DISCHARGE SUMMARY
Patient’s Name : MISS. KAVYASHREE .P ID No. : 0803051132
Age / Sex : 3 YEAR / FEMALE D.O.A. : 25.04.2005
D.O.S. : 29.04.2005
D.O.D. : 12.05.2005
DIAGNOSIS : Congenital heart disease
Multiple atrial septal defect
Moderate pulmonary artery hypertension
Non compaction of ventricles
Bi-ventricular dysfunction
OPERATION PERFORMED :
Gluteraldehyde treated pericardial patch closure of atrial septal defect with central fenestration + patent ductus arteriosus ligation + plication of atero- posterior tricuspid valve commissure.
BRIEF HISTORY :
3 year old, Kavyashree is the only child born to non-consanguinous parents. Full term normal delivery. No history of birth asphyxia. History of recurrent respiratory tract infection. No history of cyanosis / spells / convulsions. Diagnosed case of multiple atrial septal defect. She underwent Cardiac catheterization on 17.03.2005 which revealed multiple atrial septal defect, no compaction of ventricles with bi-ventricular dysfunction, moderate pulmonary artery hypertension and was advised atrial septal defect closure. Now she is admitted here for the same.
PHYSICAL EXAMINATION:
Height – 100 cms. Weight – 12 kgs. BSA – 0.58 m2
PR – 100 / min, Regular BP – 130 / 90 mmHg CVS – S1 S2 +
RS – Clear Peripheral pulses felt Saturation – 98%
INVESTIGATION:
HAEMATOLOGY
Blood Group | - | O Positive | Hb | - | 11.8gms / dl |
PCV | - | 36% | Platelets | - | 2.7 lacs/mm3 |
Reticulocyte Count | - | 4.0Cells/cu.mm | Total Leucocyte count | - | 13,800Cells/cu.mm |
Neutrophils | - | 39% | Lymphocytes | - | 56% |
Eosinophils | - | 03% | ESR | - | ½ hr – 06mm, 1 hr-15 mm |
BIO CHEMISTRY | | | | | |
RBS | - | 117mg / dl | Blood Urea | - | 22mg / dl |
S.Creatinine | - | 0.6mg / dl | Total Bilirubin | - | 2.3mg / dl |
Direct Bilirubin | - | 0.8mg / dl | Indirect Bilirubin | - | 1.5mg / dl |
SGOT | - | 35 IU / L | SGPT | - | 16 IU / L |
ALK. Phosphatase | - | 386 IU / L | Total Proteins | - | 6.5gm / dl |
S.Albumin | - | 3.5gm / dl | S.Globulin | - | 3.0gm / dl |
ELECTROLYTES | | | | | |
Sodium | - | 137mEq / L | Potassium | - | 3.12mEq / L |
Serology | - | Non Reactive | | | |
COAGULATION PROFILE
P.T Test - 18.6 sec. Control - 13.5 sec.
INR 1.49
A.P.T.T Test - 33.0 sec. Control - 32.0 sec.
CXR : CTR 75%, Gross cardiomegaly +, increased Pulmonary Blood Function, pulmonary venous congestion
ECG : Sinus rhythm, Bi-atrial enlargement,
ECHO : (16.03.2005) Mulitple ASD with left to right shunt. Ventricular non compaction involving both RV and
CATH : (17.03.2005) Multiple atrial septal defect. Non compaction of ventricles. Biventricular dysfunction. Moderate pulmonary arterial hypertension
Elevated LV & RV EDP
COURSE IN THE HOSPITAL:
Patient underwent Gluteraldehyde treated pericardial patch closure of atrial septal defect with central fenestration + patent ductus arteriosus ligation + plication of atero posterior tricuspid valve commissure on 29.04.2005 and was shifted to the ICU with inotropic support and stable haemodynamics. She was electively ventilated for a period of 48 hours and extubated on the 2nd postoperative day, weaned off inotropic support .Echo done on the 3rd postoperative day revealed bilateral pleural effusion and pericardial effusion and she was dyspnoeic too. Hence forth bilateral ICD was inserted and was taken up for re-exploration in view of increased drains and mediastinal widening by CXR. Plenty of clots evacuated from the pericardial cavity and she was stabilized and shifted to the ICU with stable haemodynamics. She was shifted to the ward on the 6th postoperative day. Sutures and pacing wires were removed on the 11th postoperative day.
