Surgical Experience with Closure of an Isolated PDA at Muhimbili Cardiothoracic Unit in Dar es Salaam, Tanzania

Background: This study describes our experience in the management of isolated patent ductus arteriosus; complications and mortality rate. Further it describes the innovative technique for the closure of the duct.Methods: We retrospectively recruited all patients’ files that underwent PDA closure from May 2008 to July 2011 in all these patients clinical evaluation and confirmation of diagnosis was made by echocardiography. There were two-treatment group. The first group underwent a standard surgical closure and these were 26 patients this group was obtained from the usual and routinely done PDA ligation. The second group also comprised 26 patients who had undergone a modified closure technique as illustrated by Kirklin1. Patients’ age, sex duration of illness, stage of the disease as classified by New York Heart Association, ventricular function as depicted by left ventricular ejection fraction, any associated lesion were noted. During operation, confirmation of the PDA was done and the total operation time (TOT), total duration of ventilation (VT), and any complication were noted. The total duration of intensive care stay and the postoperative period stayin the ward were noted. Patients had been followed at six months interval for two years; in which during follow up evaluation for their cardiac status to exclude congestive heart failure, presence of residual PDA had been done. All data were entered in a structured data sheet and analyses using Spss window 17 statistical program.Results: A total of 52 patients with clinical diagnosis of PDA, 26 patients in each treatment group of either standard closure or new closure technique. Female patients had outnumbered male patients by 5.5 folds. A total of 46.1% of patients were under five years old. A relatively younger  population of patients was seen with the new closure technique as compared to patients in the standard closure technique (p=0.02). Similarly a correspondingly less heavier weight was noted in patients who underwent new closure technique as compared to those who had standard closuretechnique(p=0.03). Long- term follow up of patients with their treatment modalities it was found that 3 patients and 2 patients had residue lesion and congestive cardiac failure respectively who were exclusively in the standard closure technique, none of such complications were seen with thenew closure technique (p=0.04). With such evidence, the practice to date has been the new closure technique for definitive surgical treatment for PDA.Conclusion Open surgery for PDA closure remains the procedure of choice for facility and technically deprived countries. The approach and the technique of closure that minimize the postoperative complications is a challenge from centre to centre. However this study with a new closure in which a purse string on the ampulla of the PDA followed by a silk ligature has proved to be efficient and reliable technique that leaves no residual lesion with no long term complications.Key words: Closure, Isolated, Patent, ductus arteriosus, PD

Cardiac Surgery: One year experience of cardiac surgery at Muhimbili National Hospital, Dar es Salaam- TANZANIA

Background: Establishing a cardiac unit in developing countries is usually difficult as it is associated with many obstacles of both expertise and financial constraints and more alarming is the mortality rate that may be high. Even after success in the initial stage sustainability of such program is a dilemma. The aim of this study was to determine pattern of disease profile, type of cardiac surgery done and the overall outcome.Methods: All patients who underwent cardiac operation at the centre were prospectively recruited. Patients’ demography and disease characteristics as demonstrated at echocardiography and its confirmation at operation were recorded. Peri-operative factors were the measurable statistics that determined the overall patients’ outcome. All data were entered and analyzed using a spss11.5 window program.Results: A total of 105 cases of cardiac surgery were done 21% were male and 79% were females. Mean age was 19.4±12.3. The majority of cases were due to Rheumatic heart diseases (47.6%), congenital heart disease (35.2%), myxomatous valvular degeneration (16.2%) and pericardial disease 1%. Mitral valve disease was the commonest cause of cardiac disease (58.1%). Prolonged duration of aortic cross-clamp and total operation time were associated with prolonged intensive care stay and poor patients’ outcome respectively (p<0.05). While, ventricular dysfunction and total cardiopulmonary bypass time were not. The overall mortality rate was 13.3%. Majority of all death (64.3%) followed mitral valve repair.Conclusion: The majority of patients (86.7%) who underwent cardiac surgery had full recovery. The mortality of (13.3%) is probably comparable to other settings. The diversity of spectrum of cardiac disease found elsewhere is also found in our community and therefore need to increase community awareness. Mitral valve repair deserve a special entity that requires skills and expertise. The mere presence of suboptimal ventricular dysfunction is probably not a contraindication to cardiac operation. The duration of aortic cross-clamp and total operation time were determinant of postoperative outcome

