Abstract

Background: 

Endovascular interventions for abdominal aortic aneurysms (AAAs) are fast evolving; however, due to higher rates of reintervention and no survival benefits after 2 years, open surgical procedures are pivotal. Here, we present mortality and morbidity analysis of open surgical procedures requiring suprarenal cross clamping for AAA repair.

Materials and Methods: 

The present study is a retrospective hospital record-based study selecting 34 cases that required suprarenal cross-clamping out of 200 abdominal aortic aneurysm surgeries. Out of the total 34 patients, 22 (64.7%) were males and 12 (35.3%) were females. The mean age of all participants was 58.05 years (with an 8.1 standard deviation). Out of 34 cases, 20 cases (58.8%) were classified as suprarenal and pararenal aneurysms and 14 cases were juxtarenal aneurysms (41.2%). Out of the 14 juxtrarenal aneurysm cases, 7 (50%) were atherosclerotic and 2 (14.3%) were Marfan’s Syndrome, while inflammatory were 2 (14.3%) and infected were 2 (14.3%) and 1 was a case of Takayasu’s arteritis (7.1%). Mortality and morbidity, including renal function decline, need for hemodialysis, acute pancreatitis, and hepatic and gastrointestinal (GI) complications, were recorded as early (up to 30 days) and late (up to 1 year). The results were recorded separately for suprarenal, pararenal, and juxtarenal aneurysm types and presented in that way, which is the highlight of our study.

Results: 

Early mortality occurred in 3/34 (8.8%) cases, where late mortality happened in 2/34 (5.9%) cases, which are exclusive of early mortality cases. Considering the early mortality and complications, 2 out of 4 cases (50.0%) of the suprarenal group died early, renal dysfunction happened in 4/34 cases (11.8%), of which 3 (8.8%) required dialysis. No cases of pancreatitis, while acute liver failure complicated 3 out of 34 (8.8%) cases. GI bleed and mesentric ischemia each complicated 2 out of 34 cases (5.9%). Prolonged ileus was noticed as the most common GI complication complication. Early mortality was highest in the suprarenal group with renal dysfunction. Considering late mortality and complications, 1 out of 16 cases (6.3%) of the pararenal group died late, and 1 out of 14 cases (7.1%) of the juxta renal cases died late. There was no late mortality in the suprarenal group. Renal dysfunction happened in 2/34 cases (5.9%), of which none required dialysis. Complete data have been presented as per the aneurysm type.

Conclusions: 

Patients requiring suprarenal aortic cross-clamping for open surgical repair of abdominal aorta aneurysm are usually high-risk surgical candidates, considering both early and late mortality and morbidity. Early mortality was maximum in the suprarenal group (50.0%), as were postoperative renal dysfunction and hemodialysis requirements. Visceral complications (acute liver failure and GI complications) were also maximum with the suprarenal group. Late mortality was recorded in the pararenal and juxtarenal groups, with renal dysfunction being recorded in the suprarenal and juxtarenal groups. Visceral complications were recorded in both pararenal and juxtarenal groups. One confounding factor could be the high early mortality in the suprarenal group, resulting in less number of survivors for late postoperative recording. Overall, we conclude that suprarenal aortic aneurysms carry the highest burden of early mortality with renal and visceral complications postoperative.

Abstract

Cardiac masses are relatively rare, with a right atrial mass being even more rare. Right atrial masses pose a diagnostic dilemma owing to the diverse range of potential diagnoses, even when the clinical context and initial imaging modalities are thoroughly evaluated. A right atrial mass can have a varied etiology as it can be a physiological variant, or a neoplastic or a non-neoplastic mass with each having a separate line of management. This paper aims to highlight the etiology and the surgical outcomes of patients having a right atrial mass.

Abstract

Objective: With advancements in technology, instrumentation and techniques in minimally invasive surgery, several new findings have arisen about patients undergoing minimally invasive cardiac valve surgery (MICVS). This study focuses on assessing the safety and effectiveness of MICVS in a particular population, characterized by advanced age, multiple comorbidities and a high-risk profile for conventional open-heart surgery amid scepticism and resistance over minimally invasive cardiac surgery.

Methods: This is a descriptive retrospective study. The patients with valvular heart disease having multiple co-morbidities (e.g. left ventricular dysfunction (LVD), elderly, severe pulmonary arterial hypertension (PAH), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), obesity, redo surgery etc.) who underwent MICVS between August 2018 to December 2021 at our tertiary cardiac care Institute (UNMICRC)(n=100) were included. Overall, 77 patients underwent minimally invasive mitral/tricuspid valve interventions through right anterolateral mini thoracotomy and 23 patients underwent minimally invasive aortic valve intervention. Various outcomes in terms of patient demographics, intraoperative findings, perioperative data, hospital length of stay, complications  were observed and analyzed.

Results: Out of 100 patients, 47 were male & 53 were female. The mean age was 43.26 (12.80) years; 13 had infective endocarditis, 11 had previous cardiac intervention, 11 had COPD, 4 had previous history of stroke, 64 patients were diabetic having HbA1C > 7%, 22 patients had severe PAH, 16  -  LVD. Nine patients had CKD, among them two patients were on hemodialysis. Average mechanical ventilation time was 9.6 (6.67) hours, average hospital stay was 4.85 (1.05) days and average ICU stay was 56.4 (13.37) hours.

Conclusion: In comparison to conventional methods, MICVS appears to have more promising results for this specific patient group, such as fewer postoperative complications, shorter mechanical ventilation time, shorter hospital & ICU stay and a tendency towards quicker recovery. The study highlights the significance of careful patient selection and surgeon experience, as well as the difficulties and complexities of applying MICVS in this specific patient group.