CONDITION ON DISCHARGE:
Ambulant, hemodynamically stable, wounds healed well.
CXR : CTR – 0.75%, lung fields clear
ECG : HR – 113/min,
ECHO : (10.05.2005) No residual ASD. Mild TR with peak gradient of 31 mmHg. Moderate mitral regurgitation. No RVOT and LVOT obstruction. Left arch. No CoA. No residual PDA. Both diaphragm moving well. No pleural and pericardial effusion. Adequate RV function. Mild
Saturation : 96%
ADVICE:
Salt free diet
Fluids – 630ml / day
Review after 3 months with prior appointment.
MEDICATIONS:
Tab. Lasix 10 mg twice daily
Tab. Aldactone 12.5 mg twice daily
DR. CHRISTOPHER ROY, MS, M.Ch.
JR.CONSULTANT CARDIAC SURGEON
DR. RAVI
CONSULTANT CARDIAC SURGEON
Dr. K.M. CHERIAN, MS, FRACS, D.Sc. (Hon)
OPERATION NOTES
Name | KAVYASHREE.P. | Patient Id | 080305001132 |
Surgery No | 1093 | Surgery Date | |
Surgeon Name | Dr K.M. CHERIAN Dr SOMA GUHATHAKURTA Dr SENTHIL KUMAR SUBBIAN | Anaethetist | Dr SUMAN |
Perfusionist | LAVANYA SEKHAR | Nurse | MARY / SUDHA |
Opn. Theatre | Theatre - II | Blood Group | O + |
Weight | 12 Kgs | Height | 100 Cms |
BSA | 0.58 Sq.m. | | |
FINAL DIAGNOSIS:
CONGENITAL HEART DISEASE
MULTIPLE ATRIAL SEPTAL DEFECT.
MODERATE PULMONARY ARTERIAL HYPERTENSION.
SURGERY PERFORMED:
GLUTERALDEHYDE TREATED PERICARDIAL PATCH CLOSURE OF ATRIAL SEPTAL DEFECT WITH CENTRAL FENESTRATION + PDA LIGATION + PLICATION OF ANTERO POSTERIOR TRICUSPID VALVE COMMISSURE.
MORPHOLOGY | Left Aortic Arch Normal Pulmonary Venous Drainage RA Hugely dilated RV dilated. Small aorta 1/3 the size of PA Large ostium secundum ASD. 4 x 3 cms. No LSVC. |
INCISION | Median Sternotomy |
CARDIAC INCISION | Right Atriotomy |
PROCEDURE | Mid line sternotomy. Right lobe of thymus excised. Systemic heparinisation followed by Aorto bicaval cannulation and CPB. PDA dissected & ligated with silk. Heart fibrillated using fibrillator and RA opened. Gluteraldehyde treated pericardial patch used to close ASD. It was fenestrated in the center. Commissure between anterior and posterior bicuspid leaflets plicated using 3/0 Prolene stitch. RA closed using 5/0 Prolene continuous sutures. After de airing heart defibrillated into normal sinus rhythm. Core rewarmed and CPB weaned off. Heparin neutralized with protamine and decannulated. Haemostasis secured and chest closed in layers. Sternum - 2/0 steel wires Subcutaneous tissue - 2/0 Centicryl Skin - 4/0 Centicryl (Subcuticular). |
CPB DATA | Cannulation : Aortic Size : 16 Type : POLYSTAN Venous SVC Size : 22 Type : RMI IVC Size : 24 Type : RMI Cooled to : 35oC Modified ultra filtration volume : 350ml Cross clamp time: 20 mins CPB time: 60 mins |
POST BYPASS DETAILS | Spontaneous Recovery into Sinus rhythm Mediastinal Drains : 2 PACING WIRES : ATRIAL 2 AND VENTRICULAR 1 |
POST BYPASS HAEMODYNAMICS | CVP:16mmHg ABP:82/44mmHg |
STERNAL CLOSURE | 2 STEEL |
CHEST CLOSURE | CENTICRYL |
SUPPORTS | ADRENALINE 0.1 Mcg/Kg/min DOPAMINE 5 Mcg/Kg/min MILRINONE 0.5 Mcg/Kg/min |
SURGEON
Medical Record(s) Incharge