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Scientific Articles

PEDIATRICS

Ebstein's Anomaly with Severe Tricuspid Regurgitation.

Aggarwal NK, Das SN, Kiran U, Bhan A.

Departments of Cardiac Anaesthesia and Cardiac Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India. dr_shambhu@yahoo.com.

Ann Card Anaesth. 2006 Jan;9(1):49-52.

Perioperative management of cor triatriatum with congenitally corrected transposition of great arteries.

Das SN, Kiran U, Bhan A, Sahu T.

Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi.

Ann Card Anaesth. 2006 Jul;9(2):135-7.

Hybrid cardiac surgical procedure: technique and anaesthetic management.

Saxena P, Banerjee S, Mahajan V, Tomer M, Bhan A, Panigrahi B.

Interact Cardiovasc Thorac Surg. 2007 Apr;6(2):200-3. Epub 2006 Dec 5.

Surgical experience of aortopulmonary window repair in infants.

Bhan A, Gupta M, Abraham S, Sharma R, Kothari SS, Juneja R.

Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi, India.

The aim of this study was to retrospectively analyze our results of both simple and complex aortopulmonary window (APW) repair in infants. From September 1994 to May 2003, 21 infants which included 15 with simple APW (weight 3.9+/-0.8 kg and age 5.1+/-3.7 months) and six with complex APW (weight 4.03+/-1.1 kg and age 5+/-3.8 months) underwent APW repair at the All India Institute of Medical Sciences, New Delhi, India. The approach for APW repair was ligation without CPB in four patients, division and suturing using CPB in one patient, trans-aortic with Goretex patch closure in 11 patients, trans-pulmonary in one patient and trans-window in four patients. The hospital mortality was 13% and 33% for simple and complex APW, respectively. On mean follow-up of 39 months there was no re-operation or late death. An early repair of APW is mandatory to achieve a good surgical result. Trans-aortic repair of APW is the procedure of choice for all APWs, except in the case of large defects where anterior sandwich patch technique (trans-window repair) may be done. In our view, simple ligation without CPB should be avoided due to the possibility of residual APW and distortion of pulmonary artery.

Interact Cardiovasc Thorac Surg. 2007 Feb;6(1):77-82. Epub 2006 Sep 18.

The bidirectional cavopulmonary (Glenn) shunt without cardiopulmonary bypass: is it a safe option?

Hussain ST, Bhan A, Sapra S, Juneja R, Das S, Sharma S.

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.

OBJECTIVES: The bidirectional cavopulmonary (Glenn) shunt is a commonly performed procedure for a variety of cyanotic congenital heart diseases that lead eventually to a single ventricle repair. It is usually performed under cardiopulmonary bypass with its associated adverse effects and costs. We report our results of bidirectional Glenn operation done without cardiopulmonary bypass. METHODS: Between January 2002 and July 2003, 37 patients with complex cyanotic congenital heart defects underwent bidirectional Glenn operation by a single surgeon at our center. Of these, 22 patients had the procedure performed without cardiopulmonary bypass. Age of the patients ranged from 7 months to 11 years (mean 3.11+/-2.38 years). The procedures were done with temporary clamping of the superior vena cava. Four patients had bilateral Glenn procedure done and one had additional right pulmonary artery-plasty done. All the patients underwent complete neurological examination, CT scan of head and developmental quotient/intelligence quotient test both preoperatively as well as postoperatively. RESULTS: There was no operative mortality in our patients. Mean follow-up was 17.18+/-5.28 months. The mean internal jugular venous pressure on clamping the superior vena cava was 34.04+/-10.15 mmHg, and the mean clamp time was 6.85+/-1.52 min. There was no hemodynamic instability during any of the procedures and oxygen saturation was maintained at more than 65-70% throughout the procedure. The mean intensive care unit stay was 1.27+/-0.45 days. There were no neurological complications in any patient as assessed clinically and by CT scan of the head. None of the patients showed deterioration of developmental quotient/intelligence quotient score during follow-up evaluation. CONCLUSIONS: Our results show that in selected patients, bidirectional Glenn operation without cardiopulmonary bypass is a safe procedure. It avoids cardiopulmonary bypass related problems and is economical, with excellent results.

Pediatr Cardiol. 2006 Sep-Oct;27(5):643-5.

Single-stage repair of interrupted aortic arch and Taussig-Bing anomaly.

Bhan A, Gupta M, Abraham S, Juneja R, Saxena A, Kothari SS.

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India. dranilbhan@yahoo.co.in

We report a case of successful single-stage repair of interrupted aortic arch with Taussig-Bing anomaly in a 5-month-old infant.

Pediatr Cardiol. 2006 May-Jun;27(3):378-80.

Persistent truncus arteriosus with double aortic arch.

Bhan A, Gupta M, Kumar MJ, Kothari SS, Gulati GS.

Department of Cardiothoracic and Vascular Surgery, Cardiology & Cardiac Radiology Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, 110029, India. dranilbhan@yahoo.co.in

We report a rare association of persistent truncus arteriosus with double aortic arch in a 34-day old neonate.

Heart Lung Circ. 2001;10(3):130-5.

Subaortic membrane excision: mid-term results.

Talwar S, Bisoi AK, Sharma R, Bhan A, Airan B, Choudhary SK, Kothari SS, Saxena A, Venugopal P.

Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

BACKGROUND: Subaortic membrane (SAM) is a form of fixed subaortic obstruction in which a fibrous membrane is located below the aortic valve. Aim: To determine the role of surgical treatment for patients with a discrete SAM. PATIENTS AND METHODS: The hospital records of 45 patients (age range: 2-23 years; median 8 years) undergoing surgery for SAM between 1990 and 1998 at the All India Institute of Medical Sciences, New Delhi, India, were analysed. Preoperative echocardiographically calculated gradients across the left ventricular outflow tract ranged from 50 to 154 mmHg (mean: 86.5 +/- 33.2 mmHg). Nine patients had trivial aortic regurgitation (AR), 10 had mild AR and five had moderate-severe AR. The left ventricular ejection fraction (LVEF) ranged from 20 to 68% (mean 48 +/- 15%). Nineteen patients had significant left ventricular dysfunction (LVEF <50%). Transaortic resection of SAM was done in all patients along with excision of a wedge-shaped segment of septal muscle underlying the membrane. RESULTS: There were no early or late postoperative deaths. On follow up (up to 113 months), only four patients had gradients >30 mmHg. LVEF improved to 45-70% (mean 58 +/- 7.7%). AR reduced to mild in four patients and trivial in four patients, and did not progress further. CONCLUSION: Resection of SAM carries long-term benefits. Routine septal myectomy appears to be associated with a low risk of recurrence.

Heart Lung Circ. 2001;10(1):3-13.

Univentricular repair in children under 2 years of age: early and midterm results.

Chowdhury UK, Airan B, Sharma R, Bhan A, Kothari SS, Saxena A, Venugopal P.

Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

BACKGROUND: Encouraging results have been obtained from early univentricular repair. Our study was designed to assess the impact of young age (less than 2 years) on the outcome of univentricular repair. PATIENTS AND METHODS: Between January 1992 and December 1998, 65 out of 311 patients undergoing univentricular repair at the All India Institute of Medical Sciences, New Delhi, were less than 2 years of age. We compared these 65 carefully selected patients (group 1) with the 246 patients who were more than 2 years of age (group 2). Since 1994, all patients of both groups had a fenestration of the intra-atrial baffle. RESULTS: The early mortality rate was 9.2% in group 1 and 7.7% in group 2. The overall Fontan failure rate was 12.3% in group 1 and 12.2% in group 2. In group 1, a higher incidence of Fontan failure was noted in patients with suboptimal weight, non-tricuspid atresia morphology, nonfenestrated Fontan and those who did not comply with more than two of Choussat's criteria, but the values were not statistically significant. Aortic cross-clamp time of more than 60 min was the only and highly significant predictor of Fontan failure (P < 0.01). The overall effusion rate was 24.05% in group 1 and 27.98% in group 2. In group 1, patients weighing less than 10 kg (P = 0.0007), without fenestration of the atrial baffle (P < 0.05) and with systemic ventricular dysfunction (P < 0.001), systemic ventricular end-diastolic pressure of more than 12 mmHg (P < 0.001), mean pulmonary artery pressure of more than 15 mmHg (P < 0.001) and aortic crossclamp time of more than 60 min (P < 0.01), were all found to be significant risk factors of pleural effusion. Pulmonary artery distortion needing reconstruction did not increase the Fontan failure or effusion rates. Oxygen saturation ranged from 85 to 94% (mean 89%) in patients having a functioning fenestration at a mean follow-up period of 30 months. The actuarial survival at 84 months was 90 +/- 0.04% in group 1 and 88 +/- 0.02% in group 2. CONCLUSIONS: Our results suggest that carefully selected patients under 2 years of age are suitable candidates for one-stage univentricular repair and that survival is not significantly different from that of older patients. Routine fenestration of the intra-atrial baffle is an option available to ameliorate morbidity and obviate mortality. Non-compliance with more than two of Choussat's criteria appears to be additive in unsatisfactory outcome.

J Cardiothorac Vasc Anesth. 2005 Apr;19(2):275-6.

The use of bispectral index for diagnosis of aortic arch arterial occlusion.

Das SN, Kiran U, Bhan A.

J Cardiothorac Vasc Anesth. 2005 Apr;19(2):274-5.

Combination of phenoxybenzamine and nitroglycerin: effective control of pulmonary artery pressures in children undergoing cardiac surgery.

Kiran U, Makhija N, Das SN, Bhan A, Airan B.

J Thorac Cardiovasc Surg. 2005 Apr;129(4):932-4.

Total arterial revascularization in a child with familial homozygous hypercholesterolemia.

Bhan A, Swain S, Juneja R, Saxena P, Venugopal P.

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India. bhan@medinst.ernet.in

Indian Heart J. 2004 Jul-Aug;56(4):320-7.

Surgical outcome of staged univentricular-type repairs for patients with univentricular physiology and pulmonary hypertension.

Chowdhury UK, Airan B, Kothari SS, Sharma R, Subramaniam GK, Bhan A, Saxena A, Juneja R, Venugopal P.

Departments of Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi. ujjwalchow@rediffmail.com

BACKGROUND: There is no consensus about the most appropriate limits of pulmonary artery pressure and vascular resistance in case of patients undergoing univentricular or one and one-half ventricular repair. This study was conducted to analyze the mortality and morbidity of a heterogenous group of patients with a functionally univentricular heart and pulmonary artery hypertension, undergoing pulmonary artery banding followed by univentricular-type repairs. METHODS AND RESULTS: Out of 254 patients undergoing pulmonary artery banding for a functionally univentricular heart with increased pulmonary blood flow, 148 patients underwent definitive second stage surgery. Post-band hemodynamic evaluation revealed persistently high pulmonary artery pressure (> 18 mmHg), and pulmonary vascular resistance (>2.0 Woods units/m2) in 78.3% patients. Sixteen patients with moderate right ventricular hypoplasia were given a one and one-half ventricle repair (Group I), 82 patients a bidirectional Glenn connection (Group II), and 50 patients a fenestrated total cavopulmonary connection (Group III). The overall mortality following second stage surgery for the high pulmonary artery pressure group (n=116) was 30.17%, while none of the low pulmonary artery pressure group died (p=0.0009). Pulmonary hypertensive crises and/or systemic desaturation were the main causes of death at second stage repair. All mortality occurred in patients with mean pulmonary artery pressure > 18 mmHg and pulmonary vascular resistance > 3.5 Woods units/m2. Survivors from this group had persistent morbidity in the form of superior vena caval syndrome and suboptimal oxygen saturation (70-75%). CONCLUSIONS: It is advisable not to proceed with definitive second stage repair if post-pulmonary artery banding mean pulmonary artery pressure is over 25 mmHg and pulmonary vascular resistance exceeds 4.0 Woods units/m2. These patients may possibly be deemed to have undergone definitive palliation during their pulmonary artery banding.

Ann Thorac Surg. 2004 Aug;78(2):658-65.

Postoperative assessment of the univentricular repair by dynamic radionuclide studies.

Chowdhury UK, Mishra PK, Sharma R, Airan B, Subramaniam GK, Kothari SS, Bhan A, Patel CD, Venugopal P.

Department of Cardiothoracic, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110 029, India. ujjwalchow@rediffmail.com

BACKGROUND: The purpose of this investigation was to determine the role of radionuclide studies in evaluating postoperative Fontan hemodynamics and to quantify its diagnostic accuracy. METHODS: One hundred five patients (105), aged 11 months to 35 years old, who had undergone univentricular repair, underwent first-pass and multigated acquisition scan 1 month to 10 years after univentricular repair. Forty-five patients with evidence of Fontan failure underwent radionuclide studies using Technetium-99 m as well as cardiac catheterization (group 1). The remaining sixty randomly selected patients with excellent functional status received radionuclide studies alone (group 2). The receiver operating characteristic curve analysis was done to quantify the diagnostic accuracy of the first-pass study. RESULTS: There was paradoxical filling of the right lung after femoral injection in all cases of tunnel or conduit obstruction. A first-pass transit time of 16 to 25 seconds (mean +/- standard deviation [SD] = 18.82 +/- 2.69) was always associated with Fontan failure and high right atrial pressure (range = 20 to 24 mm Hg, mean +/- SD = 22.02 +/- 1.58). A first-pass transit time of 16 seconds was associated with a sensitivity of 100% and a specificity of 93.33%. The predictive accuracy of a positive or negative result was 91.8% and 100% respectively. The area measured under the receiver operating characteristic curve indicates that 99.41% (SE +/- 0.0035) of the time, the value of first-pass time is higher for the Fontan failure group (group 1) compared to the normal group (group 2; p = 0.000). CONCLUSIONS: Our data indicate that Fontan circuit can be reliably evaluated for both anatomic and functional flaws by radionuclide studies; radionuclide first-pass time may be used to predict the chances of Fontan failure postoperatively as well as its presence; and in the presence of atrial fibrillation with fast ventricular rate, analysis using first-pass radionuclide may be impossible and gated equilibrium radionuclide angiocardiography may be the preferred method. Inspection of the systemic ventricular time-activity curve is of crucial importance in this regard.

