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Atrial septal defect is a common congenital acyanotic heart disease which is treated with either surgical closure or transcatheter closure. Although surgical closure is gold standard, transcatheter device closure is gaining popularity worldwide and in Nepal due to favourable outcome in selected patients. Device migration following transvenous closure of atrial septal defect is a common problem but its lodgment in right pulmonary artery is a rarely encountered and reported clinical scenario. Here, the authors report a case of 42-year-old female who had an embolisation of Amplatzer septal occluder to right pulmonary artery requiring urgent surgical intervention to retrieve the device.

The incidence of coronary artery anomalies (CAAs) is 0.2–1.2% of the population. Its paradox of being a rare entity with presentation ranging from sudden cardiac death, congestive heart failure, myocardial infarction to being clinically silent, asserts a challenge to its treating physician. Among the various major categories of CAA, we describe four different types of these anomalies in our retrospective evaluation over 2 years. They include – coronary cameral fistula with coronary aneurysm, congenital atresia of left main, anomalous aortic origin of left anterior descending (LAD) and circumflex artery (LCx) with malignant LAD course, anomalous origin of left coronary artery from pulmonary artery (ALCAPA). Although the child with ALCAPA succumbed despite every possible and available timely efforts, other patients had good postoperative recovery and a brief hospital stay.

Atrial septal defect is one of the most common congenital cardiac disorders requiring intervention. We compared a minimally invasive method for atrial septal defect closure that included total peripheral cannulation and an anterior mini-thoracotomy incision of 5 cm or less with a median sternotomy approach.This was a retrospective cross-sectional study among patients with Atrial Septal Defect. The preoperative variables, intraoperative data, and postoperative outcomes of patients undergoing minimally invasive atrial septal defect closure with total peripheral cannulation and atrial septal defect closure via median sternotomy were collected and compared.Fifty-five patients underwent minimally invasive closure of the atrial septal defect with total peripheral cannulation and 55 patients that underwent surgery by median sternotomy were included for comparison. There were 61.81% (34) female and 38.18% (21) male in the mini-thoracotomy group while there were 52.72% (29) female and 47.27% (26) male in the median sternotomy group. The mean age at surgery was 23.4 and 28.6 years in mini-thoracotomy and median sternotomy groups of patients respectively. The most common symptom was exertional shortness of breath in both groups. The mean length of stay in the intensive care unit was 1.8 and 2.5 days in mini-thoracotomy and median sternotomy groups respectively, and the length of stay in the hospital was 4.5 days and 4.8 days in mini-thoracotomy and median sternotomy groups respectively. There was a significant association was found between the mini-thoracotomy and median sternotomy group in relation to mean size of the incision, average time for cardiopulmonary bypass, average cross-clamp time, and fluid drained on the first day after surgery.Atrial septal defect closure with a mini-invasive approach is safe and cost-effective with very few perioperative complications and good patient satisfaction.

Background: Atrial Septal Defect (ASD) closure is a common cardiac surgical procedure performed worldwide. Due to favourable clinical outcome, minimal invasive approach is becoming popular. Hence this study was conducted to compare the outcome of two surgical approaches, median sternotomy and mini thoracotomy with total peripheral cannulation, in a developing country Nepal. Methods: A prospective study of 62 ASD patients, randomized to undergo surgical closure either via right anterior mini thoracotomy or median sternotomy was conducted and followed up over three years. The clinical outcome parameters like intensive care unit stay, hospital stay, post-operative duration of ventilation, cardiopulmonary bypass time, aortic cross clamp time, mediastinal drainage, size of scar and complication were compared between two groups. Results: Cardiopulmonary bypass time and aortic cross clamp time were significantly longer in right anterior mini thoracotomy group as compared to median sternotomy group (43.97 min ± 12.70 min vs 34.42 min ± 10.42 min and 25.13 min ± 7.82 min vs 19.48 min ± 6.93 min respectively, p-value 0.05). There was no significant difference in duration of surgery (2.75 hrs ± 0.43 hrs vs 2.56 hrs ± 0.41 hrs, p-value = 0.09), post-operative ventilation (2.90 hrs ± 1.22 hrs and 2.88 hrs ± 1.07 hrs, p-value = 0.96) between two groups. Post-operative mediastinal drainage was significantly less in right anterior mini thoracotomy group (214.52 ml ± 91.79 ml vs 284.03 ml ± 158.91 ml, p-value = 0.04). There was no significant difference in ICU stay and hospital stay. Conclusion: Atrial septal defect can be safely closed by right anterior mini thoracotomy with a small, cosmetically acceptable submammary scar with less pain and bleeding.