Abstract

Introduction

The age of patients undergoing coronary artery bypass grafting (CABG) is progressively declining over time. Young adults are increasingly developing coronary artery disease (CAD), a condition that was once regarded as being more prevalent in the fifth or sixth decade of life.

Materials and methods

To evaluate the etiology and clinical outcomes of CABG in this young population (10–19 years of age).

Results

A total of five patients were included in this study. Three patients had a diagnosis of familial hypercholesterolemia, one patient had hyper-homocysteinemia, while one patient had a history of Takayasu arteritis. Eighty percent of the patients (4/5) underwent total arterial CABG, while in one patient with Takayasu arteritis, saphenous vein had to be used. The 30-day mortality was 1/5 (20%). The rest of the patients were followed up for 12 months with no major adverse cardiovascular events (MACE) after the index surgery.

Conclusion

The etiology of disease in young patients presenting with CAD is usually genetic, rather than environmental. This subset tends to have coronary ostial lesions, making CABG a suitable strategy owing to the presence of good distal targets. Total arterial revascularization should be the preferred strategy in these patients due to its proven long-term patency.

Abstract

Cardiac masses are relatively rare, with a right atrial mass being even more rare. Right atrial masses pose a diagnostic dilemma owing to the diverse range of potential diagnoses, even when the clinical context and initial imaging modalities are thoroughly evaluated. A right atrial mass can have a varied etiology as it can be a physiological variant, or a neoplastic or a non-neoplastic mass with each having a separate line of management. This paper aims to highlight the etiology and the surgical outcomes of patients having a right atrial mass.

Keywords: Cardiac masses; Cardiac neoplasms; Etiology.

Introduction: This study was planned to see the mid-term clinical and 2-D echocardiographic
outcomes of extensive septal myectomy for hypertrophic obstructive cardiomyopathy.
Methods: Fifty-one patients of all age groups suffering from HOCM were enrolled in this
study. They were selected on basis of two inclusion criteria are LVOT pressure gradient≥ 50
mmHg direct by transthoracic echocardiography and second one presence of severe
symptoms despite appropriate medical therapy with Beta-blockers and calcium channe

Objective: The minimally invasive right thoracotomy approach is being increasingly used for aortic valve surgeries. It has several benefits in terms of decreased blood loss and length of hospital stay as compared to conventional sternotomy technique. Selected patients requiring aortic root and ascending aorta surgery can be operated on using a similar approach. In this case series, we share the outcomes of Bentall surgery done through right mini-thoracotomy.
Methods: This was a single-center retrospective study of five patients who underwent elective right mini-thoracotomy modified Bentall Procedure. Instruments routinely used in minimally invasive cardiac surgery were used. The outcomes that were evaluated include cross-clamp times, cardiopulmonary bypass (CPB) times, time to extubation, total length of intensive care unit (ICU) and hospital stay, re-exploration rates, and inhospital and 30-day mortality.
Results: The mean CPB times and cross-clamp times were 128 and 96 min, respectively. The total circulatory arrest was used in two patients with a mean time of 12 min. The mean time to extubation was 7 h. The mean ICU stay and the total length of hospital stay were 1.5 and 5 days, respectively. No patient required re-exploration for bleeding. We did not have any inhospital or 30-day mortality.
Conclusion: The right mini-thoracotomy modified Bentall procedure is reproducible and safe in selected patients with annuloaortic ectasia

Objective: Axillary and innominate artery (IA) cannulation using side graft has some limitations in patients having ascending aortic dissection (AAD) with flap extending in major neck vessels. We retrospectively analyzed the outcomes of a direct under vision innominate ostial cannulation strategy for antegrade cerebral perfusion (ACP) using a retrograde balloon-tip cardioplegia cannula.
Patients and Methods: This was a retrospective analysis of all patients who were operated on for AAD with a dissection flap extending into major neck vessels between November 01, 2020 and November 30, 2022. Demographic data were noted, and comorbidities were listed. The kind of surgery patients underwent was noted: three patients underwent modified Bentall's procedure, five had to ascend aortic replacement, and one patient underwent David's procedure. All patients had open distal anastomosis using moderate hypothermia with ACP by direct under vision cannulation of the true lumen of the IA using a balloon-tip retrograde cardioplegia cannula. Intraoperative parameters such as cross-clamp time, cardiopulmonary bypass time, temperature range during circulatory arrest, and total operative time were noted. The primary outcome was a comparison of the incidence of stroke, seizures, and psychosis and the secondary outcome was an analysis of end-organ malperfusion, intensive care unit (ICU) stays, total hospital stay, and 30-day mortality.
Results: We retrospectively analyzed the surgical data of nine patients who were operated on between November 01, 2020 and November 20, 2022 by this technique and found that the incidence of stroke, seizures organ malperfusion, ICU stay, and hospital stay was comparable to other techniques of ACP (axillary artery/direct IA cannulation), but the operative time was a less, and local complications due to axillary cannulation such as shoulder pain and upper limb weakness and seroma were not seen.
Conclusion: Direct vision cannulation of the true lumen of the IA using a retrograde balloon-tip cannula is a cost-effective and time-saving method. It evades the limitations of well-established ACP techniques such as direct IA cannulation using Seldinger's technique which is a blind procedure and also has no local complications of the cannulating right axillary artery. Our results show that this procedure is less time-consuming and is noninferior to the other two methods of ACP in patients getting operated on for AAD with open distal anastomosis under moderate hypothermia. Further studies with a larger sample size are needed to validate this preliminary study.

