Adverse Drug Reactions in Management of Multi Drug Resistant Tuberculosis, in Tertiary Chest Institute

Background: Multidrug resistant tuberculosis is a global threat. Effective treatment is implemented as per RNTCP guidelines. But the drugs used have great potential to develop adverse drug reactions. Such drug reactions if not managed optimally can lead to unfavourable treatment outcome. Hence, the study is to know the occurrence of adverse drug reactions. Aims: To study the occurrence of adverse drug reactions in treatment of multidrug resistant tuberculosis and hence the factors affecting the treatment. Settings and Design: Retrospective analysis of patients treated with standardised regimen for MDR-TB, as per RNTCP guidelines at a tertiary chest institute between august 2011 and December 2014. Methods and Material: Retrospective analysis of 607 patients’ records reviewed for the occurrence of adverse drug reactions. All adverse reactions are noted and diagnosed either clinically or by laboratory evidence. Results: Among the 607 patients included in the study, majority had one or more adverse drug reactions. The most common was gastritis (71.7%), which was easily treatable, and the least common was visual impairment (0.2%). Only 1.7% discontinued the treatment citing adverse drug reactions and 10.5% required permanent discontinuation of the offending drug. Conclusion: Treatment of MDR-TB is challenging mainly due to the long duration of treatment and the potential adverse reactions of the drugs used. These reactions are frequent but majority of them can be successfully managed without treatment interruption. Training the peripheral health centre workers to identify and refer the patients with adverse reaction bears a major impact on treatment outcome.

Anomalous Origin and Course of Coronary Artery—Presentation of Three Cases

Anomalous origin of coronary arteries may be encountered coincidentally in the presence of unrelated pathology or when these are affected directly. This may directly be responsible for affecting the procedure or outcome. Various types of anomalies of origin,?as well as course of coronary arteries,?have been classified in the past. Here we report 3 cases of anomalous origin of coronary arteries in different scenarios. First case had anomalous coronary with bicuspid aortic valve with dilated ascending aorta for which Bentall’s procedure was done, while the second and third cases were anomalous coronaries with coronary artery disease for which coronary artery bypass grafting was done.

Konno Procedure for Managing Small Aortic Root during Aortic Valve Replacement Surgery: An Experience of 12 Cases

Background: Small aortic annulus during aortic valve replacement can lead to implanting a smaller sized valve compared to the body surface area thereby causing patient prosthesis mismatch. Various aortic root enlargement techniques have been described depending on anterior or posterior approach. Konno procedure uses anterior approach for aortic root enlargement. In this study, we reviewed results of Konno procedure done from 2011 to 2019 by a single surgeon. Methods: 12 adult patients who underwent aortic valve replacement along with Konno procedure for small aortic root by a single surgeon at a single center between 2011 and 2019 were reviewed. Echocardiographic and demographic data and post-operative data were obtained from medical records. Symptomatic profile was assessed as per New York Heart Association Classification. Intraoperative findings and post-operative period findings were noted. Follow up symptom profile was assessed for these patients. Results: 12 patients underwent Konno procedure between 2011 and 2019 for small aortic root along with valve replacement. The main indication for surgery was aortic stenosis with small aortic annulus, with or without involvement of the mitral valve. Preoperatively, 3 patients had NYHA class II and 9 patients had NYHA class III symptoms. Mean age at operation was 26.42 years, minimum age 10 years, and maximum age 39 years. 3 were females and 9 were males. Mean bypass time was 106.4 minutes and aortic cross clamp time was 80.67 minutes. Mechanical aortic valves were implanted in all patients. Mean post-operative blood loss was 134.2 ml and duration of ventilation before extubation was 14.5 hours. Mean duration of intensive care unit (ICU) stay was 2.83 days and hospital stay was 9.1 days. Mean gradient in the post-operative period was 10.75 mm Hg. There was no mortality in these 12 patients and no reoperation was needed in the follow up period. Follow up in the outpatient department suggested all patients had NYHA class I symptoms and anticoagulation with warfarin adjusted to prothrombin time— International normalised ratio. Conclusion: Konno procedure is effective for managing small aortic root as bigger outflow orifice area through the larger valve prosthesis improves ventricular outflow and hence, improves the outcomes.

