Twenty Years of Repair of Ventricular Septal Defects in Ghana

BACKGROUND

Ventricular Septal Defect (VSD) is the commonest congenital heart disease. Without appropriate treatment, it is associated with significant morbidity and mortality. Surgical repair under cardiopulmonary bypass has been the standard treatment. Results of such treatment is not readily available from the West African sub region. We analysed the outcome of surgical repair of VSDs carried out in this Centre over a 20-year period.

PATIENTS AND METHODS

A retrospective study was done for all patients who had surgical repair of VSD from January 1993 to December 2012.

RESULTS

There were a total of 207 patients, with 6 and 23 of them operated on in the first and last years of the study respectively. There were 121 (58.5%) males and 86 (41.5%) females. The mean age was 10.0 ± 10.5 (11 months - 55 years), with a median of 7 years. The modal class interval was 0 - 5 years (46.4%). Most of the VSDs were perimembranous 168 (81.1%), followed by outlet VSDs 19 (9.2%), muscular VSDs 11 (5.3%) and inlet VSDs 9 (4.4%). Fifty-four cases (26%) had associated congenital cardiac anomalies that needed concomitant surgical intervention, with the commonest being Pulmonary Stenosis (PS) 21 (10.1%), followed by Patent Ductus Ateriosus (PDA) 10 (4.8%). The complication rate was 6.4% (13 cases), comprising a morbidity of 4.4 % (9 cases) and early mortality of 2.0% (4 cases). The morbidity was due to bleeding requiring re-exploration 2 (1.0%), residual VSD requiring re-do 3 (1.4%), complete heart block requiring permanent pacemaker implantation 2 (1.0%), acute renal failure requiring dialysis 1 (0.5%), sternal wound infection requiring debridement 1 (0.5%). The mortality was due to pulmonary hypertension.

CONCLUSION

With a morbidity of 4.4% and early mortality of 2.0%, the outcome of surgical repair of VSDs from this study is good. Children with VSDs must be offered repair as soon as possible to avoid the numerous complications that usually follow untreated VSDs.

Pattern of esophageal injuries and surgical management: A retrospective review

Background

The consequence of significant injury to the esophagus is devastating. The initial management when timely and appropriate is rewarding and often prevents lethal complications. The objective of this study is to describe the etiology of esophageal injury in our institution, the management procedures and the mid-term results.

Method

Consecutive patients diagnosed and managed for esophageal injury from January 2005 to March 2015 were retrospectively reviewed.

Results

One hundred and eleven patients were seen and treated during this period; 85 (76.6%) predominantly children were corrosive esophageal injuries who accidentally ingested caustic soda and 26 (24.4%) were traumatic esophageal injuries. Patients with corrosive esophageal injuries were predominantly male (2:1), mean age 12.8 ± 14.2 years (2-58 years) and predominantly children (53% ≤5 years; 18.8% ≥ 18 years). Patients with non-corrosive esophageal injury were also predominantly male (4:1) with a mean age of 34.4 ± 20.1 years (1-73 years). The treatment procedures for corrosive esophageal injuries included esophagocoloplasty 64 (75.3%), colopharyngoplasty 10 (11.8%), colon-flap augmentation pharyngo-esophagoplasty 4 (4.7%), colopharyngoplasty with tracheostomy 4 (4.7%) and esophagoscopy and dilatation 3 (3.5%). Mortality was 5.9% and 5 patients were lost to follow-up. In patients with noncorrosive esophageal injury, esophageal perforation from instrumentation accounted for 14 (53.9%), foreign body impaction 11 (42.3%) and spontaneous perforation 1 (3.8%) making up the rest. Management of these patients included esophagotomy and removal of foreign body 7 (26.9%), esophagectomy, cervical esophagostomy and feeding gastrostomy 10 (38.6%), primary repair 7 (26.9%), Ivor Lewis procedure 1 (3.8%) and emergency esophagectomy with colon replacement 1 (3.8%). Mortality in this group of patients was 7.7% and 4 patients were lost to follow-up.

