Clinical Case Presentation- Dr. Majidul1.pptx

Presentation

1. WELCOME TO MORNING SESSION

2. Operative procedures done on last week Presented by- DR . MD. MAJIDUL ISLAM Phase-B Resident, CV&TS NICVD

3. Adult Cardiac Surgeries performed last week TYPE OF SURGERY NUMBER CABG 1+1+1+1+1+1+ CABG with MVR Congenital CLOSURE OF VSD CLOSURE OF ASD 1+ 1+1+1+1 Valve Surgeries MVR 1+ MICS CABG 1 OTHERS ICR 1+ TOTAL 20

4. Pediatric Cardiac Surgeries performed last week TYPE OF SURGERY NUMBER ICR for TOF 1 ICR for VSD 1 Cut-Back procedure for TAPVC 1 TOTAL 3

5. Vascular Surgeries performed in last week ROUTINE Name of Operation Number Flush ligation of left SFJ with stripping of GSV with multiple phlebectomy with foam sclerotherapy 3 Foam sclerotherapy with STS (Duplex guided) 1 Left great toe amputation 1 Amputation of 1 st , 2 nd & 5 th toe (left) 1 R-C fistula 1 AVM excision 1 End arterectomy of left EIA, CFA,SFA, POP A 1 ENDOVASCULAR Stenting 2 PAG 3 Total 14

6. Emergency Name of Operation Number End to end anastomosis Radial artery 3 End to end anastomosis Radial artery And radial nerve 1 End to end anastomosis Radial and Ulnar artery 2 End to end anastomosis Ulnar artery 5 End to end anastomosis Brachial artery 3 Interposition graft in right brachial artery 1 Ligation of brachial vein 1 Ligation of ADP 1 Fasciotomy 2 Surgical toileting and hemostasis 3 Total 22

7. CLINICAL CASE PRESENTATION

8. PRESENTER DR . MD. MAJIDUL ISLAM PHASE B RESIDENT, CVTS NICVD MODERATOR DR. MD. ANWAR HOSSAIN ASSISTANT PROFESSOR, CARDIAC SURGERY NICVD

9. Particulars of the patient- Name- X Age- 9 years Sex- M ale Ward- 21 Bed- 35 Address- GouroNodi, Barishal Date of admission : 06/07/2022

10. Chief complaints- Shortness of Breath on exertion for last 7 years since his age of 2 years. Palpitation on exertion for same duration. Recurrent episodes of cough & common cold since birth.

11. History of Present illness According to the statement of the patient’s mother, the patient was suffering from shortness of breath for 7 years since his age of 2 Years. Which was--- - aggravated by moderate to severe exertion - relieved by taking rest -no seasonal or diurnal variation -not associated with exposure to dust, fumes or pollen - not associated with lying flat and nocturnal dyspnoea

12. History of Present illness (continues) The patient was also suffering from palpitation and generalized weakness for same duration which are more marked in moderate to severe exertion and relieved by taking rest. Patient’s mother also gave complains about recurrent episodes of cough and common cold since birth that was treated by local physician.

13. History of Present illness (continues) There is no history of- Chest pain Swelling of legs Fainting or Unconsciousness, Sore throat His bowel & bladder habits are normal.

14. History of past illness : No significant past history. Drug & Treatment history : Previously treated by oral medication for common cold but patient party could not mention any specific drug. History of allergy : No known allergy. Immunization history : Immunized according to EPI schedule, but not against COVID-19. Family History : No other family member is suffering from such kind of illness. Socioeconomic History : Patient belongs to a family of low socioeconomic condition.

15. Clinical examination General examination Patient is ill-looking & Body built bellow average. Co-operative No clubbing, cyanosis, Jaundice, koilonychia, leukonychia, edema, dehydration, lymphadenopathy or thyromegaly. Temperature : 98◦ F Respiratory rate: 22 breathes/min

16. Systemic examination: Cardiovascular system Pulse : All peripheral pulses were symmetrically palpable. 96 b/min, normal volu me, regular in rhythm, no radio radial or radio femoral delay with presence of normal condition of the vessel wall. JVP : Raised, 12 cm H 2 O Blood pressure: 100/70 mm Hg

17. Inspection: Apex beat visible , hyper dynamic precordium, no chest deformity, no visible scar, no venous engorgement. Palpation: Apex beat – Present on left 5 th ICS, lateral to mid clavicular line. Systolic thrill- Absent Left parasternal heave- Present P2 is palpable .

18. Auscultation: 1 st heart sound- normal in all areas Wide and fixed splitting of 2 nd heart sound P2 is loud There is Pulmonary Flow murmur found in left upper parasternal area, no radiation. Both lung bases are clear.