Background: Cannulation strategies in ascending aorta and arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the preferred strategy, but it does come with its set of demerits. Double-arterial cannulation (DAC) may decrease DHCA time and avoid its related morbidity and mortality.
Aim: The aim was to compare patients undergoing surgery in acute Type A dissection by DAC with antegrade cerebral perfusion under moderate hypothermia and single-arterial cannulation (SAC) technique under DHCA with respect to the primary outcome of stroke, seizure, and psychosis and the secondary outcome as malperfusion, hospital stay, and mortality.
Materials and Methods: This study was a retrospective analysis of 64 patients operated for acute ascending aortic dissection (AAD) extending into arch and major vessels in the Department of CTVS, UN Mehta Institute of Cardiology and Research between July 2015 and July 2020. After screening through the hospital data, 30 patients operated by SAC and 34 patients operated by DAC technique were selected and their files were studied and analyzed. All patients were diagnosed using two-dimensional echocardiogram and computerized tomography aortogram to confirm the diagnosis. Forty-four patients who presented to emergency were stabilized before taking up for emergency surgery and 20 were operated semi-electively. Out of 64 patients, 40 patients underwent Bentall's procedure using composite mechanical valve, 10 patients underwent ascending aorta replacement, 7 patients underwent ascending aorta replacement with hemiarch, 2 patients underwent Bentall's with coronary artery bypass grafting, 2 patients underwent David's procedure, 2 patients underwent Yacoub's procedure, and 1 patient underwent Bentall's procedure using biological valve. Out of 30 patients operated by SAC, 25 patients had femoral cannulation and 5 patients had only right axillary cannulation. In the DAC group, all had right axillary artery and femoral cannulation. All patients were analyzed for primary and secondary outcomes.
Results: A total of 64 patients diagnosed with Type A AAD with dissection flap extending into major vessels were included in the study. Those patients operated with DAC technique had a significantly lower incidence of stroke, malperfusion, and hospital mortality as compared to the patients with SACs.
Conclusion: In AAD involving major arch vessel and femoral arteries, the idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost iimportance. The idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost importance. The right axillary artery is least involved in acute aortic dissection and when cannulated can provide uninterrupted flow to brain and also provide sufficient inflow to maintain CPB. Along with this, if femoral artery cannulation provides flow to abdominal organs and lower limb, it will prevent malperfusion syndrome. DAC is safe in complex Type A aortic dissection and aortic arch surgery and has better perioperative outcomes compared to SAC.

Background: Since the original description of TOF, its management modalities are continuously evolving. Present modality includes complete correction of the pathology by intra-cardiac repair with or without using transannular patch. Various finer aspects of intraoperative and postoperative management of the TOF repair are still evolving.
Aims and Objectives: In this single centre study we are aiming to compare short term outcomes in patients of tof operated with transannular patch repair treated postoperatively with dobutamine vs milrinone.
Materials and Methods: Total 100 patients undergoing TOF repair with transannular patch were grouped with respect to the inotropes used. One group who received milrinone and other who received dobutamine. Postoperative outcomes depending upon the need of other inotropic support, duration of ventilatory support, icu stay , inotropic support , hospital stay , morbidity and mortality are compared between the groups.
Observations: No significant difference was seen in both groups for mean ventilation time, duration of icu and hospital stay. Only parameter which was significant was increase in usage of adjuvant inotropic support in milrinone group which were depicted in terms of increased VIS ( Vasoactive inotrope score). Almost equal incidence of adverse events were noted in both the groups.
Conclusion: Milrinone and dobutamine are fairly comparable to each other in cases of TOF repair with transannular patch. Dobutamine being a cheaper alternative have a better scope in developing countries like India.

Abstract

Left-handed individuals consist of around 11% of the population and true ambidextrous consists of only 2–3% of the total population. Almost a similar ratio is seen in medical profession also. Difficulties are obvious for left-handed cardiac surgeons in the operating room due to regular right-handed instruments, laterality, and positioning of the patients. In this article, we discuss about the problems and the potential solutions for left-handed cardiac surgeons.

Abstract

Objective: Structural valve deterioration in the form of stenosis or regurgitation or both though being a rare complication with newer generation mechanical heart valves can occur and can be critical.

Case presentation: We report two cases of severe mitral regurgitation due to structural deterioration of TTK Chitra mechanical heart valve (disc fracture) in mitral position.

Conclusion: In patients with mechanical heart valve prosthesis who present with acute decompensated heart failure or congestive heart failure, structural valve deterioration should be suspected and early diagnosis and treatment is the key to success in structural valvular deterioration.

Key words:  TTK Chitra mechanical valve, structural deterioration of prosthetic heart valve

Abstract

Background: Anomalous origin of pulmonary artery (AOPA) is a rare congenital cardiac anomaly. It requires early surgical intervention (<6 months) to prevent irreversible pulmonary vaso-occlusive disease. This study was conducted to determine the surgical outcomes of this rare and intriguing anomaly.

Methods: From January 2015 to 2022, we have studied, 20 patients who underwent surgical correction for this anomaly with a mean age of 6.25 ± 3.7 months. There were 12 patients of <6 months of age. Their preoperative, intraoperative, and postoperative data were collected. They were followed up at every three months for the first year, every six months for two years, and then annually.

Results: Among three early mortalities, two were operated before six months of age and one was older than six months (ten months). Those patients presented after six months had longer ventilation time (P = .001). There was no difference in their pulmonary artery pressure (P = .06), right ventricle systolic pressure (RVSP) (P = .85), postoperative saturation (P = .51), inotropic score (P = .06), hospital and intensive care unit stay (P > .05), or mortality (P = .79). There was no late mortality at mean follow-up of 51.31 ± 20.27 months with Kaplan-Meier survival of 85% at 1, 5, and ten years. All patients were asymptomatic, with normal biventricular function and RVSP. One patient required balloon dilatation of the anastomotic site, with Kaplan-Meier event-free survival of 100% at one year, 92% at five and ten years.