Conclusion

Corrosive esophageal injuries were the most frequent form of esophageal injury at our center due to unrestricted access to corrosive substances. Generally, appropriate surgical intervention in patients with esophageal injury based on individualization of care yields excellent early and mid-term results.

Post-operative surgical-site infection from skin bleaching: a case report

BACKGROUND

Prolonged application of steroid containing cream can pose a serious challenge to users. Apart from making the skin lighter it creates a spectrum of diseases in those that use them as the adrenal glands are suppressed and are unable to secrete more steroids when required.

OBJECTIVE

The objective is to report on a patient who presented with severe sepsis after a long period of application of steroids to the skin.

METHODS

A patient who has applied steroids to the skin over a prolonged period was followed up during treatment to ascertain the complications that the patient sustained during the period of treatment.

CONCLUSION

The patient was found to have developed a pelvic induration without abscess. She also had a large anterior abdominal wall abscess superficial to the external oblique muscle extending towards the left flank.

Thoracic endometriosis syndrome

BACKGROUND

Thoracic endometriosis syndrome is a rare constellation of different pathological entities arising from intrathoracic endometriosis. Reports from centers in Africa are scanty. Varying theories have been proposed but none satisfactorily explains the varying clinical manifestations.

OBJECTIVE

To describe the demographics, pathological spectrum, and outcome of treatment of patients seen at a single centre in West Africa with intrathoracic endometriosis.

METHODS

Twelve women who were seen at Ghana's National Cardiotharacic Centre with intrathoracic endometriosis from 2004-2012 were retrospectively reviewed.

RESULTS

The age range was from 24 - 39 years with a mean of 32 ± 5 years. Pelvic endometriosis was confirmed in 8 (66.7%) of the patients, 2 (16.7%) had ectopic endometrial tissue at the umbilicus and one (16.7%) had ectopic endometrial tissue at the mons pubis. Seven (58.3%) of the patients had undergone prior uterine surgery before the clinical onset of thoracic endometriosis. The right hemithorax was involved in all 12 (100%) patients studied. Pneumothorax was present in six (50%) women, hemothorax in five (41.7%) and hemopneumothorax in one (8.3%). Three of the four patients who benefited from video assisted thoracoscopy had abrasive pleurodesis followed by hormonal therapy. The rest of the patients had chemical pleurodesis with or without hormonal therapy.

CONCLUSION

Thoracic endometriosis may be more prevalent in West Africa than previously believed. Outcome of treatment is satisfactory using a multidisciplinary approach.

Management of intrathoracic oesophageal perforation: analysis of 16 cases

Intrathoracic oesophageal perforation remains a life-threatening lesion that requires early diagnosis and the appropriate intervention in order to reduce morbidity and mortality. Management depends largely on the cause of the perforation, the integrity of the oesophagus and the time lapse between the perforation and the commencement of treatment. Our aim was to evaluate the management options that were employed in the treatment of patients with oesophageal perforation and the outcome. The records of 16 patients (11 males and 5 females) who had been operated on from 1994–2009 were retrospectively reviewed. Their ages ranged between 2–66 years (mean 36.4). Malignant oesophageal perforations were excluded from the study. The aetiology was iatrogenic in 10 (62.5%), foreign bodies five (31.2%) and spontaneous one (6.2%). Six patients (37.5%) presented within 24 h of their injury and 10 (62.5%) presented after 24 h. Thoracotomy and intrathoracic primary repair was possible in five (31.2%) cases. Oesophagectomy, cervical oesophagostomy and feeding gastrostomy were carried out in 11 (68.8%). Oesophageal substitution was by colon, routed retrosternally. One patient (6.2%) died after oesophagectomy from overwhelming sepsis. Oesophageal perforation is a life-threatening condition. Early diagnosis and the institution of prompt and appropriate treatment ensure good outcome.

Permanent complete heart block following surgical correction of congenital heart disease

BACKGROUND

The risk of complete heart block (CHB) from congenital heart repairs in Ghana is unknown. This information is important for referring physicians and in pre-operative counselling of patients and facilitates the process of obtaining informed consent for such repairs.