Fresh Pericardial Valved Conduit for Reconstruction of Right Ventricular Outflow Tract in Tetralogy of Fallot with Pulmonary Stenosis or Pulmonary Atresia—Early Results

Objective: To study early results of hand made fresh (autologous/homologous) pericardial valved conduit in achieving right ventricle to pulmonary artery continuity. Method: Between November 2014 and September 2015, 19 cases, with diagnosis of Tetralogy of Fallot with Pulmonary stenosis (PS) or Pulmonary atresia (PA) underwent intracardiac repair and Right Ventricular Outflow Tract (RVOT) reconstruction with hand made fresh [autologous (n = 2)/ homologous (n = 17)] pericardial valved conduit. Mean age of the patients at time of surgery was 6.37 years (range 3 months to 18 years), mean weight was 18.52 kilograms (range 6 kg to 40 kg) and mean size of the conduit was 20.7 mm (range 16 mm to 24 mm). Results: All patients had a smooth post-operative course, with mean ICU (Intensive Care Unit) stay of 3.6 days (range 3 days to 6 days) and mean post-operative hospital stay 8.5 days (range 7 days to 16 days). Intra-operative and Post-operative echocardiography revealed moderate Pulmonary regurgitation (PR) in one patient, mild PR in 5 patients and no or trace PR in 13 patients. No patient has developed conduit stenosis or calcification till now. Conclusion: Autologous or homologous pericardial valved conduit provides good early results and is especially suitable for developing world because of zero cost. Long term usefulness of such option remains to be confirmed in terms of dilation, calcification and freedom from intervention.

Isolation of Left Subclavian Artery with Tetralogy of Fallot—A Case Report

Background: Isolation of Left Subclavian Artery (LSCA) is a rare subset of Right Aortic Arch (RAA). It is diagnosed as nonvisualization of LSCA in catheterization study. Case Presentation: Here we report an unusual case of Tetralogy of Fallot (TOF) with right aortic arch with isolation of left subclavian artery (LSCA). Here LSCA originated from left pulmonary artery (LPA) through an atretic patent ductus arteriosus (PDA). There was nonvisualization of LSCA in catheterization study and it was confirmed by Computed Tomography (CT) angiography. Re-implantation of LSCA was done to left common carotid artery (LCCA) so that the left upper arm maintains a better flow in the future. Conclusion: Isolation of LSCA especially with TOF is a very rare entity. Re-implantation of LSCA to LCCA was done in view of weak pulses in left upper limb. Results were satisfactory in the follow up period.

Ventricular Septal Defect after Blunt Trauma in a Case of Preexisting Prosthetic Mitral Valve

We present a case of an isolated large ventricular septal defect (VSD) following blunt chest trauma in a motor vehicle accident in the patient with preexisting mechanical mitral valve. Transthoracic echocardiography revealed a large muscular VSD with significant left to right shunt along with septal edema. Surgical repair was performed in view of Qp:Qs of 2.5 with significant hemodynamic instability despite intra-aortic balloon pump. The ventricular septal defect was found in apical muscular portion of the interventricular septum, which was closed through left ventriculotomy. We here discuss the possible mechanisms of damage and importance of timely surgery. To conclude, minor looking external injury might contain devastating damage inside, especially with patients on anti-coagulant therapy.

Malposition of Stent a Rare Complication in Coarctation of Aorta Corrected with Extraanatomic Aortic Bypass

Mal-position of stent in coarctation of aorta is very rare but a major complication. Symptoms can worsen even more. We present here one such case where stenting done in some other institute in which we did an extra-anatomical bypass from ascending aorta to supracelial aorta successfully bypassing the coarct segment. This was an early approach without assistance of Cadio-pulmonary (CP) Bypass. We conclude that this procedure should be done in centres where experienced operator and cardiac surgery back up is present. This was a good approach without assistance of CP Bypass.