Conclusion: Surgical correction of AOPA in patients beyond six months is still feasible with a higher early morbidity and comparable mortality with good clinical and echocardiographical outcomes at mid-term follow-up.

Keywords: anomalous pulmonary artery; congenital cardiac anomaly; hemitruncus.

Abstract

Background: 

The initial trial in tricuspid surgery is repair; however, replacement is done whenever the valve is badly diseased. Tricuspid valve replacement (TVR) as an isolated procedure and combined with other valve replacements presents a challenge as these patients are in the high-risk subset.

Materials and Methods: 

The present retrospective study was performed using the medical records of 42 cases who underwent TVR since 2017 at our institute. The mean age of the participants was 36.3 ± 13.2 years and male–female was 66.7% and 33.3%, respectively. Isolated TVR was done in 35.7% of cases, associated with mitral valve replacement (MVR) in 38.1%, with aortic valve replacement (AVR) in 4.8%, triple-valve replacement (MV, TV, and AV) in 19.0%, and TVR associated with pulmonary valve replacement in 2.4% of cases. This diverse variety of valve replacement cases is the highlight of our study. About 30.9% of participants were undergoing the procedure as a redo surgery. Trial of repair was given in 33.3% of cases. Moreover, bioprosthesis and mechanical valve prosthesis were used in 73.8% and 26.2%, respectively.

Results: 

Early mortality occurred in 8 (19.0%) cases. Cause of death common in all deaths was right ventricular failure in all cases 8/8 (100%) seconded by multi-organ failure in 7/8 cases (87.5%), previous cardiac surgery was a factor in 4/8 (50%) cases, mediastinitis occurred in 2/8 (25%) cases, and both arrhythmias and cerebrovascular accident happened in 1/8 (12.5%) case each. Mortality rate was 3/15 (20.0%) in cases of isolated TV surgery. Mortality rate for concomitant MVR was 3/15 (20.0%), and for concomitant AVR with MVR (triple-valve replacement) was 2/8 (25.0%). No early mortality happened in the concomitant AVR and concomitant pulmonary valve replacement group. Late mortality happened in 11/42 (26.2%) cases during follow-up. Total mortality as per the valve types has been 5/11 (45.5%) in the mechanical valve replacement group and 14/31 (45.2%) for the biological valve group.

Conclusions: 

The patients who require TVR are usually high-risk surgical candidates with high early and late mortality. The most common cause of death was right ventricular failure in this study. TVR associated with other heart valve replacement increases the risk strata of the patient which is the highlight of our study. In the end, we conclude that we had 19.0% early (0–30 days) and 26.2% late mortality (0–1 year) making a composite of 45.2% mortality at the end of 1 year. No difference in the effect of mortality as per the valve type has been observed.

ABSTRACT

Background: Constrictive pericarditis (CP) consists of a spectrum of primary cardiac and noncardiac conditions. It represents a form of severe diastolic heart failure (HF) which is usually secondary to a noncompliant pericardium. Our study was designed to evaluate immediate and short term outcomes of total pericardiectomy clinically and echocardiographically. Through this study we aimed to analyze the short-term and mid-term outcomes of total pericardiectomy using death and adverse events as end points. Between January 2001 and December 2020, a total of 166 patients with constrictive pericarditis underwent total pericardiectomy at our institute. Results: The mean age was 30.4±13.35 years. The mean post-operative CVP was 8.73±3.06 cm of H20. Histopathological results showed tuberculous pericarditis 86(51.82%) in patients, chronic constrictive pericarditis in 76(45.78%) patients, purulent pericarditis in 2(1.20%) patients and viral pericarditis in 2(1.20%) patients. At the end of 12 months, 150(92.60%) patients were in NYHA class I and 12(7.40%) patients were in NYHA class II. Conclusions: In a developing country like India, tuberculosis is still the most frequent cause of CP. Total pericardiectomy with or without the use of CPB is the surgical treatment of choice and should be performed as early as possible as it is associated with a lower mortality, early normalization of hemodynamics, less postoperative low cardiac output syndrome, and better long-term survival. KEYWORDS : Constrictive pericarditis, echocardiography, computed tomography, total pericardiectomy

Abstract

Introduction

Coronary artery disease (CAD) is the foremost single cause of mortality and loss of disability-adjusted life years globally and a large percentage of this burden is found in low and middle income countries, with the treatment strategies based on revascularisation, based on studies that have shown that on revascularisation of viable myocardium there is an improvement of function over a period of time.

Aim

To evaluate the utilization of myocardial perfusion imaging (MPI) for identifying viable myocardium and assessing the improvement.

Material and methods

This prospective observational study was conducted in patients having CAD planned for coronary artery bypass grafting. The patients were evaluated using 2D ECHO and MPI preoperatively and postoperatively after 1 year.

Results

Mean ejection fraction preoperatively was 40.6 ±9.72% and postoperatively it improved to 41.32 ±10.64% and ejection fraction was calculated using MPI and an average improvement from 35.98 ±12.72% to 45.51 ±12.61% (p ≤ 0.0001). Summed rest score was calculated and an improvement was noted from 24.28 ±8.47 to 18.02 ±8.75 (p ≤ 0.0001). Total perfusion deficit was calculated and was found to have reduced from 32.44 ±11.98 to 25.61 ±12.23 (p ≤ 0.0001).

Conclusions

MPI was able to accurately assess the improvement, which correlated not only with the 2D echocardiography data but also with the clinical wellbeing of the patients. Being a non-invasive, quick procedure, it should be added to the arsenal of the cardiac surgeon for evaluation of patients with diffuse diseases, low ejection fractions, patients who might generally be considered inoperable.