OBJECTIVES

This study was undertaken to determine the incidence of permanent post-operative CHB requiring pacemaker implantation; and the post-operative problems related to the pacemaker.

DESIGN

Retrospective study design.

SETTING

The National Cardiothoracic Centre (NCTC), Korle-Bu Teaching Hospital, Accra, Ghana.

METHOD

Review of all patients who had intra-cardiac repair of congenital heart disease known to predispose to post-operative complete heart block from January 1993 to December 2008 was carried out with computation of the frequency of complete heart block according to the intra-operative diagnoses.

RESULTS

Six out of 242 patients (2.5%) developed permanent post-operative CHB. All underwent closure of a large perimembranous ventricular septal defect (VSD) either as an isolated defect (2 of 151 or 1.3%) or in the setting of conotruncal anomalies (4 of 73 or 5.5%). The dominant parental concern relating to the implanted device was the financial implications of future multiple surgeries to replace a depleted pulse generator.

CONCLUSION

Permanent post-operative complete heart block occurred in 1.3% of patients undergoing VSD repair and 5.5% of those undergoing repair of conotruncal anomalies (Fallot's tetralogy). The dominant anatomic risk factor was a large perimembranous VSD as an isolated defect or as part of a conotruncal anomaly. Permanent pacemaker implantation in this setting is attended by a low morbidity.

Surgical management of constrictive pericarditis

SUMMARY BACKGROUND

Constrictive pericarditis is a disease characterized by marked thickening and dense scarring of the pericardium with pericardial sac obliteration, or calcification of the pericardium. Without treatment this disease is characterized by high morbidity and mortality.

OBJECTIVE

To review the surgical management of constructive pericarditis and the post operative challenges.

METHODS

Eleven patients who had pericardiectomy for constructive pericarditis between 2000 and 2005 were studied. Data was obtained from the operating theatre register, histopathological reports and patient's case notes.

RESULTS

The mean age was 33 years with a range of 14 to 53 years. There were seven males (63.6%) and four females (36.4%). Seven (63.6%) out of the eleven patients operated were treated for pulmonary tuberculosis. The cause of pericardial constriction in four patients (36.4%) was undetermined. Follow up period was between 4-59 months. The mean follow up was 17.5 months. Seven patients (63.6%) were off diuretics and had no exercise intolerance. Patients were classified using the New York Heart Association (NYHA) n (NYHA) functional and therapeutic classification in class I-V. Two patients preoperatively in class III are now in class I after surgery on low dose diuretics. One patient who had calcific constrictive pericarditis and came in class III was now in class II with diuretics after 3 years of follow up. There was no postoperative mortality. One patient was lost to follow up.

CONCLUSION

Pericardiectomy is a useful procedure for constrictive pericarditis and was beneficial to all the patients in this study with an improvement in their functional capacity. Intensive peri-operative monitoring and management reduced morbidity and mortality.

Predictors of post operative bleeding and blood transfusion in cardiac surgery

INTRODUCTION

In spite of the recent advances in heart surgery, patients undergoing cardiac surgery with cardiopulmonary bypass are at risk of developing significant post-operative bleeding and substantial blood requirements.

OBJECTIVE

To evaluate the impact of some perioperative predictors of post-operative bleeding, and blood transfusion after heart surgery and offer suggestions on preventive measures.

DESIGN AND METHODS

A prospective analytical study. The perioperative factors studied were haemoglobin level, international normalised ratio (INR), platelet count, and total bypass time. Eighty-seven consecutive patients who underwent heart surgery in the year 2004 were selected. Each patient had laboratory work up which included full blood count, clotting profile, kidney and liver function tests. The total blood loss within the first twenty-four hours and the total units of blood transfused before the patient was discharged were also recorded.