Modified Blalock-Taussig Shunt in Palliative Cardiac Surgery

Background: Cyanotic congenital heart diseases present early in life with poor general condition of the patient. Majority of deaths occurs within one year of life before surgical intervention due to severe cyanosis and metabolic acidosis. Modified Blalock-Taussig Shunt (MBTS) is one of the palliative cardiac surgeries done for cyanotic congenital heart diseases. It improves the general condition of the patient before definitive surgery is done. The aim of this study was to determine the commonest indications, post-operative anticoagulation and early complications following MBTS at CARE Hospital, India. Methods: This was a retrospective study from January 2004 to December 2006 including all patients who underwent Posterolateral Thoracotomy for MBTS. All patients had deep cyanosis, oxygen saturation of 65% or less and small pulmonary vasculature due to congenital heart defects. Acyanotic patients and those with oxygen saturation more than 65% were excluded from the study. All patients received a single dose of heparin intra-operatively and oral aspirin as anticoagulant regimen post-operatively. No heparin given post-operatively. Results: A total of 20 children with a mean age of 27.4 months were studied. Two patients had pre-operative ICU admission due to severe cyanosis (both had oxygen saturation of 35%), hypotension and severe body weakness. The commonest indications for MBTS included Tetralogy of Fallot (70%), pulmonary atresia (10%) with or without Ventricular Septal Defect (VSD), tricuspid atresia (10%) with pulmonary atresia or stenosis and Double Outlet Right Ventricle (DOVR) with pulmonary atresia or stenosis (10%). Mean duration of ICU stay was 2 days, mean duration of mechanical ventilation was four and half hours, mean duration of hospital stay was 7 days and mean systemic oxygen saturation improved significantly from 46% to 84% ( x2 = 7.03, p = 0.0080). No post-operative bleeding, seroma, shunt thrombosis or death occurred in this study. Conclusion: The commonest indication for MBTS is TOF. Intra-operative single dose of heparin followed by post-operative oral aspirin as anticoagulant regimen was not associated with a major complication in terms of bleeding, seroma, shunt thrombosis, or death

Right atrial myxoma at Muhimbili National Hospital: a case report

Background: Primary cardiac neoplasms are rare most of them are benign. Cardiac myxomas are the commonest benign lesion and the initial presentation may be accompanied with pulmonary, cerebral or systemic complications. Complete resection of the tumour is associated with good prognosis but recurrence is a frequent post operative complication. We report a first rare case from our centre of right atrial myxoma occurring in a young lady of 20 years old, a diagnosis and technique of resection is also explained. Case presentation: We report a rare case of a young girl who had presented to us with history of shortness of breath and easy fatigability, she was also found to have features of both upper andlower cava hypertension and was in NYHA class IV. The 2-D echocardiography revealed a right atrial tumor encroaching the tricuspid valve, chest radiography showed gross cardiomegally and right lower lung collapse. A clinical diagnosis of right atrial tumour was reached. The patient was scheduled to undergo open heart surgery and tumour resection on 23rd September 2009 and was prepared accordingly. A classical median sternotomy followed by major vessel cannulation in which the cava were cannulated distally. Patient was cooled to 22 centigrade the tumour was found filling the whole of right atrium cavity, friable with a broad stalk on the right atrial appendage extending and infiltrating the crista terminalis. It was excised and tissue was taken for histopathology. The right atrium was reconstructed and closed with adequate size of atrium. The histopathology revealed a typical right atrial myxoma. Postoperatively the patient developed massive right sided pleural effusion that was managed by tube thoracostomy. Eventually the patient recovered and was discharged to be followed at outpatient clinic. Conclusion: Right atrial myxomas are rare lesion occurring in 5- 10% of all cases of cardiac myxoma. The peak incidence is between 3rd to 6th decades of life. Our case was unusual as it occurred in the 2nd decade and in the right atrium with multicentric origin though still confined in the right atrium. She also presented with pulmonary complication of right sided lung collapse. Early diagnosis andresection is followed by good prognosis and recurrence rate is low. Resection was done and the postoperative period was uneventful.Keywords: cardiac myxoma, atrial tumour, cardiac tumour, multicentric, subendocardium, mesechymal tissu

Cardiac Surgery: One Year Experience of Cardiac Surgery at Muhimbili National Hospital, Dar es Salaam - Tanzania