Keywords: coronary artery bypass grafting, myocardial perfusion imaging, coronary artery disease, disability-adjusted life years

Introduction: Total anomalous pulmonary venous connection (TAPVC) is a common cyanotic congenital heart disease seen in developing countries at tertiary referral centers. Association with persistent left superior vena cava (LSVC) without innominate vein (H-connection) is an extremely rare condition which makes the surgical correction extremely challenging. Materials and Methods: This was a retrospective case record review of 18 patients with TAPVC in the presence of LSVC without innominate vein (without H-connection) at our institution from January 2007 to February 2021. We detail our experience of our modified surgical technique for this complex anatomy using various modifications for each type of TAPVC with LSVC in the absence of innominate vein. Results: Out of 18 patients of TAPVC with LSVC, 17 patients survived and are being followed up regularly. There was one mortality (5.5%) in a 5-month-old infant with double-outlet right ventricle with ventricular septal defect with severe pulmonary arterial hypertension with infracardiac TAPVC who died in intensive care unit on the 5th postoperative day. Conclusion: In our experience, the modified surgical technique for treating this complex variant of TAPVC is especially useful for favorable long-term outcomes with minimal incidence of recurrent pulmonary venous obstruction.

Abstract

Objective: The differing pattern of dyslipidemia combined with inherent insulin resistance and contribution from varying lifestyles makes Indians more vulnerable to coronary artery disease (CAD) at a younger age. Smoking and other forms of tobacco, dyslipidemia and hypertension are major risk factors in the young. Our aim of the study is to find out risk factors to predict severity of CAD in young patients undergoing coronary artery bypass  surgery (CABG).

Methods: Young patients below 45 years of age consecutively admitted at our hospital and undergoing CABG were included. Demographic data are collected and analyzed. All the risk factors for early coronary artery disease and its outcome and intraoperative and immediate postoperative complications are analyzed. Early outcome analysis was done at the end of 1 year and midterm analysis was done at the end of 5 years.  All routine investigations, 2D-echocardiography, electrocardiogram, and chest X-ray were analyzed at regular intervals and when required in the follow-up period also.

• We retrospectively evaluated 148 adult CAD patients aged ≤45 years, who underwent their first isolated CABG surgery at our institute. We observed that smoking was the most common risk factor followed by hypertension, altered lipid profile and diabetes. Family history of CAD and obesity were also noted in 32.4% and 21.6% of patients.
• Our young surgical patients have a high frequency of risk factors such as smoking and dyslipidemia, hypertension and obesity which may lead to accelerated atherosclerosis and high frequency of 80% of multivessel disease in our cohort. Hypertension is the significant predictor of severe CAD in our cohort. High prevalence of CAD risk factors and LV dysfunction are associated with mortality in our cohort.  Five-year survival in young Indian population after CABG is 91.8% with good functional class..

Prevention of risk factors is necessary to prevent CAD in young adults. Optimal secondary prevention with medications and strict adherence to lifestyle changes should be ensured to reduce future coronary events.

Key words: coronary artery bypass grafting, coronary artery disease, young patients

Abstract

Background: Off-pump coronary artery bypass (OPCABG) grafting has emerged as an effective alternative technique for allowing coronary revascularization without the use of cardiopulmonary bypass. OPCABG has been associated with decreased postoperative morbidity, shorter hospital stay, reduced cost, and reduced operative mortality in some studies.
Materials and Methods: A total of 190 patients who underwent isolated coronary artery bypass graft surgery were evaluated with the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk scoring system. Moreover, we also compared the discriminatory potentials between the EuroSCORE II with <5 and >5 scores.
Results: EuroSCORE high-risk patients showed higher rates of blood transfusion (66.9%), intraaortic balloon pump insertion (12.6%), atrial fibrillation (21%), and renal failure (46.8%). There was one mortality in each EuroSCORE group.
Conclusion: OPCABG can be accomplished safely in selected high-risk patients with acceptable morbidity and mortality without compromising complete revascularization. Severe renal failure needing dialysis, stroke, and deep sternal wound infection in the postoperative period carries high morbidity and mortality after OPCABG. There is no ideal risk prediction model for an individual patient but multidisciplinary approach and individual patient factors determine the operative risk.

Keywords: European system for cardiac operative risk evaluation II, left ventricular ejection fraction, off-pump coronary artery bypass

Abstract

Introduction: Surgical management of diffuse coronary artery disease (CAD) requires aggressive techniques for complete revascularization. Coronary endarterectomy (CE) coupled with coronary artery bypass grafting (CABG) is a valuable technique for this subset. The aim is to evaluate the perioperative and early results following CE.
Materials and Methods: Three hundred and eighty patients of diffuse CAD undergoing off-pump CABG were included in the study. CE was performed in 204 patients. The mean age of the patients was 62 ± 16.32 years. The male-to-female ratio was 1.43, and the mean SYNTAX score was 33.12 ± 6.42. The mean stay in the intensive care unit was 4.94 ± 2.72 for patients undergoing CABG with CE. The perioperative mortality was 4.9%. The patients were followed up at 3 months, and graft patency was assessed with computed tomography coronary angiography. The average graft patency was 86.725% for the grafts with CE. Patients with left anterior descending (LAD) CE had higher perioperative mortality (5%), overall survival (89.79% at 3 months), and graft patency rates (87%) were favorable. The outcome following single vessel CE was better than multivessel CE.
Conclusion: In patients with diffuse CAD, CE is a safe technique with comparable mortality and lesser complication rate if performed adequately. Despite perioperative difficulties, early outcomes are favorable for CE to the LAD artery grafted with the left internal thoracic artery. Single vessel CE yielded a better result as compared to multivessel CE.

