percentage improvement in left ventricular end-systolic volume index (LVESVI) and MR grade were recorded 6 monthly.

Results: Analysis of the continuous variable "RFEF" in conjunction with jet direction was performed. At 12 months, the patient in good subset with central direction of jet showed improvement in LVESVI % in both groups ( = 0.428), while the patients in bad subset with eccentric direction of jet showed significantly higher improvement in LVESVI %, group II as compared to group I ( = 0.004).

Conclusion: This study thus identifies "RFEF" as a surrogate for reverse remodeling capacity. In association with MR jet direction, predicts the subset of moderate CIMR patients most likely to have maximum LVESVI and MR grade reduction.
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http://dx.doi.org/10.1007/s12055-018-0717-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525430PMC
April 2019

'CLAS' score: an objective tool to standardize and predict mitral valve repairability.

Indian J Thorac Cardiovasc Surg 2019 Jan 9;35(1):15-24. Epub 2018 Oct 9.

Department of Cardiology, U. N. Mehta Institute of Cardiology and Research Center (affiliated to BJ Medical College, Ahmedabad), Ahmedabad, Gujarat India.

Purpose: Carpentier's classification has been used to classify both stenotic and regurgitant lesions. However, given the extreme variability of lesions, a universal nomenclature suggestive of the complexity and the prognosis of the repair procedure for the entire spectrum of the mitral valve disease still remains elusive. We present the predictors of mitral valve repairability with the help of a four-level-based 'CLAS' scoring system.

Methods: A total of 394 patients undergoing mitral valve procedure were prospectively studied. The valvular apparatus was divided into four sub-units, namely Commissures (C), Leaflet (L), Annulus (A), and Subvalvular apparatus (S), and the components were scored individually and the summation scores were calculated. Based on our results, three CLAS groups were formulated.

Results: A total of 376 ( = 394) patients underwent successful MVRep (95.43%; on-table failure in 18 patients). A total of 276 were rheumatic, 51 degenerative, 28 congenital, and 16 had infective endocarditis. Thirty-day mortality was 14 (3.72%) while delayed re-intervention rate was 8 (2.12%). The mean follow-up period was 30 months. One hundred percent patients with a CLAS score ≤ 8 had a successful repair as compared to 93.33 and 69.69%, respectively, for patients with scores between 9 and 12 and > 12, respectively. The cardio pulmonary bypass time, aortic-cross-clamp time, and ICU stay also showed a significant correlation with the patient's 'CLAS' groups.

Conclusion: The CLAS score is highly predictive of a successful repair. We thus propose that, in the patients with a score of ≤ 8, repair should always be attempted irrespective of the pathology. The patients expected to be scored > 8 should be referred to a repair reference center.
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http://dx.doi.org/10.1007/s12055-018-0721-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525520PMC
January 2019

Concomitant Left Atrial Reduction in Rheumatic Mitral Valve Disease With Giant Left Atrium: Our Technique With Midterm Results.

Innovations (Phila) 2018 Sep/Oct;13(5):349-355

Medical Research, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), Civil Hospital Campus, Asarwa, Ahmedabad, India.

Objective: The giant left atrium is a frequent finding with rheumatic heart disease. The enlarged left atrium was found to be a risk factor for early mortality and postoperative higher thromboembolic events, but its management remains controversial. Most of the surgeons just do the mitral valve procedure without any intervention for enlarged left atrium. We present our center's experience of patients with giant left atrium who underwent a newer technique of left atrium reduction concomitant with mitral valve procedure.

Methods: Between January 2012 and February 2015, 25 patients, who underwent surgery for concomitant left atrium reduction with mitral valve disease, were included in the study after institute's ethics committee clearance. Patients having combined aortic and mitral valve disease were excluded. Preoperative, intraoperative, and postoperative data were collected. All the patients were also followed up clinically and echocardiographically in postoperative period.

Results: There were 15 (60%) females. The mean ± SD age of the patients was 36.92 ± 5.4 years. Preoperatively, all patients were in long-standing persistent atrial fibrillation. The mean ± SD bypass and aortic cross-clamp time were 74.56 ± 3.85 and 51.72 ± 4.32 minutes, respectively. There was a significant reduction of left atrium diameter and volume from 94.48 ± 11.0 mm to 40.08 ± 1.35 mm and 348.3 ± 121.1 to 26.57 ± 2.9 mL/m, respectively. There was no early or late mortality. At a mean ± SD follow-up of 42.28 ± 12.1 months, all patients were in New York Heart Association I or II class and 24 (96%) patients were in normal sinus rhythm.