RESULTS

Pre-operative haemoglobin was significant in determining the total units of blood received by a patient. Increasing total bypass time caused a significant increase in the percentage reduction of the pre-operative platelet count (p <0.004). However even though there was an increasing trend of post-operative bleeding with increase in total bypass time, this was not significant from the analysis (p<0.069). The percentage reduction in platelet count and immediate postoperative platelet count were significant predictors of postoperative bleeding (p <0 .009) and (p <0.003) respectively.

CONCLUSION

Pre-operative haemoglobin, percentage reduction in the platelet count after cardiopulmonary bypass and immediate postoperative platelet count are significant predictors of postoperative bleeding and blood requirements.

Impalement injuries of the chest

Impalement injuries of the chest are uncommon in civilian practice with few reports in the literature. We report three cases of thoracic impalement seen over a 5 year period with unusual underlying mechanisms. In two of the cases, the impalement was obvious; in the third, the impalement was concealed having occurred 5 months earlier. In Case 1, the underlying mechanism was a high-speed road traffic accident. The patient was impaled by a metallic square pipe piled by the roadside. In Case 2, the gun-housing of a locally-made rifle gave way as it was fired and allowed a reverse ejection of the barrel during recoil that impaled the hunter's chest. In Case 3, a domestic assault with an old umbrella caused an impalement injury as one of the umbrella spokes broke off, penetrated and lodged in the left chest going unnoticed for 5 months. Persistent chest pain and haemoptysis led to a request for chest radiographic examination upon which the foreign body was discovered. Massive haemoptysis brought the patient to emergency thoracotomy. All three patients underwent thoracotomy with a successful outcome.

Sprouty-2 controls c-Met expression and metastatic potential of colon cancer cells: sprouty/c-Met upregulation in human colonic adenocarcinomas

Sprouty negatively regulates receptor tyrosine kinase signals by inhibiting Ras/ERK pathways. Sprouty is down-regulated in breast, prostate and liver cancers and appears to function as a tumor suppressor. The role of Sprouty in colonic neoplasia, however, has not been investigated. Sprouty-2 protein and mRNA transcripts were significantly up-regulated in human colonic adenocarcinomas. Strikingly, the c-Met receptor was also upregulated in tumors with increased sprouty-2. To delineate a potential causal relationship between sprouty-2 and c-Met, K-ras mutant HCT-116 colon cancer cells were transduced with purified TAT-sprouty-2 protein or stably transfected with full-length human sprouty-2 gene. Sprouty-2 up-regulation significantly increased cell proliferation by accelerating cell cycle transition. Sprouty-2 transfectants demonstrated strong up-regulation of c-Met protein and mRNA transcripts and hepatocyte growth factor stimulated ERK and Akt phosphorylation and enhanced cell migration and invasion. In contrast, knockdown of c-Met by siRNA significantly decreased cell proliferation, migration and invasion in sprouty-2 transfectants. Further, knockdown of sprouty-2 by siRNA in parental HT-29 and LS-174T colon cancer cells also decreased cell invasion. Sprouty-2 transfectants formed significantly larger tumor xenografts and demonstrated increased proliferation and angiogenesis and suppressed apoptosis. Sprouty-2 tumors metastasized to liver from cecal orthotopic implants suggesting sprouty-2 might also enhance metastatic signals. Thus in colon cancer sprouty functions as an oncogene and its effects are mediated in part by c-Met up-regulation.

Outcome of thrombolysis for massive pulmonary embolism

BACKGROUND

Deep vein thrombosis is increasingly being diagnosed in Ghana. The commonest complication that leads to death is pulmonary embolism. The mortality rate from massive pulmonary embolism is high even with intervention. Thrombolysis is recommended in massive embolism.

OBJECTIVE

To determine the outcome of thrombolysis in the management of massive pulmonary embolism in patients admitted to the Cardiothoracic Intensive Care unit.

METHOD

A retrospective audit of the patients who were admitted to the Intensive care unit of the National Cardiothoracic centre with a diagnosis of massive pulmonary embolism between 1st January 2003 and 31st September 2007.