19. Examination of the other systems reveals no abnormalities

20. Salient feature Ms X , 9 years old normotensive , non-diabetic boy admitted in paediatric cardiac surgery ward on 06/07/22 . According to the statement , he was suffering from breathlessness for last 7 years Since his age of 2 Years which was aggravated by moderate to severe exertion, relieved by taking rest, no seasonal or diurnal variation, not associated with exposure to dust, fumes or pollen, orthopnoea and PND.

21. Salient feature (continues) The patient was suffering from palpitation and generalized weakness for last 7 years which are more marked in moderate to severe exertion and relieved by taking rest. On further asking, Patient’s mother complains about recurrent episodes of cough and cold since birth that was treated by local physician.

22. Salient feature (continues) On examination, Patient was ill looking and below average body build. No clubbing, cyanosis, Jaundice, koilonychia , leukonychia, edema, dehydration, lymphadenopathy or thyromegaly . CVS: Pulse : All peripheral pulses were symmetrically palpable. 96 b/min, low volu me pulse, regular in rhythm, no radio radial or radio femoral delay with presence of normal condition of the vessel wall. JVP : Raised, 12 cm H2O Blood pressure: 100/70 mm Hg

23. Salient feature (continues) Apex beat is visible, hyper dynamic precordium, no chest deformity, no visible scar, no venous engorgement. Apex beat is palpable in left 5 th ICS, lateral to mid clavicular line. Systolic thrill- Absent Left parasternal heave- Present P2 is palpable .

24. Salient feature (continues) Auscultation: 1 st heart sound- normal in all areas Wide and fixed splitting of 2 nd heart sound P2 is loud There is a Pulmonary flow murmur found in left upper parasternal area, no radiation. Both lung bases are clear.

25. PROVISIONAL DIAGNOSIS

26. ASD with Pulmonary Arterial Hypertension

27. DIFFERENTIAL DIAGNOSIS

28. DIFFERENTIAL DIAGNOSIS 1. Partial AV Canal Defect with PAH 2. PAPVC with PAH

29. MS Partial AV Canal Defect with PAH POINTS IN FAVOUR POINTS AGAINST Palpable P2 Loud P2 Left Para sternal Heave Pulmonary flow murmur Fixed, wide splitting 2 nd heard sound. Features of MR absent.

30. PAPVC with PAH POINTS IN FAVOUR POINTS AGAINST Pulmonary flow murmur found in left upper parasternal area Left parasternal heave Palpable P2. Fixed, Wide, splitting 2 nd heart sound.

31. INVESTIGATIONS ECG: 12 lead ECG showing- Heart rate is 100 bpm Rhythm is regular Right Axis deviation. Right Atrial Hypertrophy. Right Ventricular hypertrophy with strain pattern.

32. CXR PA VIEW Cardiomegaly. RV type Apex. Pulmonary Conus full.

33. COMPLETE BLOOD COUNT Hb - 15.1 g/dl ESR- 05 WBC- 6.000 / cumm Platelet- 2,71,00 / cumm

34. INVESTIGATIONS RESULT RBS 8.2 mmol/L S. Creatinine 0.99 mg/dl S electrolytes Na+: 138.5 mmol/L; K+: 3.38 mmol/L; Cl-: 103.0 mmol/L. CRP Negative S bilirubin 0.57 mg/dl SGPT 18.3 IU/L TSH 1.9 u IU/ml

35. ECHOCARDIOGRAPHY (TTE) All pulmonary veins forms confluence behind the coronary sinus And Ultimately draining Into RA through Coronary Sinus. Out of 4 pulmonary veins Right Upper & Lower forms separate confluence. Moderate PAH. RA, RV Dilated Coronary Sinus dilated.

36. Final diagnosis TAPVC with Large ASD secundum with Large PDA with pulmonary arterial hypertension (Moderate)

37. Procedure & Findings Cut Back Procedure & Re-routing of the four pulmonary veins into LA along with pericardial patch closure of ASD through right atriotomy with Ligation of PDA under CPB. All 4 pulmonary veins formed a common vein and drained into Coronary Sinus. A Large ASD secundum. RA , RV and pulmonary artery found dilated. A large PDA.

38. Procedure Total thymectomy was done. CPB was established. Cut-back of intervening tissue between Coronary Sinus & ASD along with part of roof of Coronary sinus. Rerouting of Pulmonary Venous blood by Repair of ASD Gluteraldehyde treated pericardial patch keeping Coronary Sinus to left side.

39. Procedure

40. Patient on 2 nd POD:

41. On 3 rd POD

42. Indication of cardiac catheterization: for possible associated anomalies for possible pulmonary hypertension To see status of mitral valve In any patient in whom noninvasive tests suggest PAPVC If arterial desaturation (<97%) exists when measured by the usual finger sensor

43. Causes of cyanosis in ASD: Unroofed coronary sinus syndrome Large eustachian valve, flow from IVC goes to LA Shunt reversal

44. ESC Guideline- 2020

45. ESC Guideline- 2020