Conclusions: Concurrent left atrium reduction with mitral valve procedure is a feasible and effective technique for event-free survival of the patients having giant left atrium with mitral disease.
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http://dx.doi.org/10.1097/IMI.0000000000000559DOI Listing
March 2019

Direct Femoral Cannulation in Minimal Invasive Pediatric Cardiac Surgery: Our Experience With Midterm Result.

Innovations (Phila) 2018 Jul/Aug;13(4):300-304

Nuclear Medicine, U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India.

Objective: One of the major challenges faced in minimally invasive pediatric cardiac surgery is cannulation strategy for cardiopulmonary bypass. Central aortic cannulation through the same incision has been the usual strategy, but it has the disadvantage of cluttering of the operative field. We hereby present the results of femoral cannulation in minimally invasive pediatric cardiac surgery in terms of adequacy and safety.

Methods: From January 2013 to June 2016, 200 children (122 males) with mean ± SD age of 9.2 ± 4.51 years (median = 6 years, range = 3-18 years) and weight of 19.22 ± 8.49 kg (median = 15 kg, range = 8-45 kg) were operated for congenital cardiac defects through anterolateral thoracotomy. The most common diagnosis was atrial septal defect (144 patients). In all the patients, femoral artery and femoral vein were cannulated along with direct superior vena cava cannulation for institution of cardiopulmonary bypass.

Results: There were no deaths or any major complications related to femoral cannulation. Femoral artery cannulation provided adequate arterial inflow, whereas femoral vein with direct superior vena cava cannulation provided adequate venous return in all the patients. No patient required vacuum-assisted venous drainage. No patient required conversion to sternotomy or developed vascular, neurological complications. At discharge and at 1-year follow-up, both femoral artery and vein were patent without a significant stenosis on color Doppler ultrasonography in all the patients. At mean ± SD follow-up period of 30.63 ± 10.09 months, all the patients were doing well without any wound-related, neurological, or vascular complications.

Conclusions: Femoral arterial and venous cannulation is a feasible, reliable, and efficient method for institution of cardiopulmonary bypass in minimally invasive pediatric cardiac surgery.
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http://dx.doi.org/10.1097/IMI.0000000000000540DOI Listing
December 2018

OPCABG for Moderate CIMR in Elderly Patients: a Superior Option?

Braz J Cardiovasc Surg 2018 Jan-Feb;33(1):15-22

Department of Research of the U. N. Mehta Institute of Cardiology and Research Center (affiliated to BJ Medical College, Ahmedabad), Gujarat, India.

Objective: To compare the early and late outcomes of off-pump coronary artery bypass grafting and coronary artery bypass graft + mitral valve repair in elderly patients with moderate chronic ischemic mitral regurgitation.

Methods: One hundred and fifty elderly (age > 70 years) patients with moderate chronic ischemic mitral regurgitation who underwent off-pump coronary artery bypass grafting (n=95) or coronary artery bypass graft + mitral valve repair (n=55) between January 2007 and December 2014 were studied. They were subdivided according to presence or absence of high operative risk. Peri-operative variables and early operative outcomes were retrospectively studied. Survival, mitral regurgitation grade, and functional outcomes were prospectively analysed.

Results: Both groups were comparable in terms of age (P=0.23), sex (P=0.74), left ventricle ejection fraction (P=0.6) and preoperative functional class (P=0.52). The mean number of grafts for off-pump coronary artery bypass grafting group was 3.14 and coronary artery bypass graft + mitral valve repair was 3.21. Off-pump coronary artery bypass grafting group had statistically significant better early operative outcomes i.e perioperative blood transfusions, intraaortic balloon pump usage, arrhythmias, renal dysfunction, liver dysfunction, sepsis, mean hours of ventilation, intensive care unit stay and operative mortality. On a prospective follow up of 5±2.33 years (1-9 years), coronary artery bypass graft + mitral valve repair in low operative risk subgroup had better improvements in mitral regurgitation grade than off-pump coronary artery bypass grafting. Both groups had similar improvements in functional class and cumulative survival was also comparable (63.2% vs. 54.5%).