Indian Heart J. 2004 Jan-Feb;56(1):37-9.

Minimally invasive pulmonary artery banding: a new approach.

Bhan A, Agarwal S, Saxena P, Venugopal P.

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi. anil_bhan@hotmail.com

BACKGROUND: A variety of approaches have been described for banding of the pulmonary artery. The indications for this procedure are limited; however in developing countries, many patients still need pulmonary artery banding for a variety of reasons. We describe a new approach, minimally invasive, using only a split in the manubrium sterni to conduct the procedure. METHODS AND RESULTS: Between January 2000 and May 2002, 19 patients who had undergone pulmonary artery banding using a minimally invasive technique were compared with 20 cases of pulmonary artery banding performed by the conventional technique. The mortality was similar in the two groups (p=0.45). The period of intubation and duration of intensive care unit stay were significantly shorter in the minimally invasive group (p=0.015 and 0.002, respectively). The duration of hospital stay was not significantly different between the 2 groups (p=0.139). In the minimally invasive group, three patients underwent subsequent reoperation. CONCLUSIONS: Minimally invasive pulmonary artery banding is useful in babies with high-flow cardiac lesions and cardiac cachexia.

Indian Heart J. 2003 Jan-Feb;55(1):78-80.

An infant with "dying spells".

Kothari SS, Roy A, Sharma S, Bhan A.

Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi. kotharis@del2.vsnl.net.in

A 45-day-old infant presented with the unusual and intriguing symptom of episodic crying and loss of consciousness. The infant was discovered to have a vascular compression of the trachea by the innominate artery, almost serendipitously. He was cured of his symptoms by anterior suspension of the innominate artery.

Indian Heart J. 2002 Nov-Dec;54(6):681-6.

Ten-year experience with the arterial switch operation.

Sharma R, Bhan A, Choudhary SK, Kumar RP, Juneja R, Kothari SS, Saxena A, Venugopal P.

Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi. rsharmacvs@hotmail.com

BACKGROUND: Arterial level repair is considered the most appropriate procedure for transposition of the great arteries. This report describes our experience with the arterial switch operation over the past decade. METHODS AND RESULTS: From January 1991 to January 2001, a total of 299 patients underwent an arterial switch operation for transposition of the great arteries or double-outlet right ventricle. Group I (n=169, 56.5%) comprised patients with transposition of the great arteries in whom the ventricular septum was essentially intact. Group II patients (n=130, 43.5%) had transposition of the great arteries with an additional significant ventricular septal defect or had double-outlet right ventricle with a subpulmonic ventricular septal defect. Of the total, 245 (82%) were males and 54 (18%) were females. In group I, the ages ranged from 2 days to 18 years (median 19 days) and weight ranged from 1.7 to 68 kg (median 2.5 kg). In group II, the ages ranged from 4 days to 4 years (median 90 days) and weight ranged from 2.5 to 17 kg (median 4 kg). Fifteen percent of the patients (25/169) in group I and 30% of the patients (39/130) in group II had features of bacteriologic infection. Arterial switch operation was performed on standard lines. In group I, 141 patients (83.4%) had a primary arterial switch operation while 28 (16.6%) underwent a rapid two-stage repair. Twenty-three patients required concomitant relief of associated anatomic left ventricular outflow tract obstruction. Operative mortality was 8.8% (15/169) in group I and 33% (44/130) in group II with an overall mortality of 19% (59/299). The major causes of operative mortality included pulmonary arterial hypertensive crisis (n=21), sepsis and related complications (n=16), and left ventricular failure (n=8). Coexisting arch anomalies, longer cross-clamp time, late presentation, and preoperative bacteriologic infections were incremental risk factors. Follow-up ranged from 1 to 10 years and was 87% complete. On follow-up, 91% of the patients were asymptomatic and off all medications. There were 3 late deaths and 5 patients required reoperation. CONCLUSIONS: Excellent long-term results are obtained in operative survivors following the arterial switch operation. However. operative mortality remains a concern in our set-up.

Ann Thorac Surg. 2002 Dec;74(6):1986-91.

Late outcome after arterial switch operation for complete transposition of great arteries with left ventricular outflow tract obstruction.

Sharma R, Choudhary SK, Bhan A, Kumar RP, Juneja R, Kothari SS, Saxena A, Venugopal P.

Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India. rsharmacvs@hotmail.com

BACKGROUND: Long-term follow-up of patients who underwent arterial switch operation for complete transposition of great arteries with anatomic left ventricular outflow tract obstruction (LVOTO) has rarely been brought into the focus. METHODS: Of 299 patients who underwent an arterial switch operation between January 1991 and January 2001, 23 patients had anatomic LVOTO. Age ranged from 4 days to 18 years (median 90 days) and weight ranged from 2.6 to 35 kg (median 4.3 kg). Surgical management included arterial switch operation, closure of ventricular septal defect wherever indicated, and excision of LVOTO. RESULTS: Among patients with preoperative LVOTO there were 2 early deaths and 8 patients had mild neoaortic regurgitation at the time of discharge. Follow-up ranged from 8 months to 9 years (mean 60 +/- 12 months). In 4 patients who had mild neoaortic regurgitation at discharge, the regurgitation progressed to moderate or severe degree after a follow-up of 22 to 72 months. In 1 patient mild mitral regurgitation present at the time of discharge progressed to severe mitral regurgitation. This patient subsequently underwent double valve replacement. CONCLUSIONS: Presence of preoperative anatomical LVOTO in patients undergoing arterial switch operation predicts high incidence of postoperative neoaortic regurgitation.

Indian Heart J. 2002 Jul-Aug;54(4):390-3.

Medium-term outcome of anatomically repaired congenitally corrected transposition: the double switch operation.

Sharma R, Choudhary SK, Juneja R, Bhan A, Kothari SS, Saxena A, Venugopal P.

Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi. rsharmacvs@hotmail.com

BACKGROUND: The double switch operation is emerging as the procedure of choice for congenitally corrected transposition of the great arteries. However, rhythm disturbances in the postoperative period are rarely discussed. METHODS AND RESULTS: Eighteen survivors who underwent corrective surgery for congenitally corrected transposition of the great arteries were followed up. Patients in group I (n=8), who also had a ventricular septal defect and pulmonary stenosis, had undergone the Senning plus Rastelli operation. Patients in group II (n=10), who did not have pulmonary stenosis, had undergone the Senning and arterial switch operation. The patients were followed up by periodical clinical examination, echocardiography and 24-hour Holter monitoring. In group I, follow-up ranged from 24 to 66 months (mean 44 months). There was no late death and all the patients are symptom free. There was no significant atrioventricular valve regurgitation and left ventricular function was normal. There were no rhythm disturbances. In group II, follow-up ranged from 2 to 72 months (mean 48 months). There were 2 late deaths due to atrial tachyarrhythmia and residual pulmonary hypertension 36 and 8 months after the procedure, respectively. One patient had significant mitral regurgitation and required mitral valve replacement. Three patients had recurrent atrial/junctional tachyarrhythmia: one of them was lost to follow-up after 1 year while another died of resistant atrial tachyarrhythmia. The third patient underwent mitral valve replacement for severe mitral regurgitation and developed complete heart block necessitating a permanent pacemaker implantation. CONCLUSIONS: Though good long-term results are obtained following the double switch operation, the problem of atrial arrhythmias still needs to be addressed suitably.

Ann Thorac Surg. 2002 Nov;74(5):1612-5.

Left ventricle is better suited as pulmonary ventricle in simple transposition with severe pulmonary hypertension.

Sharma R, Choudhary SK, Bhan A, Juneja R, Kothari SS, Saxena A, Venugopal P.

Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi. rsharmacv@hotmail.com

BACKGROUND: The conventional treatment of transposition of great arteries with prepared left ventricle is an arterial switch operation. This, in our experience, does not hold for patients with transposition of great arteries with intact ventricular septum where the left ventricle continues to be prepared secondary to severe pulmonary arterial hypertension without an immediately reversible cause. METHODS: Ten infants with D-transposition of the great arteries with essentially intact interventricular septum and severe pulmonary arterial hypertension underwent surgical treatment. Age ranged from 3 to 6 months (mean, 4.2 months). One of these patients had a large ductus with left to right shunting but the others had no intra- or extracardiac shunt to account for their pulmonary hypertension. All 10 had "prepared" left ventricles. The first 4 children underwent an arterial switch operation. Uneventful surgery was followed by prolonged ventilator dependence in all 4 with occurrence of severe pulmonary arterial hypertension every time weaning from ventilator was attempted. This was accompanied by metabolic acidosis and features of right heart failure. Only 1 patient with large ductus could be extubated and discharged from hospital. Subsequently, the other 6 infants underwent a Senning repair. RESULTS: There was no early mortality. All patients were separated from mechanical ventilation within 48 hours of surgery without blood gas derangement or heart failure despite elevated pulmonary artery pressure in all. The child with the arterial switch operation has pulmonary artery pressure of 50% systemic 4 years following repair; although among the Senning group, 2 patients continue to have pulmonary artery pressure more than 60% of systemic and 4 have normal pulmonary artery pressure at a mean follow-up of 1 year. CONCLUSIONS: Atrial level repairs seem to perform better than arterial level repairs in children having TGA with persistent pulmonary artery hypertension without a correctable cause. Better tolerance of pulmonary arterial hypertension in this group is probably consequent to the superior ability of the left ventricle to tolerate a pressure load in the early postoperative period.

Ann Thorac Surg. 2002 Sep;74(3):931-2.

Diaphragmatic fenestration for resistant pleural effusions after univentricular repair.

Durairaj M, Sharma R, Choudhary SK, Bhan A, Venugopal P.

A 12-year-old child with chronic pleural effusions for a month and a half after a fenestrated Fontan operation underwent bilateral diaphragmatic fenestrations with complete relief. We suggest this approach as an alternative treatment for chronic pleural effusions that may ensue after total cavopulmonary connection.

Indian Heart J. 2002 Jan-Feb;54(1):67-73.

Ventricular septal defect with congenital mitral valve disease: long-term results of corrective surgery.

Agarwal S, Airan B, Chowdhury UK, Choudhary SK, Sharma R, Bhan A, Saxena A, Venugopal P.

Department of Cardiothoracic Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi.

BACKGROUND: A retrospective analysis of the mortality, morbidity and long-term follow-up of patients undergoing corrective surgery for ventricular septal defect and congenital mitral valve disease is presented. METHODS AND RESULTS: Between January 1991 and December 2000, 69 consecutive patients aged 2 months to 45 years (median 18 months) underwent repair of ventricular septal defect and associated mitral valve disease. In 52 patients (75%), the ventricular septal defects were located in the perimembranous and subarterial area. Forty-six patients had congenital mitral incompetence and 23 had congenital mitral stenosis. The ventricular septal defect was repaired through the right atrium in all. Sixty-five patients underwent reconstruction of the mitral valve and 4 underwent primary mitral valve replacement. Another 4 patients underwent mitral valve replacement after a failed repair. Associated procedures included: patent ductus arteriosus ligation (n=12), aortic valve replacement (n=6), coarctation repair (n=13), interrupted aortic arch repair (n=1), atrial septal defect closure (n=17) and Takeuchi repair (n=1). There were 6 early deaths (8.6%). Three deaths were due to pulmonary arterial hypertensive crisis and one due to residual mitral stenosis. One death was due to intractable congestive heart failure. Another patient died due to persistent low cardiac output. Follow-up ranged from 6 months to 120 months (mean 64.4+/-33.6 months). Reoperation was required in 22 patients, mainly for recurrent/residual mitral valve dysfunction or hemodynamically significant left ventricular outflow tract obstruction. There were 4 late deaths, 2 due to residual mitral stenosis and the other 2 as a result of a thrombosed prosthetic valve. At 10 years, the actuarial survival rate was 850+/-5.0%, and freedom from reoperation was 45%+/-10.0%. CONCLUSIONS: Reconstruction of the mitral valve along with closure of VSD is possible in most cases. However, careful follow-up is recommended to detect changes in the mitral valve status over a course of time.

Indian J Pathol Microbiol. 2001 Apr;44(2):125-9.

Indian Heart J. 2001 Nov-Dec;53(6):754-60.

Total anomalous pulmonary venous connection: surgical experience in Indians.

Choudhary SK, Bhan A, Sharma R, Airan B, Devagourou V, Saxena A, Kothari SS, Venugopal P.

Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi.