Penetrating heart trauma is a surgical emergency and can be fatal. However, cardiac penetration occurring due to non-explosive shrapnel is a rare occurrence. We report a case of a 20-year-old man, who sustained a laceration in his left chest, while he was breaking a rock with a chisel and a hammer. He was diagnosed to have an intramyocardial foreign body in his left ventricle. He underwent left ventriculotomy, foreign body localization under fluoroscopic guidance and successful extraction of the shrapnel from the left ventricular cavity.

Introduction: Diaphragmatic hernia and eventration are amongst the less commonly encountered thoracic surgical problems in Nepal. Unlike, the cases of traumatic herniation, adults with congenital hermination and eventration seek medical attention very late.Methods: It is a retrospective observational study of patients presenting with diaphragmatic hermiation and eventration at Manmohan Cardiothoracic Vascular and Transplant Center, Kathmandu, Nepal. Medical records of five years (May, 2010 to April, 2015) were reviewed. Analysis of the demographic profile, clinical features, management and outcome was done.Results: There were a total of 15 patients who were diagnosed to have diaphragmatic hermiation and eventration. There were eight cases of hermiation and seven cases of eventration. There were three cases of acute diaphragmatic hermiation. Thoracic trauma was found to be associated in three cases of herniation only. The mean age at presentation was 46.5 years. Thoracic trauma was seen in Younger age (mean age being 34 yrs). There were two cases of morgagni hernia and one of these was diagnosed incidentally. Mean duration of symptoms was two months. The most common presenting symptoms were shortness of breath and cough. Twelve cases were repaired via thoracotomy. Mean size of diaphragmatic defect was six centimeters. The most commonly herniated organ was stomach followed by momentum. Placation was the most commonly performed procedure in eventration and primary repair was done in six cases of hermiation and mesh repair in two cases. Only two patients had superficial surgical site infection. Mean duration of hospital stay was eight days. The patients were doing good up to mean follow up period of four months.Conclusion: Diaphragmatic hermiation and eventration in symptomatic patients should be managed surgically. Surgical approaches can be thoracotomy, laparotomy and Video Assisted Thoracoscopic Surgery. Outcome following surgery is good with minimal postoperative complications. JSSN 2015; 18 (1), Page : 1-4

Pulmonary embolism carries a significant morbidity and mortality. Metastatic choriocarcinoma presenting as pulmonary embolism is a rare event. Here, we report a case of a 25-year-lady with a history of worsening shortness of breath for 4 months who was treated as a case of pneumonia and tuberculosis. Owing to the worsening condition, she had a contrast enhanced computed tomography (CECT) chest done and was diagnosed to have pulmonary embolism. She underwent pulmonary embolectomy. The histopathological examination of the embolus revealed it to be metastatic choriocarcinoma. She showed a good response to chemotherapy. Metastatic choriocarcinoma should be considered as a differential diagnosis in females presenting with pulmonary embolism.

Inflammatory myofibroblastic tumour (IMT) is an uncommon mesenchymal tumour, which can occur anywhere in the body, rarely in esophagus. Mostly, the diagnosis is postoperative, after the hispathological evaluation of the specimen. There are no definite guidelines regarding the diagnosis and management. Here, we report a 60 year old lady presenting with dysphagia, diagnosed to have a submucosal esophageal tumor with Barium esophagogram and contrast enhanced computed tomography. She was managed successfully with surgical enucleation with the final histopathological diagnosis of IMT. Surgical excision is not only therapeutic but also diagnostic in such cases.