Conclusion: Off-pump coronary artery bypass grafting is a safer alternative to coronary artery bypass graft + mitral valve repair with better early operative outcomes and comparable late survival and functional outcomes in elderly patients with moderate chronic ischemic mitral regurgitation, especially those with higher operative risk.
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http://dx.doi.org/10.21470/1678-9741-2017-0114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5873778PMC
December 2018

Surgical overview of cardiac echinococcosis: a rare entity.

Interact Cardiovasc Thorac Surg 2018 08;27(2):191-197

Department of Cardiovascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center (Affiliated with B.J. Medical College), Ahmedabad, Gujarat, India.

Objectives: The purpose of this study was to describe our experience with the presentation and management of cardiac echinococcosis and the outcomes.

Methods: We performed a retrospective study from January 2012 to September 2017 in 10 patients operated on for cardiac echinococcosis. There were 6 men and 4 women; the age range was 17-55 years (mean age, 35.9 ± 12.04 years). Among the 10 patients, 3 had multiple cysts and of the 7 patients with a solitary cyst, 5 cysts were in the left ventricle, 1 was in the right ventricle and 1 was in the interventricular septum. All patients were evaluated with electrocardiography, transthoracic echocardiography, computed tomography/magnetic resonance imaging of the thorax, ultrasound examinations of the abdominal organs, haemagglutination tests and histopathological examination of the cyst.

Results: Nine operations were performed using cardiopulmonary bypass. One patient with a pericardial cyst was operated on with a beating heart with cystectomy and partial pericardiectomy. Preoperatively, all patients received albendazole for 2 weeks except for 1 patient who had an emergency operation. Albendazole was continued postoperatively in all patients for 12 weeks. There were no postoperative complications. No recurrences have been observed so far.

Conclusions: Cardiac echinococcosis is an infrequently encountered entity, but with clinical suspicion and early diagnosis it can be successfully managed with good outcomes.
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http://dx.doi.org/10.1093/icvts/ivy053DOI Listing
August 2018

Anterior Minithoracotomy: a Safe Approach for Surgical ASD Closure & ASD Device Retrieval.

Braz J Cardiovasc Surg 2017 Jul-Aug;32(4):270-275

Department of Research of the U. N. Mehta Institute of Cardiology and Research Center (affiliated to BJ Medical College, Ahmedabad), Gujarat, India.

Objective: Midline sternotomy is the preferred approach for device migration following transcatheter device closure of ostium secundum atrial septal defect. Results of patients operated for device migration were retrospectively reviewed after transcatheter closure of atrial septal defect.

Methods: Among the 643 patients who underwent atrial septal defect with closure device, 15 (2.3%) patients were referred for device retrieval and surgical closure of atrial septal defect. Twelve patients underwent device retrieval and surgical closure of atrial septal defect through right antero-lateral minithoracotomy with femoral cannulation. Three patients were operated through midline sternotomy.

Results: Twelve patients operated through minithoracotomy did not require conversion to sternotomy. Due to device migration to site of difficult access through thoracotomy, cardiac tamponade and hemodynamic instability, respectively, three patients were operated through midline sternotomy. Mean aortic cross-clamp time and cardiopulmonary bypass time were 28.1±17.7 and 58.3±20.4 minutes, respectively. No patient had surgical complication or mortality. Mean intensive care unit and hospital stay were 1.6±0.5 days and 7.1±2.2 days, respectively. Postoperative echocardiography confirmed absence of any residual defect and ventricular dysfunction. In a mean follow-up period of six months, no mortality was observed. All patients were in New York Heart Association class I without wound or vascular complication.

Conclusion: Minithoracotomy with femoral cannulation for cardiopulmonary bypass is a safe-approach for selected group of patients with device migration following transcatheter device closure of atrial septal defect without increasing the risk of cardiac, vascular or neurological complications and with good cosmetic and surgical results.
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http://dx.doi.org/10.21470/1678-9741-2017-0024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5613724PMC
October 2017

Normokalemic nondepolarizing long-acting blood cardioplegia.