RESULTS

Seventeen patients were admitted with the diagnosis of massive pulmonary embolism of which 14 were thrombolysed. Commonest clinical presentations were dyspnoea in 17(100.0%) and hypotension in 12(70.3%) of the patients. Streptokinase was used in 13(92.9%) and urokinase in 1(7.1%) of the patients. The main complications of thrombolysis were bleeding in 12(85.7%), hypotension in 10(71.4%) and nausea and vomiting in 7(50.0%) of the patients. Postthrombolysis, the respiratory function deteriorated in 12 (85.7%) of the patients which required mechanical ventilation. The overall mortality rate was 35.3%. Three patients died before thrombolysis. Of the 14 (82.4%) who were thrombolysed 3(21.4%) died within 8 hours.

CONCLUSION

The mortality rate of patients with massive pulmonary embolism is high even after thrombolysis. The commonest complication of thrombolysis was bleeding.

Synchronised cardioversion for chronic atrail fibrillation

SUMMARY OBJECTIVE

To determine whether elective cardioversion was successful in establishing sinus rhythm in patients with chronic atrial fibrillation and the energy used for the cardioversion using a monophasic defibrillator.

DESIGN

This is a retrospective descriptive study.

SETTING

Intensive care unit of the National Cardiothoracic Centre, Korle-bu Teaching Hospital.

SUBJECTS

Twelve consecutive patients referred by physicians with chronic atrial fibrillation which had not responded appropriately to pharmacological agents.

METHOD

Using the intensive care admissions and discharge register and report book, the patients case notes were retrieved. The pre-cardioversion echocardiography diagnosis and drugs were noted. The results of cardioversion, and the current rhythm status were also reviewed.

RESULTS

There were twelve elective cardioversions for chronic atrial fibrillation during the period under investigation. All the patients were on warfarin with INR-2.2-2.8. Eight of the patients had initial echocardiographic evidence of thrombi in the left atrium. Sinus rhythm was established in 9(75%) of the patients. The mean energy used for the cardioversion was 384.4+/-167.7J. Of the 3 with failed cardioversion, one was later successfully cardioverted to sinus rhythm. On review, 9(75%) of the patients are still in sinus rhythm 6 months to 15 months after cardioversion. Six of these patients continue with oral amiodarone however.

CONCLUSION

Synchronized cardioversion for chronic atrial fibrillation is safe and may be successful after failure of pharmacologic cardioversion in patients where sinus rhythm is desirable.

Stabilization of molten globule state of papain by urea

Papain exists in molten globule (MG) state at pH 2.0 and in this state protein tends to aggregate in the presence of lower concentrations of guanidine hydrochloride (GuHC1). Such aggregation is prevented if a low concentration of urea is also present in the buffer; in addition, stabilization of the protein is also induced. Intrinsic fluorescence properties of papain as well as ANS binding suggest significant changes in the structure of papain, in the presence of urea with the absence of major changes in the secondary structure of the protein. The GuHCl- and temperature-induced unfolding of papain, in the presence of urea, indicates stabilization of the protein as seen from the higher transition midpoints, when monitored by fluorescence and circular dichroism (CD). However, a similar phenomenon is not seen under neutral conditions in the presence of urea either at low or high concentrations. The utility of prevention of aggregation by urea is also discussed.

Anion-induced folding of rabbit muscle pyruvate kinase: existence of multiple intermediate conformations at low pH

Structural and functional characteristics of rabbit muscle pyruvate kinase (PK), a tetrameric enzyme having identical subunits, were investigated under neutral as well as acidic conditions by using enzymatic activity measurements and a combination of optical methods, such as circular dichroism, fluorescence, and ANS binding. At low pH and low ionic strength, pyruvate kinase exists in a partially unfolded state (UA state) retaining half of the secondary structure and no tertiary interactions along with a strong binding to the hydrophobic dye, ANS. Addition of anions, like NaCl, KCl, and Na2SO4, to the acid-unfolded state induces refolding, resulting structural propensities similar to that of native tetramer. When anion concentration exceeds a critical limit (0.7 M KCl), a sudden loss of secondary structure and decrease in fluorescence intensity with a redshift in the emission maximum are seen which may be due to the aggregation of the protein, probably due to the intermolecular association. The anion-refolded state is more stable than the UA state, and its stability is nearly equal to that of native protein toward chemical-induced unfolding by Gu-HCl and urea. Moreover, at low concentrations, Gu-HCl behaves like an anion, by inducing refolding of the acid-unfolded state with structural features equivalent to that of native molecule. These observations support a model of protein folding where certain conformations of low free energy prevail and are populated under non-native conditions with different stability.