BACKGROUND: We report a retrospective analysis of the demographic. morphological and clinical profiles of patients along with results of operative repair for total anomalous pulmonary venous connection. METHODS AND RESULTS: In the last 15 years, 248 patients (168 boys, 80 girls) underwent repair for total anomalous pulmonary venous connection. Their ages ranged from I day to 24 years (median 8 months) and 145 of them were < or = 1 year of age. The patients' weight ranged from 2 to 52 kg (median 5 kg). About 70% of patients (n = 174) were less than the 50th percentile of predicted weight for age and sex. The anomalous connection was supracardiac in 134 (54%), cardiac in 80 (32.2%), infracardiac in 9 (3.6%) and mixed in 25 (10.1%) patients. Fifty (20.2%) patients had obstructed drainage and 76 patients (30.2%) had moderate or severe pulmonary arterial hypertension. Forty-five patients (18.1%) had to be operated upon on an emergency basis. All the patients were operated upon using moderately hypothermic cardiopulmonary bypass. In 114 patients, circulatory arrest was used. There were 45 (19.1%) in-hospital deaths. The major causes of early death were pulmonary arterial hypertensive crisis in 19 (7.7%) and low cardiac output syndrome in 17 (6.9%) patients. Age < or = 1 year (odds ratio 2.16; 95% confidence interval: 1.22-3.82, p=0.008), severe pulmonary arterial hypertension (odds ratio 5.86; 95% confidence interval: 2-17, p=0.001), and need for emergency surgery (odds ratio 3.65; 95% confidence interval: 1.59-8.38, p=0.002) were independent risk factors for early death. Follow-up ranged from 1 to 180 months (median 48 months). There were 4 lake deaths. Actuarial survival at 12 years was 92.6% +/- 2.8%. CONCLUSIONS: In Indian circumstances, mortality continues to be high in infants with total anomalous pulmonary venous connection. Severe pulmonary arterial hypertension appears to be the most important predictor of operative mortality. Severe malnutrition, delayed diagnosis and late referrals possibly contribute to the high mortality.

Ann Thorac Surg. 2001 Dec;72(6):2186-7.

Online CO2 monitoring during cardiopulmonary bypass using ETCO2 gas analysis during pH stat strategy of acid-base management.

Saxena P, Bhan A, Sharma R, Saxena N.

Does inhaled nitric oxide improve survival in operated congenital disease with severe pulmonary hypertension?

Sharma R, Raizada N, Choudhary SK, Bhan A, Kumar P, Juneja R, Kothari SS, Saxena A, Venugopal P.

Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi. rsharmacvs@hotmail.com

BACKGROUND: The present study aimed to assess the impact of inhaled nitric oxide on survival following correction of congenital heart defects with residual pulmonary arterial hypertension. METHODS AND RESULTS: Inhaled nitric oxide was utilized for the management of residual pulmonary hypertension in 24 children following surgical correction of their underlying heart defects. Their ages ranged from 15 days to 14 months (median 5 months). Pulmonary artery hypertension was diagnosed either by direct pulmonary artery pressure monitoring or by echocardiography. Inhaled nitric oxide was used electively in 22 patients when the ratio of the mean pulmonary arterial pressure and mean systemic arterial pressure exceeded 0.5. In the remaining 2 patients, nitric oxide was used only to manage a pulmonary hypertensive crisis. Inhaled nitric oxide was also used a second time in 2 patients who developed delayed pulmonary hypertensive crisis. Twenty-two patients showed an initial response to therapy and the pulmonary artery pressures dropped significantly. Of the patients on direct pulmonary artery pressure monitoring, a pulmonary artery to systemic artery pressure ratio below 0.3 on prolonged therapy was associated with a survival ratio of 4/6 (including 1 neurological death and one reoperation); that between 0.3 and 0.5 with a survival ratio of 3/4. Three out of four patients with sustained echocardiographic and clinical response also survived and were discharged from the hospital. All the patients who showed a lack of response to (n=2), tolerance to (n=1), or dependence on (n=6) the use of inhaled nitric oxide died. In addition, all 5 patients who had a pulmonary hypertensive crisis died, 3 in spite of successful resuscitation with nitric oxide. Thus, excluding one neurological death and one re-operation, only 9 (41%) out of 22 patients survived. CONCLUSIONS: Though inhaled nitric oxide is effective in lowering pulmonary pressure, it does not appear to improve the survival rate following repair of congenital heart disease in those with associated severe pulmonary hypertension. A randomized trial between the use and non-use of inhaled nitric oxide is warranted to determine its exact role in influencing survival in patients with residual pulmonary hypertension following surgical repair.

PMID: 11456141 [PubMed - indexed for MEDLINE]

Ann Thorac Surg. 2001 Jun;71(6):1995-2002.

One and a half ventricle repair with pulsatile bidirectional Glenn: results and guidelines for patient selection.

Chowdhury UK, Airan B, Sharma R, Bhan A, Kothari SS, Saxena A, Venugopal P.

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi.

BACKGROUND: The guidelines for performing a one and a half ventricle repair with pulsatile bidirectional Glenn remains controversial. This retrospective report summarizes the experience of a single institution, with an attempt at providing an answer. METHODS: Fifty consecutive patients, aged 4 months to 42 years, underwent intracardiac repair along with a superior cavopulmonary connection. Twenty-seven of the patients had had previous surgical palliation. Repair consisted of patch closure of the ventricular septal defect (n = 25), tricuspid valve repair (n = 26), reconstruction of the right ventricular outflow tract (n = 34), transpulmonary annular patch (n = 34), right ventricle to pulmonary artery homograft conduit (n = 4), and concomitant repair of atrioventricular canal (n = 9). Ten patients were left with a fenestration in the atrial septum. RESULTS: There were six hospital deaths (12%) and two late deaths (4.5%). Forty-two survivors were followed from 8 months to 116 months. Eighty-eight percent are in functional class I. Actuarial survival at 97 months was 74%. CONCLUSIONS: Moderate right heart hypoplasia constitutes a safe anatomic category for a pulsatile bidirectional Glenn. It is advisable not to proceed with a one and a half ventricle repair if postoperative residual pulmonary artery hypertension is anticipated. Patients requiring an intricate intracardiac repair and those with concomitant right heart hypoplasia may be better suited for a Fontan type of repair to reduce the complexity of the procedure.

Eur J Cardiothorac Surg. 2001 Jan;19(1):41-6.

Indian Heart J. 2000 Jul-Aug;52(4):427-30.

Cardiac arrhythmias in surgically repaired total anomalous pulmonary venous connection: a follow-up study.

Bhan A, Umre MA, Choudhary SK, Saxena A, Sharma R, Airan B, Kothari SS, Juneja R, Venugopal P.

Department of Cardiothoracic, All India Institute of Medical Sciences, New Delhi.

Twenty-five patients with diagnosis of total anomalous pulmonary venous connection, who had undergone corrective surgery, were studied at variable time period after surgery with 24-hour ambulatory electrocardiographic monitoring (Holter) and echocardiography. The aim of this study was to record arrhythmias, if any, and to correlate occurrence of arrhythmia with adequacy of repair and other related variables. All the patients were clinically asymptomatic. Twenty-four hours ambulatory electrocardiographic monitoring of these patients showed the presence of significant arrhythmias in 21 of the 25 patients. These included supraventricular ectopics in 19 patients, ventricular ectopics in 8, atrioventricular block in 2, right bundle branch block and atrial fibrillation 1 each and atrial tachycardia in 2 patients. There was no correlation between development of arrhythmia and age at repair, type of connection, operative approach and adequacy of repair. The study indicates that cardiac arrhythmias can occur in otherwise asymptomatic patients after correction for total anomalous pulmonary venous connection. Thus, these patients require long-term follow-up, even if they are asymptomatic.