Asian Cardiovasc Thorac Ann 2017 Sep-Oct;25(7-8):495-501. Epub 2017 Oct 4.

4 Department of Cardiac Anesthesia, U N Mehta Institute of Cardiology and Research Center, Civil Hospital, Ahmedabad, Gujarat, India.

Objective Blood cardioplegia, the gold-standard cardioprotective strategy, requires frequent dosing, resulting in hyperkalemia-induced myocardial edema. The aim of our study was to compare the efficacy and safety of a long-acting blood-based cardioplegia with physiological potassium levels versus the well-established cold blood St. Thomas' Hospital no. 1 cardioplegia solution in multivalve surgeries. Methods One hundred patients undergoing simultaneous elective aortic and mitral valve replacement ± tricuspid valve repair were randomized in two groups. In group 1, adenosine 12 mg was given via the aortic root after crossclamping, followed by a single dose of long-acting solution at 14℃ (30 mLċkg); in group 2, an initial 30 mLċkg of St. Thomas' cardioplegia at 14℃ was administered, followed by 15 mLċkg every 20 min. Duration of cardiopulmonary bypass, inotropic score, arrhythmias, ventilation time, and the levels of interleukin-6, creatinine kinase-MB, and troponin I were compared. Results Mean cardiopulmonary bypass and crossclamp times were 134.04 ± 36.12 vs. 154.34 ± 34.26 ( p = 0.004) and 110.37 ± 24.80 vs. 132.48 ± 31.68 min ( p = 0.002), respectively, in the long-acting and St. Thomas' groups. Cardiac index, creatinine kinase-MB and troponin I levels were comparable. Interleukin-6 levels post-bypass were 61.72 ± 15.33 and 75.44 ± 31.78 pgċmL ( p = 0.007) in the long-acting and St. Thomas' cardioplegia groups, respectively. Conclusions Single-dose long-acting cardioplegia gives a cardioprotective effect comparable to repeated doses of the well-established St. Thomas' Hospital no. 1 cold blood cardioplegia.
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http://dx.doi.org/10.1177/0218492317736448DOI Listing
June 2018

Techniques, Timing & Prognosis of Post Infarct Ventricular Septal Repair: a Re-look at Old Dogmas.

Braz J Cardiovasc Surg 2017 May-Jun;32(3):147-155

Department of Research of the U. N. Mehta Institute of Cardiology and Research Center (affiliated to BJ Medical College, Ahmedabad), Gujarat, India.

Objective:: The study aimed to identify the factors affecting the prognosis of post myocardial infarction (MI) ventricular septal rupture (VSR) and to develop a protocol for its management.

Methods:: This was a single center, retrospective-prospective study (2009-2014), involving 55 patients with post MI VSR. The strengths of association between risk factors and prognosis were assessed using multivariate logistic regression analysis. The UNM Post MI VSR management and prognosis scoring systems (UPMS & UPPS) were developed.

Results:: Thirty-day mortality was 52.5% (35% in the last 3 years). Twenty-eight (70%) patients underwent concomitant coronary artery bypass grafting. Residual ventricular septal defect was found in 3 (7.5%) patients. The multivariate analysis showed low mean blood pressure with intra-aortic balloon pump (OR 11.43, P=0.001), higher EuroSCORE II (OR 7.47, P=0.006), higher Killip class (OR 27.95, P=0.00), and shorter intervals between MI and VSR (OR 7.90, P=0.005) as well as VSR and Surgery (OR 5.76, P=0.016) to be strong predictors of mortality. Concomitant coronary artery bypass grafting (P=0.17) and location (P=0.25) of VSR did not affect the outcome. Mean follow-up was 635.8±472.5 days and 17 out of 19 discharged patients were in NYHA class I-II.

Conclusion:: The UNM Post-MI VSR Scoring Systems (UPMS & UPPS) help in management and prognosis, respectively. They divide patients into 3 groups: 1) Immediate Surgery - Patients with scores of <25 require immediate surgery, preferably with extracorporeal membrane oxygenation support, and have poor prognosis; 2) Those with scores of 25-75 should be managed with "Optimal Delay" and they have intermediate outcomes; 3) Patients with scores of >75 can undergo Elective Repair and they are likely to have good outcomes.
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http://dx.doi.org/10.21470/1678-9741-2016-0032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5570397PMC
September 2017

A rare malformation of bilateral superior vena cava with bilateral partial anomalous pulmonary venous connection in the presence of ostium secundum atrial septal defect: management strategies and pitfalls.

