This document summarizes the cardiac surgeries and vascular surgeries performed at NICVD last week. For cardiac surgeries, there were 20 adult cases including CABG, valve repairs/replacements, and other procedures. There were also 6 pediatric cardiac surgeries. For vascular surgeries, there were 14 routine cases and 22 emergency cases covering procedures such as artery repairs and bypass grafts. The document then presents a clinical case of a 6-year-old female with anomalous pulmonary venous drainage, ASD, and pulmonary hypertension who underwent repair surgery.

1. WELCOME
TO
MORNINGSESSION

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 8
CABG with MVR 1
Congenital CLOSURE OF ASD 5
Valve Surgeries MVR 3
DVR 1
OTHERS BENTALL PROCEDURE 1
BENTALL PROCEDURE with CABG 1
TOTAL 20

4. Pediatric Cardiac Surgeries performed last week
TYPE OF SURGERY NUMBER
ICR for TOF 4
ICR for ASD 1
PDA ligation 1
TOTAL 6

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 1st, 2nd & 5th 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
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. KHONDOKAR SHAMIM
SHAHRIAR ZIBAN RUSHEL
◦ ASSISTANT PROFESSOR,
◦ PAEDIATRIC CARDIAC SURGERY
◦ NICVD

9. Particulars of the patient-
◦ Name- X
◦ Age- 6 years
◦ Sex- Female
◦ Ward- 03
◦ Bed- 26
◦ Address- Naogaon
◦ Date of admission: 14/07/2022

10. Chief complaints-
1. Recurrent episodes of RTI for same duration.
2. Shortness of Breath for same duration.
3. Palpitations for same duration.

11. History of Present illness
According to the statement of the patient’s mother, She is suffering from
recurrent episodes of cough and cold since birth that was treated local physician.
She has also complaint of Shortness of Breath particularly during her attack of
RTI since her birth and increased in intensity for last 6 months which is….
- aggravated by Caugh, common cold.
- relieved by taking Medications.
-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 has also been suffering from palpitation and generalized
weakness for 4 years which are more marked in moderate to severe
exertion and relieved by taking rest.
She was diagnosed as a case of CHD at the age of 2.

13. History of Present illness (continues)
◦ There is no history of-
1. Chest pain
2. Swelling of legs
3. Fainting or Unconsciousness,
4. Sore throat
Her 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.
◦ Co-operative
◦ No clubbing, cyanosis, Jaundice, koilonychia, leukonychia,
edema, dehydration, lymphadenopathy or thyromegaly.
◦ Temperature : 98◦ F
◦ Respiratory rate: 24 breathes/min

16. Systemic examination:
Cardiovascular system
◦ Pulse : All peripheral pulses were symmetrically palpable.
96 b/min, normal volume, 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

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

18. ◦ Auscultation:
1st heart sound- normal in all areas
2nd heart sound- normal in all areas.
P2 is loud
There is a Mid Diastolic Murmur parasternal area, radiates to the left Axilla
best heard in left lateral position, by the bell of stethoscope with breath
holding after expiration.
Both lung bases are clear.

19. Examination of the other systems reveals no
abnormalities

20. Salient feature
Ms X, 6 years old normotensive , non-diabetic girl admitted in
paediatric cardiology ward on 14/07/22. According to the statement, she
has been suffering from repeated episodes of RTI since birth
breathlessness for last 3 years, 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 has also been suffering from palpitation and generalized
weakness for 4 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 local physician.

22. Salient feature (continues)
On examination, Patient was ill looking and mildly anemic.
No clubbing, cyanosis, Jaundice, koilonychia, leukonychia, edema,
dehydration, lymphadenopathy or thyromegaly.
CVS:
◦ Pulse : All peripheral pulses were symmetrically palpable.
96 b/min, low volume 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 5th ICS, lateral to mid clavicular line,
thrusting in nature.
Systolic thrill- Absent
Left parasternal heave- Present
P2 is palpable.