Background: Establishing a cardiac unit in developing countries is usually difficult as it is associated with many obstacles of both expertise and financial constraints and more alarming is the mortality rate that may be high. Even after success in the initial stage sustainability of such program is a dilemma. The aim of this study was to determine pattern of disease profile, type of cardiac surgery done and the overall outcome. Methods: All patients who underwent cardiac operation at the centre were prospectively recruited. Patients’ demography and disease characteristics as demonstrated at echocardiography and its confirmation at operation were recorded. Peri-operative factors were the measurable statistics that determined the overall patients’ outcome. All data were entered and analyzed using a SPSS 11.5 window program. Results: A total of 105 cases of cardiac surgery were done 21% were male and 79% were females. Mean age was 19.4±12.3. The majority of cases were due to Rheumatic heart diseases (47.6%), congenital heart disease (35.2%), myxomatous valvular degeneration (16.2%) and pericardial disease 1%. Mitral valve disease was the commonest cause of cardiac disease (58.1%). Prolonged duration of aortic cross-clamp and total operation time were associated with prolonged intensive care stay and poor patients’ outcome respectively (p<0.05). While, ventricular dysfunction and total cardiopulmonary bypass time were not. The overall mortality rate was 13.3%. Majority of all death (64.3%) followed mitral valve repair. Conclusion: The majority of patients (86.7%) who underwent cardiac surgery had full recovery. The mortality of (13.3%) is probably comparable to other settings. The diversity of spectrum of cardiac disease found elsewhere is also found in our community and therefore need to increase community awareness. Mitral valve repair deserve a special entity that requires skills and expertise. The mere presence of suboptimal ventricular dysfunction is probably not a contraindication to cardiac operation. The duration of aortic cross-clamp and total operation time were determinant of postoperative outcome

Closed Mitral Valvotomy-a Life Saving Procedure in Facility Deprived Countries: Experience at Muhimbili National Hospital, Tanzania.

Background: Rheumatic heart disease remains a major health cardiac problem in developing countries as the culprit of rheumatic fever. Mitral valve stenosis is the most common complication of valvular heart disease and its consequences of increase in pulmonary hypertension, heart failure, pulmonary vascular disease and if untreated death ensues. The management of this condition varies depending on availability of expertise and resource; however in a facility deprived country with low economic status closed mitral valvotomy remain the standard palliative treatment! The aim of this study was to evaluate the clinical status of patients with mitral stenosis following closed mitral valvotomy treated at Muhimbili National Hospital, Cardiothoracic Unit. Methods: All patients presenting with severe mitral stenosis in absence of calcification in its leaflets and regurgitation were enrolled for the study from May 2008 to November 2009. Excluded were those who failure consents. Results:A total of fourteen patients were included in the study of which 10 (71.4%) were females and 4 (28.6%) were males. They had a mean age of 21.5&plusmn;8.8 and range from 11 to 41 years. The diagnosis was based on clinical evaluation using NYHA class and 2D-Echocardiography findings. All patients&rsquo; demographic data, preoperative and post operative findings were taken and data analysis was done using an SPSS 11.5 program. Categorical data were compared and analyzed using two Tailed- &chi;2 and values were taken 5% significance level. Conclusion: There was an overall highly significant improvement in clinical stage of the disease, reduction in mean pressure gradient across the mitral valve, reduction in pulmonary hypertension and mean left atrial size. Similarly there was improvement in ventricular function in terms of ejection fraction and increase in mean mitral valve area

Closed Mitral Valvotomy-a Life Saving Procedure in Facility Deprived Countries: Experience at Muhimbili National Hospital, TANZANIA.

Background: Rheumatic heart disease remains a major health cardiac problem in developing countries as the culprit of rheumatic fever. Mitral valve stenosis is the most common complication of valvular heart disease and its consequences of increase in pulmonary hypertension, heart failure, pulmonary vascular disease and if untreated death ensues. The management of this condition varies depending on availability of expertise and resource; however in a facility deprived country with low economic status closed mitral valvotomy remain the standard palliative treatment! The aim of this study was to evaluate the clinical status of patients with mitral stenosis following closed mitral valvotomy treated at Muhimbili National Hospital, Cardiothoracic Unit. Methods: All patients presenting with severe mitral stenosis in absence of calcification in its leaflets and regurgitation were enrolled for the study from May 2008 to November 2009. Excluded were those who failure consents. Results:A total of fourteen patients were included in the study of which 10 (71.4%) were females and 4 (28.6%) were males. They had a mean age of 21.5±8.8 and range from 11 to 41 years. The diagnosis was based on clinical evaluation using NYHA class and 2D-Echocardiography findings. All patients’ demographic data, preoperative and post operative findings were taken and data analysis was done using an SPSS 11.5 program. Categorical data were compared and analyzed using two Tailed- χ2 and values were taken 5% significance level. Conclusion: There was an overall highly significant improvement in clinical stage of the disease, reduction in mean pressure gradient across the mitral valve, reduction in pulmonary hypertension and mean left atrial size. Similarly there was improvement in ventricular function in terms of ejection fraction and increase in mean mitral valve area