Off pump coronary artery bypass (OPCAB) in critical left mainstem stenosis—Our experience

Background Beating heart surgery has now become the commonest technique of doing Coronary Artery Bypass Graft Surgery (CABG) in our country. It is being used even in such high risk situations like diffuse coronary disease and Critical Left Main stem Stenosis (LMCS) with good results. The aim of this study is to retrospectively review our results in Off-Pump Coronary Artery Bypass Surgery (OPCAB) in patients with critical left main stem stenosis. Methods This study is a retrospective analysis of the data of patients who underwent primary coronary artery bypass surgery. During the period from April 2003 to September 2005 a total of 64 patients underwent OPCAB procedure for critical LMCS. During the same period 10 patients underwent CABG on Cardio Pulmonary Bypass (CPB). The age range was 36–77yrs. The sex distribution was M: F 53∶10. Ten patients were done as emergency. 2 of them were on Intra Aortic Balloon Pump (IABP) support preoperatively. 10 patients were high risk with a Euro score of ≥5. Results Left Internal Mammary Artery (LIMA) was used in 78% of cases. Average grafts per patient was 2.96. The median ventilation time was 5.91 hrs. New IABP insertion in postoperative period was required in 1 patient. One patient was reexplored for bleeding. There was one perioperative myocardial infarction. 57% of patients did not need any blood transfusion. There was no conversion to CPB. There was no operative mortality. Inotropes were used in ten cases. Conclusions OPCAB is a safe method of revascularization in patients with critical LMCS. Preoperative IABP is useful in patients with cardiogenic shock. However, there is a place for CPB in patients needing additional procedures like Mitral Valve repair (MV repair) or Dor's procedure or when the vessels are very diffusely diseased. Those patients who are unstable despite IABP support may be managed by Beating heart On Pump (BHOP) technique.     

Lenticulostriate vasculopathy in twin-to-twin transfusion syndrome.

Intracranial pathology is a common and important complication in extremely low birth weight babies. Lenticulostriate vasculopathy (LSV) is an abnormal finding on cranial ultrasounds of sick babies and has been associated with congenital infection, chromosomal aberration and twin-to-twin transfusion. We describe a previously unreported situation of LSV being detected in both donor and recipient twin. This pair of monochorionic, diamniotic twins was admitted to the Neonatal Intensive Care Unit at 28 weeks of gestation. The mother underwent an emergency caesarean section because ultrasound and Doppler studies showed stage III twin-to-twin transfusion syndrome. The first twin weighed 998 g and second twin weighed 600 g. The first twin had an uneventful stay, whereas the second twin needed prolonged continuous positive airway pressure and indomethacin for patent ductus arteriosus. Both of them developed LSV. The clinical significance of this condition on the neuro-developmental outcome of a neonate has not yet been fully determined.     

Retrohepatic cavoatrial bypass for coarctation of inferior vena cava with a polytetrafluoroethylene graft

Eight patients with chronic Budd-Chiari syndrome resulting from coarctation of the inferior vena cava underwent operation. Transatrial dilatation was of no avail in the first case. The obstructed segment was directly visualized in the subsequent seven cases by a transthoracic, transdiaphragmatic, retroperitoneal approach. In these latter seven cases, severe hourglass constriction of the inferior vena cava was observed just above the right hepatic vein. There was no evidence of inflammation, extrinsic compression, or thrombosis. Retrohepatic cavoatrial bypass with an antibiotic-sterilized aortic homograft was unsuccessful in three patients. Five patients including one with homograft failure underwent successful retrohepatic cavoatrial bypass with a polytetrafluoroethylene graft (20 mm plain in four cases and 16 mm ringed graft in one case). These patients have been followed up for 21 months to 6 years with no recurrence of symptoms. The term coarctation of the inferior vena cava appears more appropriate than membranous obstruction of the inferior vena cava because of the operative findings in the present series.     

Genitourinary non-tuberculous mycobacterial (GU-NTM) infections: A single institution experience in South India

IntroductionNon-tuberculous mycobacterial (NTM) infections are rarely reported, and more so with genitourinary infections. This retrospective study was designed to understand the proportion and behaviour of genitourinary non-tuberculous mycobacterial (GU-NTM) infections compared with genitourinary mycobacterial tuberculosis (GU-MTB) treated at a tertiary care hospital in South India.Materials and methodsThe hospital records of every bacteriologically proved GU-MTB and GU-NTM infections treated at this centre from 2010 to 2016 were retrospectively reviewed.ResultsThere were ten patients of GU-NTM and 15 patients of GU-MTB. There was no significant difference in presentation other than lesser frequency of irritative lower urinary tract symptoms (LUTS) among patients with GU-MTB. Urine smear for AFB was positive in 60% and 47% of GU-NTM and GU-MTB patients. 40% of GU-NTM patients had history of urinary tract instrumentation. Mycobacterium abscessus was grown in four patients and one had Mycobacterium fortuitum/chelonae complex; all the rest were rapid growers. No patient had multi-drug resistant tuberculosis. Imaging studies of GU-NTM patients were indistinguishable from GU-MTB with renal, ureteral and bladder involvements, and stone formation. The drug sensitivities varied among the NTM patients but all showed sensitivity to clarithromycin uniformly. Need for varieties of surgeries in the early and late phases were also comparable.ConclusionsGU-MTB and GU-NTM infections are indistinguishable from their clinical presentation and imaging studies. All cases of suspected genitourinary mycobacterial infections must be subjected to nucleic acid testing. Treatments based on clinical and radiological features without culture studies may misdiagnose GU-NTM infections as MDR GU-MTB, thereby delaying the appropriate treatment.