Salt-induced folding of a rabbit muscle pyruvate kinase intermediate at alkaline pH

The effect of alkaline denaturation on the structural and functional characteristics of rabbit muscle pyruvate kinase (PK) was investigated using enzymatic activity measurements and a combination of optical methods such as circular dichroism, fluorescence, and ANS binding. At a critical pH, 10.5, PK exists in an intermediate state (alkaline unfolded state) with predominant secondary structure along with some of the tertiary interactions and a strong binding to the hydrophobic dye ANS. This intermediate retains the enzymatic activity and corresponds to a dimeric state of the molecule. Above pH 10.5, a sudden fall in the spectral properties and enzymatic activity occurs suggesting the dissociation of the molecule followed by unfolding at very high pH. Addition of salts such as NaCl, KCI, and Na2SO4 to the alkali-induced state induces both secondary and tertiary structure to a level equivalent to that of native tetramer (salt-induced state). Chemical- and temperature-induced unfolding of the alkali-induced state as well as the salt-induced refolded state of PK reveal the presence of intermediate conformations in the unfolding pathway. The unfolding transition curves are noncoinciding and noncooperative along with ANS binding at intermediate concentrations of denaturants during unfolding. The observations presented in this paper suggest that the native pyruvate kinase tetramer dissociates to an active dimer around pH 10.5 and further to inactive monomer before attaining a completely unfolded monomeric conformation.

Single disulfide bond reduced papain exists in a compact intermediate state

Partially reduced proteins and other chemically modified derivatives are very useful model systems to understand the protein folding in vivo. Upon reduction, proteins attain different conformations with varying degrees of compactness. The reduction of papain in the presence of 8 M urea leads to the partial reduction of one disulfide bond. This derivative (single disulfide reduced carboxymethylated 1RCM papain (3RCM papain)) was characterized by spectroscopic methods and the effect of this reduction on the unfolding of the protein was investigated. Under this partial reduction, papain exhibits more than half of the tertiary and most of the secondary structures relative to the non-reduced molecule (free cysteine reduced and carboxymethylated papain (1RCM papain)). Hydrophobic regions are exposed to the solvent as observed through 8-anilino-1-naphthalene sulfonic acid binding which was absent in the fully intact and unfolded protein, at neutral pH. Hydrodynamic studies indicated that 3RCM papain, under neutral conditions, possess expanded conformation as compared to the native protein. Tryptophan fluorescence quenching studies suggested the exposure of aromatic residues to solvent. Guanidine hydrochloride induced unfolding of this derivative, at neutral pH, showed a non-cooperative transition contrary to the cooperativity seen with intact protein. Thermal unfolding indicates that 3RCM papain is less stable compared to the intact protein. These findings suggest that partial reduction of papain has a significant effect on the unfolding behavior of papain.

Sequential unfolding of papain in molten globule state

Papain exhibits the characteristics of molten globule under acidic conditions as seen by circular dichroism, fluorescence and ANS binding. Between pH 2.0-2.5 the protein exhibits substantial secondary structure as indicated by far-UV CD spectrum but loses the persistent tertiary interactions of the native state. Enhanced binding of ANS to the state at pH 2.0 in relation to the native and unfolded states at neutral pH indicates a considerable exposure of aromatic side chains. Temperature and guanidine hydrochloride induced unfolding of papain in this state is noncooperative and the transition curves are biphasic in nature. As papain molecule consists of two domains, the results suggest that the domains unfold independently and sequentially.