Keywords: Coronary endarterectomy, diffuse coronary disease, coronary artery bypass grafting

Abstract

Context: Postinfarction ventricular septal defect (VSD) is a rare but serious complication of myocardial infarction with a reported incidence of 1% to 3% in the pre thrombolytic era and <0.5% post thrombolytic therapy. Risk of death is greatest immediately after myocardial defect and then gradually declines. Early surgical treatment is recommended; however, surgical repair is associated with a high rate of mortality.
Aim: To investigate the immediate survival outcome and prognostic factors associated with surgical repair of postinfarction ventricular septal rupture at our institute over a 3-year period.
Materials and Methods: From April 2012 to April 2015, 32 patients underwent surgical repair of post-infarction ventricular septal rupture at our institute. Patients were identified from the electronic medical records database and preoperative, intraoperative, and postoperative variables were retrieved. Multiple perioperative variables such as anthropometric data, demography, and clinical history and preoperative details such as echocardiographic indices, coronary angiography, and intraoperative variables were analyzed. The outcomes were compared between the survivors and nonsurvivors.
Results: Overall, younger patients tolerated the disease and the surgery better than the older population (59.96 ± 10.67 vs. 69.11 ± 8.11; P = 0.02). Female sex, cardiogenic shock (n = 20, 86.95% vs. n = 2, 22.22%; P = 0.001), and emergency surgery were independently associated with higher risk of postoperative mortality. History of systemic hypertension was found to be significantly associated with poor postoperative outcomes (survivors n = 9, 39.1% vs. nonsurvivors n = 8, 88.9%; P = 0.017). In our series, the overall mortality was 28.1% (n = 9). Higher NYHA class at presentation, intra-aortic balloon pump requirement and low ejection fraction are all independently associated with poor outcomes. Longer interval between the myocardial infarct and surgical repair is associated with a lower risk of operative mortality. Preoperative renal dysfunction (61.77 ± 19.04 vs. 41.36 ± 21.15; P = 0.025) and postoperative renal dysfunction (65.26 ± 28.81 vs. 27.27 ± 9.04; P = 0.001) is one of the most important predictors of postoperative outcome. The duration of aortic cross-clamp and cardiopulmonary bypass was not associated with early mortality in this study (89.17 ± 42.70 vs. 97.11 ± 76.38; P = 0.775).
Conclusion: Postinfarction VSD still remains one of the most challenging conditions to treat surgically with considerable early mortality. Although percutaneous device closure and left ventricular assist devices may be used as a method to stabilize the patient preoperatively and improve the chances of survival after surgery, it is currently not advocated as a definitive treatment option. All efforts should be made to predict and prevent postoperative renal dysfunction as it is the single-most important factor affecting both short- and long-term survival outcomes.

Keywords: Cardiogenic shock, complications of myocardial infarction, coronary artery bypass grafting, early outcome, ventricular septal defect

Abstract

Atrial fibrillation is the most common tachyarrhythmia associated with mitral valve disease, resulting in significant morbidity and mortality. Atrial fibrillation is a marker of advanced cardiovascular disease and an independent predictor of death. As a large number of patients undergoing mitral valve operations are associated with chronic atrial fibrillation, pulmonary vein isolation procedure with cut and sew method can be concomitantly performed with a mitral valve operation and it is enough to improve the quality of life after operation by eliminating the morbidity associated with chronic atrial fibrillation. The aim of this study is to find out the immediate postoperative outcomes of the patients with known mitral valve disease with atrial fibrillation who are undergoing mitral valve surgery with concomitant pulmonary vein isolation at our institution. The perioperative risk factors such as older age, duration of atrial fibrillation, the size of the left atrium, and the mitral valve pathology were evaluated for their clinical significance. Preoperative, intraoperative, and postoperative variables were retrieved and analyzed retrospectively. The outcomes were compared between these subgroups using various statistical tools. Conversion to normal sinus rhythm was more significant in the younger age group (<45 years) as compared to the older age group. Seventy-eight percent patients (n = 117) were free from atrial fibrillation at the time of discharge. The overall mortality was 4% (n = 6). There was no procedure-related death.

Keywords: Atrial fibrillation, atrial fibrosis, combined procedure, cox-maze procedure, cryoablation, cut and sew method, mitral valve operation, pulmonary vein isolation, radiofrequency ablation, thromboembolism

Abstract

Background:

 Inflammations resulting from cardiac surgical procedures have traditionally been controlled with corticosteroids such as dexamethasone. However, the use of these medications to attenuate the inflammatory responses from cardiac surgery remains contentious. The aim of this systematic review and meta-analysis was to evaluate the effect of administering dexamethasone intraoperatively on major complications and mortality compared to placebo interventions. 

Study Design: This was a systematic review and meta-analysis.

Methods: The research was conducted on online databases such as PubMed, Google Scholar, EMBASE, and the Cochrane Central Register of Control Trials until August 5, 2022. The studies in the online databases were written between January 1, 2000, and August 1, 2022. The studies that were selected were scanned and analyzed based on an established eligibility criteria for the study.

