Successful Rheumatic heart disease / Mitral stenosis / AF / PAH / LA. clot Surgery. [A Lilavati Hospital]

(Dr. Pavan Kumar, Dr. S Borkar, Dr. Amit Modi, Dr. N. Kothari, Dr.Asmita Hegde)

Department Of Cardiac Surgery.

A female patient aged 44yrs, Mrs. Jayashree Nathani , presented to us with Orthopnoea and breathlessness on mild exertion since a month.
Patient had been taking anti-failure treatment and oral anticoagulants (ACITROM).

CLINICAL FEATURES:

She was conscious, Co – operative and well oriented in time, space and person,
but tachypnoeic with R. R of 35 – 40 min.
Pulse – Irregularly irregular with Rate b / w – 100 – 110 / min and an apex pulse deficit of 15 – 20bts/ min.
BP – 90 / 70mmHg
CVS – Mid Diastolic murmur at apex with loud St at palm area.
RS – B/L course crepts with air entry at bases.
CNS & abdominal Examination was unremarkable. 

INVESTIGATIONS :

Blood Aneurysm involving arch of aorta compressing one upper lobe of R lung & grossly dilated descending aorta. Coronary angiography revealed (N) coronaries with (N) L.V. Ejection Fraction.

Chest X-Ray showed cardiomegaly ( + ), Severe pulmonary hypertension , huge left atrium and pulmonary edema. 

ECG S/ o Mitral valve disease, AF, Left atrial enlargement.

ECG S/ o Mitral valve disease, AF, Left atrial enlargement.

TREATMENT :

Patient was admitted and Rxed aggressively with I.V.Lasix and other antifailure medications. Oral anticoagulants were stopped and she was put on LMWH.
She was taken up for surgery on June 26th, 2004.

OPERATIVE PROCEDURE

Std. midsternotomy incision. Sternum divided. Pericardium split. Routine cannulation aortic and bi-caval after full systemic heparinisation. CPB instituted. Aorta clamped. Intermittent as Antegrade warm blood cardioplegia
given. Heart arrested. LA - full of old and fresh clots - 150 gm of clots removed. Mitral Valve - Calcific stenotic valve. Mitral Valve Excised & replaced by # 3 M STARR - EDWARD BALL - VALVE prosthesis, using interrupted 2.0 ethibond pledgeted interrupted sutures.
Standard LA closure. Deairing done. Patient rewarmed. Aorta unclamped. Heart started beating spontaneously. CPB terminated. Heparin reversed. LA line put in. Decannulation done. Hemostasis done. Pericardium closed partially. Pleura & mediastinum drained separately, pacemaker wire put in. Sternotomy closed, wound closed in two layers.

Patient was shifted to surgical ICCU with hemodynamically stable condition. Post operative recovery was uneventful and patient was discharged on seventh post operative day with oral anticoagulants with good hemodynamic status without any neurological deficit.