24. Salient feature (continues)
◦ Auscultation:
1st heart sound- normal in all areas
Wide and fixed splitting of 2nd heart sound
P2 is loud
There is a ejection systolic murmur (grade 3/6)found in left upper
parasternal area, no radiation.
Both lung bases are clear.

25. PROVISIONAL
DIAGNOSIS

26. ATRIAL SEPTAL DEFECT with
Pulmonary hypertension

27. DIFFERENTIAL
DIAGNOSIS

28. DIFFERENTIA
L DIAGNOSIS
PULMONARY STENOSIS
MITRAL STENOSIS

29. PS
Pulmonary stenosis
POINTS IN FAVOUR POINTS AGAINST
• Ejection systolic murmur found
in left upper parasternal area
• Left parasternal heave
• 1st hear sound- normal
• Fixed splitting of 2nd heart sound
• Palpable P2
• Thrill absent
• Radiation

30. MS
MITRAL STENOSIS
POINTS IN FAVOUR POINTS AGAINST
• A2-P2 vs S2-OS
• Loud P2
• Left parasternal heave [if P.
HTN]
• Normal volume pulse
• Thrusting apex beat
• Normal 1st heart sound
• Absence of classical murmur
in mitral area
MDM (Tricuspid flow murmur) vs MDM (MS)

31. INVESTIGATIONS
◦ ECG: 12 lead ECG showing-
• Heart rate is 125 BPM
• Rhythm is regular
• RSR1 pattern in V1 &V2- complete RBBB
• Right atrial enlargement
• Right axis deviation
• Crochetage sign (Lead II, III & aVF)

32. CXR PA VIEW

33. COMPLETE BLOOD COUNT
◦ Hb- 11.52 g/dl
◦ ESR- 02
◦ WBC- 7,800/cumm
◦ Platelet- 2,18,00/cumm

34. INVESTIGATIONS RESULT
RBS 6.5 mmol/L
S. Creatinine 0.7 mg/dl
S electrolytes Within normal range
CRP Negative
S bilirubin 0.3 mg/dl
SGPT 20 IU/L
Urine R/E NAD

35. ECHOCARDIOGRAPHY (TTE)
◦ Two ASD II in two different
places-
Larger one (24 mm) high up
ASD II with absent posterior
superior rim (L-R)
Another 10 mm ASD II (L-R)
◦ Cor triatriatum of LA
◦ Pathological mitral valve:
Rudimentary, thick PML, MR
grade II
◦ Pathological triocuspid valve,
TR grade I
◦ RA, RV hugely dilated
◦ Mild pulmonary artery HTN
(PAH)

37. ECHOCARDIOGRAPHY (TTE)

38. CT pulmonary
angiogram

39. CT pulmonary angiogram

40. CT pulmonary angiogram

41. Final diagnosis
PAPVC with Large ASD secundum with pulmonary
arterial hypertension [severe]

42. Procedure & Findings
Re-routing of the RUPV & RLPV into LA along with pericardial patch
closure of ASD through right atriotomy under CPB
◦ Right upper and lower pulmonary veins were draining into RA
◦ Left upper and lower pulmonary veins were draining into LA
◦ A 24 mm ASD secundum and a 10 mm ASD secundum
◦ A bridge of tissue found between the two ASD
◦ Azygos vein, RA, RV and pulmonary artery found dilated
◦ AML & PML of mitral valve were normal

43. Procedure

44. Take Home Message
DIAGNOSIS OF ANOMALOUS PULMONARY VENOUS
DRAINAGE BY ECHOCARDIOGRAPHY IS VERY DIFFICULT
SURGEONS SHOULD ALWAYS LOOK FOR INSERTION OF
PULMONARY VEINS CAREFULLY DURING PROCEDURE AS
THERE IS WIDE RANGE OF VARIATION
CT PULMONARY ANGIOGRAM MAY ALSO MISLEAD SURGEON

45. THANK
YOU

49. 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
sensor

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

51. ESC Guideline- 2020

52. ESC Guideline- 2020