Ann Thorac Surg. 2000 Sep;70(3):723-6.

Right ventricular outflow tract after non-conduit repair of tetralogy of Fallot with coronary anomaly.

Kalra S, Sharma R, Choudhary SK, Airan B, Bhan A, Saxena A, Kothari SS, Venugopal P.

Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi.

BACKGROUND: A total of 25 patients with tetralogy of Fallot and an important coronary artery crossing the right ventricular outflow tract underwent complete repair without use of an extracardiac conduit between January 1990 and December 1994. Repair was exclusively done by the transatrial or transatrial-transpulmonary approach. Age of these patients ranged from 1 to 12 years (mean 3.6 years). Three of the patients had already received a systemic to pulmonary artery shunt. METHODS: All patients reporting for follow-up (n = 18) were subjected to transthoracic echocardiography and, if required, cardiac catheterization and angiography. Right ventricle to pulmonary artery gradients were noted preoperatively, at discharge following repair and at follow-up study. RESULTS: Mean follow-up was 40.6 months (24 to 62 months). Mean early postoperative gradient was 23.5+/-13.4 mm Hg and 4 patients had significant (> 30 mm Hg) gradients. Mean late postoperative gradient was 20.6+/-12.4 mmHg and 2 patients had gradients greater than 30 mmHg. All the patients were in New York Heart Association functional class I at the time of last follow-up. CONCLUSIONS: Acceptable gradients across the right ventricular outflow tract are achievable following repair of tetralogy of Fallot in the presence of anomalous coronary artery across the right ventricular outflow tract using the transatrial or transatrial-transpulmonary approach. Most gradients were found not to vary significantly on subsequent follow-up.

Indian Heart J. 2000 May-Jun;52(3):343-5.

Multiple fungal mycotic pulmonary artery aneurysms in an infant.

Talwar S, Sharma R, Das B, Bhan A, Ray R, Saxena A, Venugopal P.

Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi.

Ann Thorac Surg. 2000 Aug;70(2):575-81.

Neurological evaluation and intelligence testing in the child with operated congenital heart disease.

Sharma R, Choudhary SK, Mohan MR, Padma MV, Jain S, Bhardwaj M, Bhan A, Kiran U, Saxena N, Venugopal P.

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi. rsharmacvs@hotmail.com

BACKGROUND: The immediate and intermediate-term neurodevelopmental outcome in infants undergoing open heart procedures using deep hypothermic cardiopulmonary bypass was assessed prospectively. METHODS: One hundred consecutive infants (age 2 to 174 days) were operated on using either deep hypothermic bypass only (group A, n = 28), or with associated circulatory arrest (group B, n = 72). Early neurological outcome was recorded. Survivors underwent mental development evaluation after 31 to 55 months. Fifty other children of similar demographic profile but without heart disease were also tested as controls. RESULTS: In group A, there were two neurological deaths. In group B, 5 patients had clinical seizures, 1 had monoparesis and 1 had hyperkinetic syndrome with decreased attention span. Mean mental performance quotient was 90.0+/-8.2 in group A, and 89.1+/-6.8 in group B, (group A vs. B, p = 0.60). Mean mental performance quotient in the control group was 101.4+/-8.4, which was significantly higher than the patient population (p << 0.001). No correlation was found between duration of circulatory arrest and postoperative mental performance quotient. CONCLUSIONS: There was significant retardation of mental development in infants operated with deep hypothermic cardiopulmonary bypass. However, use of total circulatory arrest and its duration did not affect clinical outcome up to preschool age.

Indian Heart J. 2000 Mar-Apr;52(2):192-7.

Surgical considerations of univentricular heart with total anomalous pulmonary venous connection.

Chowdhury UK, Airan B, Sharma R, Bhan A, Kothari SS, Saxena A, Juneja R, Venugopal P.

Department of Cardiothoracic, All India Institute of Medical Sciences, New Delhi.

Out of the 600 patients undergoing univentricular repair during the last 11 years, 20 children had associated total anomalous pulmonary venous connection. The objective was to outline the clues to establish the diagnosis of this rare disease combination and the various surgical options available to manage the same. Bidirectional Glenn, bilateral bidirectional Glenn, total cavopulmonary connection and atriopulmonary connection were performed in combination with rechannelling of various types of total anomalous pulmonary venous connection in 20 children aged 6 months to 36 months (mean +/- SD 17.65 +/- 9.02 months). Diagnosis could be established pre-operatively in only 13 (65%) patients. Out of 6 early deaths (30%), 4 were directly attributable to missed diagnosis. No late deaths occurred over a follow-up period ranging from 1 month to 132 months. None of the surviving children required reoperation and all are in NYHA functional class I. Doppler echocardiography of the surviving children revealed unrestricted atrio/cavopulmonary anastomosis and pulmonary vein to atrium connection in all survivors. Our own experience, coupled with a review of the literature, indicates that a missed diagnosis increases the hospital mortality. Cross sectional 2D echocardiography is a superior method of detection of associated total anomalous pulmonary venous connection compared to angiocardiography. Exclusion of the diagnosis of anomalous pulmonary venous connection is imperative in all univentricular hearts pre-operatively and on operation table. Failure to recognise this disease combination results in formation of a closed systemic circuit after bidirectional Glenn or a modified Fontan of connection and is lethal as happened in our early experience. It is suggested that one-stage Fontan operation should be performed only if other criteria for Fontan procedure are satisfied.

PMID: 10893897 [PubMed - indexed for MEDLINE]

Ann Thorac Surg. 2000 Jun;69(6):1900-6.

Univentricular repair: is routine fenestration justified?

Airan B, Sharma R, Choudhary SK, Mohanty SR, Bhan A, Chowdhari UK, Juneja R, Kothari SS, Saxena A, Venugopal P.

Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi. bairan@medinst.ernet.in

BACKGROUND: A decade after the introduction of baffle fenestration, the outcome of Fontan-type repair for hearts with a functional single ventricle finally looks promising. Our study was designed to assess the impact of fenestration on the outcome of univentricular repairs. METHODS: From January 1988 to December 1997, 348 patients (104 with tricuspid atresia and 244 with other morphological diagnoses) underwent univentricular repair at our institute. Since 1994, routine fenestration of the atrial baffle was performed in all patients (n = 126). RESULTS: The overall Fontan failure rate was 14% (50 of 348) and included 45 early deaths and five Fontan take downs. Absence of fenestration was the only and highly significant predictor of Fontan failure (risk ratio [RR] 3.3, 95% confidence interval [CI] 1.49 to 7.31, p = 0.002). Significant pleural effusion was seen in 27% of patients. Absence of fenestration of the atrial baffle (RR 3.97, 95% CI 2.17 to 7.26, p < 0.001) and aortic cross-clamp time more than 60 minutes (RR 2.15, 95% CI 1.3 to 3.5, p = 0.002) were found to be significant risk factors. The follow-up ranged from 6 to 120 months (mean 46.0 +/- 18.0 months). There were 12 late deaths and 5 patients were lost to follow-up. Actuarial survival (Kaplan Meier) at 90 months was 81% +/- 4%. Two hundred and fifty-eight patients (90%) were in New York Heart Association class I at their last follow-up visit. Oxygen saturation in the fenestrated group ranged from 85% to 94% (mean 89%). Thirty patients (26%) had spontaneous closure of the fenestration over a mean period of 34 months, and there has been no incidence of late systemic thromboembolism. In no instance has there been a need to close the fenestration. CONCLUSIONS: Elective fenestration of the intraatrial baffle is associated with decreased Fontan failure rate and decreased occurrence of significant postoperative pleural effusions. Routine elective fenestration of the atrial baffle may, therefore, be justified in all univentricular repairs.