Results: Ten randomized and controlled trials were included in this systematic review and meta-analysis. The incidence of mortality was 2.2% (154 out of 7007 patients) in the dexamethasone group and 2.3% (164 out of 7038 patients) in the placebo group (odds ratio [OR],0.94; 95% confidence interval [CI], 0.75–1.01; P = 0.73; I² = 0%). Myocardial infarction incidence was 1.88% (88 out of 4685 patients) in the dexamethasone group and 2.12% (100 out of 4708 patients) in the placebo group (OR, 0.88; 95% CI, 0.66–1.18; P = 0.39; I² = 9%). The incidence of stroke for the dexamethasone group was 1.56% (70 out of 4488 patients) and 1.82% (82 out of 4511 patients) in the placebo group (OR, 0.86; 95%CI, 0.62–1.18; P = 0.34; I² = 0%). The prevalence of new onset atrial fibrillation was 32.3% (797 out of 2469 patients) for dexamethasone and 34.7% (859 out of 2478 patients) for placebo (OR, 0.90; 95%CI, 0.80–1.01; P = 0.08; I² = 0%). The incidence of renal failure was slightly higher in the placebo group with 1.58% (108 out of 6857 patients) compared to the dexamethasone group 0.97% (66 out of 6823 patients) (OR, 0.61; 95% CI, 0.45–0.83; P = 0.002; I² = 0%). 

Conclusion: According to this review, dexamethasone does not result in a significant decrease in incidences of mortality, myocardial infarction and stroke. However, the medication was associated with decreased incidences of renal failure and atrial fibrillation in a majority of the studies.

Measurements and Main Results

The primary composite outcome was occurrence of any of the following events during admission for OHT: (1) graft dysfunction requiring mechanical circulatory support (MCS); (2) respiratory failure requiring tracheostomy; (3) renal failure requiring hemodialysis; (4) 30-day mortality; (5) complication requiring readmission to intensive care unit; (6) sepsis; and (7) stroke. The authors evaluated these outcomes in relation to all blood component transfusions received intraoperatively and in the first 24 hours postoperatively. The study included 197 patients and the primary composite outcome was present in 72 (36.6%). After adjusting for propensity score, red blood cell (RBC) transfusion was associated with composite outcomes (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.05-1.31, p = 0.004), postoperative MCS use (OR 1.36, 95% CI 1.18-1.58, p < 0.001), acute renal failure requiring hemodialysis (OR 1.21, 5% CI 1.06-1.38, p = 0.004), and 30-day mortality (OR 1.29, 95% CI 1.05-1.59, p = 0.02). Fresh frozen plasma was associated with composite outcome (OR 1.07, 95% CI [1.003-1.15], p = 0.042) and renal failure (OR 1.08, 95% CI 1.08 [1.002-1.17], p = 0.04).

Conclusions

Intra- and postoperative transfusions (first 24 hours) of RBC and FFP were associated with adverse postoperative composite outcomes in patients undergoing OHT.

Background

Anomalous origin of coronary artery from pulmonary artery (AOCAPA), as is evident from the name, is defined as abnormal origin of either coronary artery from the pulmonary artery. The consequences vary in most cases and these anomalies lead to severe coronary hypo-perfusion and ventricular dysfunction. The common variants of this cardiac malformation are an anomalous origin of a left coronary artery from a pulmonary artery (ALCAPA) and anomalous origin of the right coronary artery from a pulmonary artery (ARCAPA). Another rare variant is left main coronary artery atresia that resembles ALCAPA in its mode of presentation. This article presents a single surgeon experience of managing this complex subset of the coronary anomaly from April 2006 to July 2019.

Material and methods

The 105 patients, who underwent surgery for AOCAPA from April 2006 to July 2019, have been included in the study. The patients have been analysed by follow-up echocardiography and electrocardiography (ECG) at our hospital by paediatric cardiologists. Out of 105 patients of AOCAPA, 98 (93.3%) patients underwent ALCAPA repair, of which 59 (60.2%) were males and 39 (39.7%) were females. Four out of five patients, who had an anomalous origin of the left coronary artery from the right pulmonary artery (ALCARPA), had an intramural aortic course. Three patients (3%) had left main coronary artery atresia and four patients (4%) had ARCAPA. It may be mentioned that seven infants (7.14%) and one adult patient (1%) underwent concomitant mitral valve repair. All the patients with ALCAPA, left main coronary artery atresia and ARCAPA, and 1 of the patients with ALCARPA, underwent coronary relocation. In four out of five patients with ALCARPA, unroofing of intra-aortic intramural course was performed.

Results

Out of 105 patients of AOCAPA, 9 (8.5%) patients had in-hospital mortality. Five infants (5.0%) with ALCAPA and one patient (1%) with ALCARPA died in the post-operative period due to severe left ventricular dysfunction, mitral regurgitation (MR) and sepsis. One adult patient (1%) with ALCAPA, who underwent coronary relocation using in situ trap door technique and mitral valve (MV) repair, died due to massive intracranial bleeding. Two patients out of three (66.6%) with left main coronary atresia died in intensive care unit (ICU) after 3rd and 4th postoperative day, due to low cardiac output, severe ventricular dysfunction and severe MR. Patients were followed up for a median 5.9 years. Seven patients were lost to follow-up, including the sole survivor of left main coronary atresia, after a median follow-up of 4 years after surgery. Three patients underwent mitral valve replacement for progressive residual MR. There has been no late mortality.

Conclusion

AOCAPA is a rare congenital cardiac anomaly, which usually presents in infancy with left ventricular dysfunction and mitral valve regurgitation. Early diagnosis and surgical re-establishment of the dual coronary system has given gratifying results, with improvement in left ventricular function in survivors. Mitral valve intervention for MR was required, in both early and late phases.

Keywords: AOCAPA: Anomalous origin of coronary artery from pulmonary artery, ALCAPA: Anomalous origin of left coronary artery from pulmonary artery, ALCARPA: Anomalous origin of left coronary artery from right pulmonary artery, ARCAPA: Anomalous origin of right coronary artery from pulmonary artery, Left main atresia, Congenital coronary anomaly

The superiority of surgical revascularization in ischemic cardiomyopathy is established beyond doubt, and off-pump CABG (OP-CABG) is a safe way of revascularization in this high-risk subset. Data on the effect of postoperative ventricular function and size on their midterm outcome is scarce.