Malignant Tumors of Heart: A Review

Malignant cardiac tumors are rare and challenging entity. Experience in treating these aggressive and lethal tumors is minimal and management protocols are not well defined and have to rely on case reports, and personal experiences. Most effective therapy for primary cardiac malignancy is a complete surgical resection and the role of chemoradiotherapy is still evolving.

An Experience on Normothermic Beating Heart Pulmonary Thromboendarterectomy

Objective: To study the outcome of normothermic beating heart pulmonary thromboendarterectomy (PTE) performed in patients with chronic pulmonary thromboembolism. Methodology: A retrospective analysis of 15 patients who underwent PTE under normothermic beating heart cardio-pulmonary bypass from July 2009 to September 2018 was done. The patients were followed up with clinical assessment, transthoracic echocardiography and computerized tomographicangiography (CTA) for 1 month to 82 months. Results: Data were analysed for 15 consecutive patients. Mean age of the patients was 35.28 years and 10 patients were male. Pre-operatively 6 (40%) patients presented with New York Heart Association (NYHA) class II dyspnoea on exertion symptomatology, 7 (47%) were in NHYA class III, and 2 (13%) were in NYHA class IV. The preoperative and postoperative mean pulmonary artery pressures (mPAP) (mmHg) were 36.50 ± 11.3 and 20.21 ± 7.19, the systolic PAPs (mmHg) were 73.35 ± 14.12 and 35.21 ± 7.89 and the diastolic PAPs (mmHg) were 19.28 ± 8.60 and 12.85 ± 7.26 respectively. 2 (13%) patients had Jamieson’s type I and 12 (87%) had Jamieson type II disease. One patient (7%) expired on 9th postoperative day. All the patients had improved pulmonary gas exchange and did not require oxygen supplementation from 5th postoperative day;symptoms improved to NYHA class I & II in 12 (80%) & 3 (20%) of patients respectively. There was no reperfusion pulmonary edema or any neurologic complications. Postoperative echocardiogram showed improved right ventricular function and Computerised Tomographic Angiogram showed completeness of the procedure. Conclusion: Pulmonary thromboendarterectomy under normothermic beating heart cardiopulmonary bypass has good immediate postoperative results with significant progressive improvement in hemodynamics and quality of life during the course of follow-up. The results were not only comparable to those of the procedure done under deep hypothermic circulatory arrest by other centres but also without its associated adverse events. This technique requires more expertise but gives equivalent good results in immediate and short- to mid-term follow-up with less morbidity than the standard procedure, but it requires long-term follow-up to substantiate the evidence.

Accessory Leaflet of Tricuspid Valve Masquerading as Infective Endocarditis Preoperatively and Causing RVOT Obstruction Postoperatively

Accessory tricuspid valve tissue is a rare congenital anomaly. We report a case where preoperative echocardiogram was suggestive of infective vegetations over the tricuspid valve but intra-operatively it was found to be accessory tricuspid valve leaflets which were causing right ventricular outflow tract obstruction.

Sudden cardiac death in a case of Crohn's disease with COVID-19: A case report

Rationale:The mechanism of sudden cardiac death in COVID-19 can be multifactorial.Cardiac hypersensitivity to 5-ASA therapy leading to myocarditis has been reported in some cases.Cytokine storm syndrome and idiosyncratic reaction with mesalazine use may lead to sudden cardiac death in COVID-19.Use of immunosuppressants in hospitalized COVID-19 patients should be continued with caution,especially in patients with inflammatory bowel disease.Patient’s concern:A 75-year-old man who was tested positive for SARS-CoV-2 was admitted with a history of shortness of breath for the last two days.He was a known case of Crohn’s disease treated with mesalazine.Diagnosis:COVID-19 pneumonia with underlying Crohn’s disease leading to sudden cardiac death.Intervention:Remdesivir,antibiotics,steroids,low molecular weight heparin,tablet zinc,tab vitamin C,and other supportive treatment were started.Because of increased inflammatory markers,itolizumab was given to the patient on the 2nd day.Outcome:On the 5th day of the intensive care unit,the patient complained of sudden chest pain with respiratory distress leading to bradycardia and asystole and could not be resuscitated.Lessons:Causes for sudden cardiac death in COVID-19 pneumonia patients with Crohn’s disease is multifactorial.Although mesalazine may be a safe and effective drug in the management of inflammatory bowel disease,it can induce sytokine strom syndrome and idiosyncratic reactions that could be one of the reasons of sudden cardic death.Therefore,we should be aware of its serious and potentially life-threatening complications,especially in COVID-19 infected patients.