Indian Heart J. 2000 Jan-Feb;52(1):54-9.

Management of tetralogy of Fallot with absent pulmonary valve: early and mid-term results of a uniform approach.

Chowdhury UK, Airan B, Kumar AS, Sharma R, Bhan A, Kothari SS, Saxena A, Juneja R, Venugopal P.

Department of Cardiothoracic & Vascular Surgery, All India Institute of Medical Sciences, New Delhi.

The operative management of absent pulmonary valve syndrome remains controversial regarding palliative or one-stage correction, the need for pulmonary valve implantation and pulmonary arterioplasty. This retrospective report summarises the experience of a single centre with a view to provide some answers to this controversy. Forty-six consecutive patients including five infants, aged 2 months to 43 years, underwent primary surgical correction during the last 8.5 years. All the patients underwent two-dimensional echocardiography and cardiac catheterisation. Nine patients had mild and 10 moderate pulmonary artery hypertension. Repair consisted of patch closure of the ventricular septal defect and reconstruction of the right ventricular outflow tract. A valve was incorporated in the pulmonary position in 19 patients. Pulmonary arterioplasty was performed only in infants. Overall hospital mortality was 4 out of 46 patients (8.6%). Two out of five infants died accounting for 40 percent mortality. Forty-two survivors were followed up from 4 to 101 months; 40 patients are in functional class I and two in class II. Actuarial survival at 8.5 years was 91 percent. It is concluded that reconstruction of the right ventricular outflow tract with a transannular patch is sufficient in majority of patients. A selective approach to pulmonary valve insertion is recommended in patients with pulmonary hypertension or other anomalies. Pulmonary arterioplasty should be performed as the primary treatment in infants.

J Card Surg. 1997 Sep-Oct;12(5):300-8.

Sinus of Valsalva aneurysms: 20 years' experience.

Choudhary SK, Bhan A, Sharma R, Airan B, Kumar AS, Venugopal P.

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.

BACKGROUND: Aneurysms of sinus of Valsalva are rare. Here, we analyze retrospectively patients operated on at our center during the last 20 years. PATIENTS AND METHODS: One hundred four cases of congential aneurysm of sinus of Valsalva were operated upon between January 1977 and April 1996. Only 12 aneurysms were unruptured. The majority (76.9%) arose from the right coronary sinus. The right ventricle was the most common chamber of rupture (58.6%). Ventricular septal defect was associated in 46 patients (44.2%), of which 28 (60.9%) were supracristal. Ventricular septal defect was more common in aneurysms arising from the right coronary sinus (91.3%). Aortic incompetence was found in 45 patients (43.3%). The defect was closed through the aortic root alone in 24 patients (23.1%) and through both the aortic root and the chamber of rupture in the remaining 80 patients. Six patients underwent aortic valve repair, and 21 an aortic valve replacement. RESULTS: There were two hospital deaths (1.92%). Morbidities were few. Follow-up ranged from 1 to 20 years (mean 8.2 +/- 1.1). There was one late noncardiac death, and in the majority, the long-term follow-up was uneventful. CONCLUSION: Surgery for aneurysm of sinus of Valsalva yields gratifying results, and it should be undertaken as soon as the condition is diagnosed.

Ann Thorac Surg. 1998 Mar;65(3):735-40.

Aneurysm of sinus of Valsalva dissecting into interventricular septum.

Choudhary SK, Bhan A, Reddy SC, Sharma R, Murari V, Airan B, Kumar AS, Venugopal P.

Cardiothoracic Centre, All India Institute of Medical Sciences Ansari Nagar, New Delhi.

BACKGROUND: Dissection of interventricular septum by aneurysm of the sinus of Valsalva is extremely rare. We present our experience with the management of 10 patients with this condition. METHODS: Ten patients with aneurysm of the sinus of Valsalva dissecting into the interventricular septum were managed at All India Institute of Medical Sciences, New Delhi, between May 1987 and September 1996. Conduction abnormalities and aortic insufficiency dominated the clinical picture. Eight patients underwent surgical repair. Two patients refused operation, and only permanent pacemaker implantation was done for complete heart block in both these patients. RESULTS: There was no hospital mortality. Follow-up ranged from 1 to 9 years. There was one late death due to carcinoma of the larynx, and 1 patient required reoperation for persistent aortic insufficiency. All other patients who underwent operation are in New York Heart Association functional class I. CONCLUSIONS: We recommend surgical repair of this condition to deal with aortic regurgitation and to avoid the potential risk of rupture, thromboembolism, and infective endocarditis. However, surgical repair offers no guarantee against arrhythmias and conduction abnormalities.

Int J Cardiol. 1998 Jan 31;63(2):121-8.

Total correction of tetralogy of Fallot in adults--surgical experience.

Rammohan M, Airan B, Bhan A, Sharma R, Srivastava S, Saxena A, Sampath KA, Venugopal P.

Department of Cardiothoracic and Vascular Surgery Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi.

A total of 100 patients of tetralogy of Fallot aged 13 years and over were operated upon at the All India Institute of Medical Sciences, New Delhi, India between January 1991 and December 1996. There were 69 males (69%) and 31 females (31%). Age ranged from 13 years to 43 years (mean 19.66 years). Twenty % of patients had preoperative complications like haemoptysis, cerebrovascular accidents, brain abscess and infective endocarditis. Twenty-two patients had previous palliative shunts. Fifteen patients had coil embolisation of major collaterals prior to surgery. In hospital mortality rate was 4%. Follow-up ranged from 1 month to 5 years (mean 3.4 years). There was one late death due to infective endocarditis. Postoperatively 93.6% patients were in NYHA class I. Significant residual defects warranting re-operation were present in three patients. Total correction of tetralogy of Fallot in older patients can be performed with acceptable results.

Ann Thorac Surg. 1998 Sep;66(3):810-3.

J Card Surg. 1997 Sep-Oct;12(5):300-8.

Sinus of Valsalva aneurysms: 20 years' experience.

