Successful Rheumatic heart disease / Mitral stenosis / AF / PAH / LA. clot Surgery [At Nanavati 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 parameters were unremarkable except INR which was high due to oral anticoagulants.
Chest X-Ray showed cardiomegaly ( + ), Severe pulmonary hypertension , huge left atrium and pulmonary edema.
ECG S/ o Mitral valve disease, AF, Left atrial enlargement.
2D Echo revealed severe critical calcific Mitral stenosis ( Rheumatic etiology ) with dilated L. atrium and L. A. clot.

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.