Right Ventricular Failure Following Left Ventricular Assist Device Implantation

Left ventricular assist device (LVAD) is being used increasingly in recent years for end stage heart failure as a bridge to transplant (BTT) and also as a destination therapy (DT). Patients with end stage heart failure have some degree of elevated pulmonary capillary wedge pressure, causing right ventricular hypertrophy which in due course leads to decreased dilatation of the RV and fall in cardiac output & severe tricuspid regurgitation (TR) presenting with features of RV failure (RVF). Implantation of LVAD improves left heart function at the cost of right ventricular output with an incidence of 25%-30%. RVF may lead to impaired LVAD flow, difficulty in weaning from cardio-pulmonary bypass (CPB), decreased tissue perfusion and multi-organ failure. In this article we comprehended the pathophysiology leading to RVF post LVAD implantation and its preoperative predictors and the various treatment modalities for managing RVF post LVAD implantation.

Nurses and nursing students’knowledge regarding blood transfusion:A comparative cross-sectional study

Objective:The objective of this study is to measure and compare the knowledge of nursing students and nurses on blood transfusion in an Indian context.Materials and Methods:The present comparative,cross-sectional study enrolled 296 nurses and 177 nursing students through a purposive sampling from a medical university hospital and different nursing institutions.The data were collected in the month of June and July of year 2021,using a self-structured questionnaire.The questionnaire had two sections:Section-I contained demographic data(8 items for nurses and 5 for students)and section-II included 26 items that assessed nurses’and nursing students’knowledge on blood transfusion.Results:Findings indicated that nurses and nursing students had insufficient knowledge about blood transfusion.Nurses,however,had significantly greater total blood transfusion knowledge scores than nursing students(16.51±3.85 vs.12.10±3.28;P<0.001).The marital status(adjusted odds ratio[AOR]=0.456,95%confidence interval[CI]0.244,0.853;P=0.037),educational level(AOR=5.072,95%CI 1.982,9.634(P=0.003);AOR=6.540,95%CI 2.54,16.871;P=0.001)and work experience(AOR=0.216,95%CI 0.067,0.702[P=0.037];AOR=0.331,95%CI 0.135,0.811;P=0.013)were the significant predictors of the level of knowledge among nurses.The attendance in any educational programme on blood transfusion(AOR=0.225,95%CI:0.062,0.818;P=0.041)was a significant predictor of the level of knowledge among nursing students.Conclusion:Nurses and nursing students have unsatisfactory knowledge on blood transfusion;emphasizing the critical need for immediate and successful teaching activities in this area.

Pseudoaneurysm of Ascending Aorta with Extrinsic Compression of Left Main Coronary Artery

Pseudoaneurysm of ascending aorta carries high mortality and morbidity due to adhesions and compression over surrounding structures. It occurs either after some form of injury to aorta or after infectious pathology. Spontaneous pseudoaneuryms are very rare as are the extrinsic compression of left main coronary artery. We are presenting a case with both of these rare ties. Patient was a female of middle age presented with cough and a past history of treated pulmonary tuberculosis 12 years before. During evaluation by X-ray, CECT is a large pseudoaneurysm of ascending aorta with oval defect in posterior wall above sinotubular junction. It was compressing 90% of the left main coronary artery, occluding 100% of the right pulmonary artery with formation of collaterals to it from surrounding arteries. Active tuberculosis and syphilis were ruled out. Patient underwent excision of pseudoaneurysm, replacement of ascending aorta by Dacron graft and coronary artery bypass under TRCA and CPB. There was massive intraoperative bleeding, and patient died on the fourth day due to sepsis and ARDS.