Choudhary SK, Bhan A, Sharma R, Airan B, Kumar AS, Venugopal P.

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.

BACKGROUND: Aneurysms of sinus of Valsalva are rare. Here, we analyze retrospectively patients operated on at our center during the last 20 years. PATIENTS AND METHODS: One hundred four cases of congential aneurysm of sinus of Valsalva were operated upon between January 1977 and April 1996. Only 12 aneurysms were unruptured. The majority (76.9%) arose from the right coronary sinus. The right ventricle was the most common chamber of rupture (58.6%). Ventricular septal defect was associated in 46 patients (44.2%), of which 28 (60.9%) were supracristal. Ventricular septal defect was more common in aneurysms arising from the right coronary sinus (91.3%). Aortic incompetence was found in 45 patients (43.3%). The defect was closed through the aortic root alone in 24 patients (23.1%) and through both the aortic root and the chamber of rupture in the remaining 80 patients. Six patients underwent aortic valve repair, and 21 an aortic valve replacement. RESULTS: There were two hospital deaths (1.92%). Morbidities were few. Follow-up ranged from 1 to 20 years (mean 8.2 +/- 1.1). There was one late noncardiac death, and in the majority, the long-term follow-up was uneventful. CONCLUSION: Surgery for aneurysm of sinus of Valsalva yields gratifying results, and it should be undertaken as soon as the condition is diagnosed.

Ann Thorac Surg. 1998 Mar;65(3):735-40.

Aneurysm of sinus of Valsalva dissecting into interventricular septum.

Choudhary SK, Bhan A, Reddy SC, Sharma R, Murari V, Airan B, Kumar AS, Venugopal P.

Cardiothoracic Centre, All India Institute of Medical Sciences Ansari Nagar, New Delhi.

BACKGROUND: Dissection of interventricular septum by aneurysm of the sinus of Valsalva is extremely rare. We present our experience with the management of 10 patients with this condition. METHODS: Ten patients with aneurysm of the sinus of Valsalva dissecting into the interventricular septum were managed at All India Institute of Medical Sciences, New Delhi, between May 1987 and September 1996. Conduction abnormalities and aortic insufficiency dominated the clinical picture. Eight patients underwent surgical repair. Two patients refused operation, and only permanent pacemaker implantation was done for complete heart block in both these patients. RESULTS: There was no hospital mortality. Follow-up ranged from 1 to 9 years. There was one late death due to carcinoma of the larynx, and 1 patient required reoperation for persistent aortic insufficiency. All other patients who underwent operation are in New York Heart Association functional class I. CONCLUSIONS: We recommend surgical repair of this condition to deal with aortic regurgitation and to avoid the potential risk of rupture, thromboembolism, and infective endocarditis. However, surgical repair offers no guarantee against arrhythmias and conduction abnormalities.

Int J Cardiol. 1996 Sep;56(1):35-40.

Surgical experience with total correction of tetralogy of Fallot in infancy.

Kaushal SK, Iyer KS, Sharma R, Airan B, Bhan A, Das B, Saxena A, Venugopal P.

Department of Cardio Thoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.

Fifty two patients less than one year old with tetralogy of Fallot underwent primary repair between January 1991 and December 1994. Age range was three to twelve months (mean 10.09 +/- 2.01 months) and body weight ranged from 4.5 to 9 kg (mean 8.38 +/- 2.79 kg). Transatrial-transpulmonary repair was performed in 36 patients and the classical transventricular approach was used in 16 patients. Six patients underwent emergency surgery for severe cyanosis and spells. Five patients had left pulmonary artery plasty for pulmonary artery bifurcation stenosis and two out of the five patients who had anomalous coronary arteries needed a right ventricle to pulmonary artery conduit. Mean post repair peak right ventricular/systemic pressure ratio was 0.74 +/- 0.18 in the transventricular group and 0.71 +/- 0.26 in the transatrial-transpulmonary group. There were three hospital deaths. Follow-up ranged from 3 to 46 months (mean 21.18 months). Forty patients underwent echocardiography and twenty patients underwent cardiac catheterisation six to eighteen months after surgery. Mean right ventricular outflow tract gradient on echocardiography was 20.35 +/- 10.12 and, at cardiac catheterisation, 17.51 +/- 13.49 mmHg with mean post repair peak right ventricle/left ventricle pressure ratio of 0.44 +/- 0.11. These were significantly less than the values obtained in the operating room. Only one patient had residual ventricular septal defect with left to right shunt of 1.6:1 at cardiac recatheterisation. There was one late death after reoperation for residual obstruction. Encouraging results with primary repair of tetralogy of Fallot in infancy prompt us to continue this policy in suitable cases.

Ann Thorac Surg. 1996 Sep;62(3):951.

Coronary sinus size as a determinant of outcome in cardiac TAPVC.

Bhan A, Saxena A, Sharma R, Venugopal P.

Indian Heart J. 1996 May-Jun;48(3):290-1.

Chronic constrictive pericarditis presenting as mass lesion in infancy.

Dharmapuran AK, Bhan A, Sharma R, Reddy SC, Venugopal P.

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi.

PMID: 8755021 [PubMed - indexed for MEDLINE]

J Thorac Cardiovasc Surg. 1995 Dec;110(6):1692-700; discussion 1700-1.

Univentricular repair. Early and midterm results.

Sharma R, Iyer KS, Airan B, Saha K, Das B, Bhan A, Rao IM, Venugopal P.

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.

A total of 202 patients (62 with tricuspid atresia and 140 without tricuspid atresia) underwent univentricular repair at our unit from January 1990 to September 1994. Of these patients, 182 had nonfenestrated and 20 had fenestrated interatrial baffles. Early mortality was 15.9% (29/182) in the group with nonfenestrated baffles and 5% (1/20) in the group with fenestrated baffles. The follow-up period ranged from 2 to 58 months. Seven late deaths occurred, and five patients were lost to follow-up. Of 160 patients who have been evaluated in the outpatient department in the past 3 months, 142 (88.75%) required no cardiac medicines and were in functional class I. Risk factors analyzed for early mortality and significant effusion were age, preoperative diagnosis, type of Fontan modification, cardiopulmonary bypass time, aortic crossclamp time, pulmonary artery size, associated pulmonary arterioplasty, takedown of systemic-pulmonary artery shunt, and pulmonary artery debanding, along with the Fontan operation. Bypass time exceeding 120 minutes was associated with a higher early mortality (12/47 vs 18/155; p = 0.0187). Bypass time exceeding 120 minutes (p = 0.0456) and aortic crossclamp time exceeding 60 minutes (p = 0.0278) were associated with significant postoperative effusion. Other factors were not associated with any significantly increased risk for early mortality or postoperative effusions. Fenestration of the interatrial baffle appeared to decrease early mortality, although the numbers are too small to be statistically significant. The prevalence of effusions did not differ significantly between the group with fenestrated baffles and the group without fenestrated baffles.

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