Gen Thorac Cardiovasc Surg 2017 Dec 3;65(12):713-716. Epub 2017 Mar 3.

Department of Cardio vascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center, (Affiliated to B. J. Medical College), New Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, 380016, India.

Bilateral superior vena cava (SVC) with bilateral partial anomalous pulmonary venous connection is a very rare congenital cardiac malformation. Here, we are reporting a case of 18-year-old male who had bilateral SVC with bilateral anomalous pulmonary venous connection associated with ostium secundum atrial septal defect. The patient underwent successful surgical correction for the same.
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http://dx.doi.org/10.1007/s11748-017-0764-2DOI Listing
December 2017

Dialyzer-based cell salvage system: a superior alternative to conventional cell salvage in off-pump coronary artery bypass grafting.

Interact Cardiovasc Thorac Surg 2017 04;24(4):489-497

Department of Research, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College, Ahmedabad), Ahmedabad, Gujarat, India.

Objectives: Our goal was to test the hypothesis that the use of a dialyzer-based cell salvage system during off-pump coronary artery bypass grafting (OPCABG) reduces requirements for homologous blood transfusions (HBT) and improves postoperative haemtochemical parameters.

Methods: Data were prospectively collected for 222 patients who had OPCABG using 3 different cell salvage techniques: (1) dialyzer-based cell salvage (DBCS) ( n  = 75), (2) conventional cell salvage (CCS) ( n  = 73) and (3) without cell salvage (WCS) ( n  = 74). Salvaged blood was transfused at the end of the operation. The primary outcome of the study was the amount of homologous blood transfused. Secondary outcomes were changes in haemtochemical parameters, postoperative bleeding, need for non-invasive ventilation (NIV), postoperative complications, renal dysfunction, clotting derangement, duration of intensive care unit (ICU) and hospital stay and mortality rates.

Results: There were no deaths. In patients with >1000 ml blood loss, there was a significant reduction in HBT in the DBCS group (300 ± 161 ml) compared with the WCS group (550 ± 85 ml) ( P  <   0.0001). Postoperative changes in haemtochemical parameters were significantly fewer in the DBCS group compared with the other 2 groups. The incidence of NIV ( P  =   0.002), renal dysfunction ( P  =   0.009) and postoperative complications ( P  =   0.003) was least in the DBCS group and highest in the WCS group. Mean ICU stays were comparable ( P  =   0.208); however, the mean hospital stay was significantly shorter in the DBCS group (6.08 ± 3.12 days) compared with the WCS group (7.54 ± 4.46 days) ( P  =   0.022). There was no significant increase in coagulopathy in any group as suggested by comparable chest tube drainage ( P  =   0.285) and comparable prothrombin time.

Conclusions: The use of the DBCS system in OPCABG resulted in a significant reduction in HBT, improvement in postoperative levels of haemoglobin, platelets and albumin and reduction in complications without increased risk of coagulopathy.
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http://dx.doi.org/10.1093/icvts/ivw371DOI Listing
April 2017

Hemodiafiltration-A Technique for Physiological Correction of Priming Solution in Pediatric Cardiac Surgery: An In Vitro Study.

Artif Organs 2017 Aug 7;41(8):773-778. Epub 2016 Dec 7.

Department of Research, U.N. Mehta Institute of Cardiology and Research Center and B.J. Medical College, New Civil Hospital, Ahmedabad, Gujarat, India.