Iatrogenic Disruption of Left Main Coronary Artery during Aortic Valve Replacement

This aortic valve replacement (AVR) remains the gold standard for symptomatic aortic stenosis. Peri-operative complications like dissection, stenosis involving coronary artery are well described in many series. We present a rare iatrogenic complication of disrupted left main coronary artery during the delivery of cardioplegia while performing AVR in a 54 year male patient for severe calcific aortic stenosis. The inadvertent injury to the artery was timely noticed and managed successfully with long saphenous vein graft.

Composition of Human Atheroma Collected from Coronary Arteries during Coronary Artery Bypass Surgery

Coronary arteries supply blood and nutrients to the heart. Coronary Artery Disease (CAD) develops by narrowing of the arteries. Once the inner walls of the arteries are damaged, fatty deposits made of cells, connective tissue elements, lipids and debris decrease their lumens which block blood flow to distal tissues. This process is called arteriosclerosis. This study intends to detect the composition of human coronary atheroma collected from the arteries during bypass surgeries in Bangladesh. It shows that all lesions are present in the advanced types, namely, type 4, 5 and 6. Infrequently thrombotic materials and necrotic debris were found in type 6 plaque. The mean length of plaque was 3.36 ± 1.71 cm and mean weight was 0.13 ± 0.12 gm. Insufficient lipid was obtained from each atheroma. Few raised areas were lipid laden whereas most of the strands were fibrous. Biochemical assessment was formidable. The cholesterol composition of coronary plaque ranged between 0.20% - 9.83% with mean 3.06% ± 2.09% and total fatty acids ranged between 0.47% - 3.04% with mean 1.31% ± 0.63%. The most abundant fatty acid was oleic acid (unsaturated) closely followed by palmitic acid (saturated). The mean calcium content was 41,180.20 ± 34,918.59 ppm and ranged from 1148.00 - 140,311.00 ppm or, 0.115% - 14.031%. This study was undertaken to detect the composition of human coronary atheroma in Bangladesh which revealed that it depended upon the type of lesion.

Urgent Off-Pump Revascularisation in ACS and Cardiogenic Shock with Anomalous Origin of Right Coronary Artery from Left Anterior Descending Artery: A Case Report

A 55-year-old female known case of essential hypertension and diabetes was brought to the Emergency Department in a drowsy state with cardiogenic shock. At presentation systolic BP was 70 mm Hg, pulse rate was 44/min and random blood sugar was 239 mg/dl. Troponin I was 8.07. Electrocardiography showed junctional rhythm and bradycardia. Ejection Fraction (LVEF) was 15% - 20%. Coronary angiography was done which revealed single vessel disease in LAD with anomalous origin of RCA from midsegment of LAD. Patient was immediately taken up for Off-pump Coronary Artery Bypass Grafting (OPCAB). Right saphenous vein graft was harvested and anastomosed proximally to aorta and distally to LAD on beating heart using Medtronic Octopus heart stabilizer and coronary shunts. Wound closed in layers after achieving complete hemostasis. Patient was taken off ventilatory support on first post-operative day and discharged in a stable condition on fourth post-operative day. Post-operative Echocardiography showed LVEF increased from 15% - 20% at time of admission to 38% and 52% after 3 months and 12 months of surgery respectively.

Late Presentation of Bronchial Foreign Body in Young Adult: A Case Report

Foreign body aspiration is common in young children or in adults with advanced age and altered mentation. Usually symptoms present acutely, leading to early intervention. We present a rare case of a healthy young female who aspirated her nasal ring but remained asymptomatic for almost eight years. The patient ultimately required a right upper lobe lobectomy for bronchiectasis.