Pediatric cardiopulmonary bypass (CPB) circuit invariably requires priming with packed red blood cells (PRBCs). Metabolic composition of stored PRBCs is unphysiological and becomes worse with increasing duration of storage. It is recommended to correct these abnormalities before initiation of CPB. We tested the hypothesis that hemodiafiltration of the prime with 0.45% saline is sufficient for reducing the metabolic load and reaching a physiologic state. In an in vitro study, 100 mL of blood each from 45 units of PRBCs stored for 3-20 days were used for priming the 45 neonatal CPB circuits. Based upon the method used for removal of excess crystalloid from the prime, circuits were divided into three groups. Group 1: Direct removal through manifold line. Group 2: Ultrafiltration of prime. Group 3: Hemodiafiltration of the prime. Blood gas analyses were obtained from the PRBCs and from the prime before and after removal of crystalloid. Both direct removal of crystalloid and ultrafiltration resulted in significant reduction in biochemical and metabolic load of blood (P < 0.001). However, the final composition of the prime was far from being physiological. Hemodiafiltration resulted in improvement of metabolic parameters to near physiological range (lactate: 33.8 ± 4.44 vs. 14 ± 2.53 mg/dL, pH: 7.05 ± 0.15 vs. 7.34 ± 0.06, bicarbonates: 4.83 ± 0.59 vs. 27.6 ± 2.94 meq/L; P < 0.001). Similarly, sodium (147.76 ± 12.73 vs. 144.6 ± 5.96 meq/L) and potassium (9.6 ± 2.83 vs. 4.23 ± 0.37 meq/L) also changed significantly (P < 0.001) to near physiologic range. Hemodiafiltraion of final prime is a simple, efficients and rapid method of correcting the biochemical parameters and reducing the metabolic load of stored PRBCs towards the physiological range before initiating the CPB.
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http://dx.doi.org/10.1111/aor.12830DOI Listing
August 2017

Transposition of Great Arteries with Intramural Coronary Artery: Experience with a Modified Surgical Technique.

Braz J Cardiovasc Surg 2016 Feb;31(1):15-21

Mehta Institute of Cardiology and Research Center, Asarwa, India.

Objective: Transposition of the great arteries is a common congenital heart disease. Arterial switch is the gold standard operation for this complex heart disease. Arterial switch operation in the presence of intramural coronary artery is surgically the most demanding even for the most experienced hands. We are presenting our experience with a modified technique for intramural coronary arteries in arterial switch operation.

Methods: This prospective study involves 450 patients undergoing arterial switch operation at our institute from April 2006 to December 2013 (7.6 years). Eighteen patients underwent arterial switch operation with intramural coronary artery. The coronary patterns and technique used are detailed in the text.

Results: The overall mortality found in the subgroup of 18 patients having intramural coronary artery was 16% (n=3). Our first patient had an accidental injury to the left coronary artery and died in the operating room. A seven-day old newborn died from intractable ventricular arrhythmia fifteen hours after surgery. Another patient who had multiple ventricular septal defects with type B arch interruption died from residual apical ventricular septal defect and sepsis on the eleventh postoperative day. The remainder of the patients are doing well, showing a median follow-up duration of 1235.34±815.26 days (range 369 - 2730).

Conclusion: Transposition of the great arteries with intramural coronary artery is demanding in a subset of patients undergoing arterial switch operation. We believe our technique of coronary button dissection in the presence of intramural coronary arteries using coronary shunt is simple and can be a good addition to the surgeons' armamentarium.
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http://dx.doi.org/10.5935/1678-9741.20160003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5062693PMC
February 2016

Surgical removal of failed ruptured Sinus of Valsalva Aneurysm device.

Asian Cardiovasc Thorac Ann 2017 Mar 11;25(3):213-215. Epub 2016 Jul 11.

Department of Cardiovascular and Thoracic Surgery, UN Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College), Civil Hospital Campus, Asarwa, Ahmedabad, India.

A Sinus of Valsalva Aneurysm can cause aortic insufficiency, coronary artery flow compromise, cardiac arrhythmia, or aneurysm rupture. There are different management plans available, ranging from open surgery to percutaneous device closure, but sometimes, device closure may be life-threatening. We report a case of ruptured Sinus of Valsalva Aneurysm in a 42-year-old woman, which was managed by percutaneous device closure that failed and required surgical removal of the device.
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http://dx.doi.org/10.1177/0218492315609460DOI Listing
March 2017

Anomalous right coronary from aortopulmonary window in tetralogy of Fallot.

Asian Cardiovasc Thorac Ann 2015 Nov 21;23(9):1140. Epub 2014 May 21.

Department of Cardiovascular and Thoracic Surgery, UN Mehta Institute of Cardiology and Research Center, Ahmedabad, India.

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http://dx.doi.org/10.1177/0218492314537505DOI Listing
November 2015
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