A retrospective study was done on 211 consecutive patients with severe LV dysfunction who underwent OP-CABG from January 2017 to December 2018. Data were collected from the institutional database. Their operative and midterm outcomes were statistically analyzed.

The mean age of the cohort was 58.4 ± 8.3 years. An average number of grafts was 3.1 ± 0.8 (cumulative intended number of grafts—3). Operative mortality was 10.9%. Preoperative NYHA class (p < .0001; OR, 19.72) and postoperative IABP insertion (p < .008; OR, 88.75) were independent predictors of operative mortality. The mean follow-up period was 3.14 ± 0.07 years, was 97.4% complete with cardiac mortality of 5.8%. Postoperative LVEF (p = .002; OR, 0.868) and LV dimensions (systole & diastole) (p = .013, OR = 1.182 and p = .036, OR = 1.184, respectively) were independent predictors of midterm mortality. Midterm major adverse cardiovascular event-free survival of operative survivors was 89%. There was no correlation between postoperative LV dimension and NYHA status(p > .05). Myocardial viability was not associated with early (p = .17) or midterm mortality (p = .676).

OP-CABG can achieve complete revascularization in patients with severe LV dysfunction with good midterm outcomes, albeit with high early operative mortality. Postoperative change in LV dimension and EF are predictors of midterm mortality.

Abstract

Levoatriocardinal vein without left-sided valvular atresia is rare. We hereby present an image of the levoatriocardinal vein in a patient with multiple muscular ventricular septal defect with small atrial septal defect and mitral regurgitation.

A nine-month-old female child was admitted with complaints of recurrent respiratory tract infection. Echocardiography showed a mid-muscular ventricular septal defect (VSD) and moderate eccentric mitral regurgitation (Figure 1A and B). Echocardiography also showed a connecting vein from the left atrium (LA) to the left brachiocephalic vein (LBCV) with anomalous connection of the left upper pulmonary vein (LUPV) to the left-sided connecting vein with left-to-right shunt (Figure 1 C). For further delineation, contrast-enhanced computed tomography was performed, which confirmed the presence of a levoatriocardinal vein with partial anomalous pulmonary venous connection (PAPVC) of the LUPV. Also shown are two muscular VSDs and a small patent foramen ovale (Figure 2).

Abstract

Concomitant presence of acute type A dissection, coarctation of aorta and levoa-triocardinal vein has not been described. We here present a case of aortic anuerysm complicated by type A dissection with coarctation of aorta and levoatriocardinal vein.

KEYWORDS

Acute type A dissection, coarctation of aorta, levoatriocardinal vein

Abstract

Objectives: Adult patients undergoing tetralogy of Fallot (TOF) repair have a higher risk of mortality compared to pediatric patients. Pulmonary regurgitation (PR) further predisposes these patients to heart failure, arrhythmias, and sudden death. Pulmonary valve replacement (PVR) may improve the symptoms in these patients but, fails to reverse the other deleterious effects. Aim of our study was to evaluate the effect of concomitant PVR with TOF repair on right ventricular (RV) parameters, cardiopulmonary exercise capacity, and bioprosthetic valve durability at mid-term.

Materials and methods: Between January 2013 and August 2018, 37 adolescents and adults with TOF who had hypoplastic pulmonary annulus underwent concomitant TOF repair with PVR at our institute. We retrospectively collected the data from the hospital records including follow-up.

Results: Mean age of the patients was 18.48 ± 7.53 years. Bioprosthetic valve size ranged from 19 mm to 25 mm. There was no early or late mortality. No patient had developed significant perioperative complications. At a mean follow-up of 53.3 ± 16.4 months, there was no significant change in mean QRS duration, RV function, RV end-systolic and end-diastolic dimensions, RV myocardial performance index, and functional status (including NYHA class and 6-min walk test) compared to at-discharge values. Four patients developed prosthetic valve degeneration with mild PR and without significant increase in gradient.

Conclusion: Concomitant PVR with TOF repair in adult provides excellent mid-term outcome, with a minimal rate of pulmonary valve degeneration. It not only eases the early postoperative course but also preserves the RV function as well as functional status at mid-term.

Keywords: Bioprosthetic valve; pulmonary valve; tetralogy of fallot.

Abstract

Introduction: This study was planned to compare postoperative hemodynamics, blood loss, platelet count, and coagulation parameters in patients undergoing intracardiac repair for tetralogy of Fallot with and without hemofiltration and, in addition, to determine whether hemofiltration during cardiopulmonary bypass (CPB) reduces cytokines in children undergoing intracardiac repair for tetralogy of Fallot.
Methods: Thirty children suffering from tetralogy of Fallot were enrolled in the study and randomly divided into two groups: one group had hemofiltration from beginning of rewarming till weaning off CPB, whereas in the other group, hemofiltration was not used during CPB. In the hemofiltration group, samples were taken for the comparison of tumor necrosis factor-α, interleukin-6 (IL-6), and IL-8 levels, before and after hemofiltration. Platelet count, coagulation parameters, postoperative blood loss, extubation time, hemodynamic parameters were recorded for hemofiltration as well as non-hemofiltration group and analysed.
Results: The extubation time in the hemofiltration group was 15.6 h (mean), whereas that in the control group was 28.6 h (mean), and the difference, when compared, was significant between the two groups (P = 0.05). The cumulative postoperative blood loss at 24 h was significantly less in the hemofiltration group compared to the control group, 97.4 ml (80–114 ml) versus 159 ml (100–210 ml), respectively, with P = 0.001. No other statistically significant difference could be appreciated in the parameters analyzed.
Conclusion: There was a significant reduction in postoperative blood loss and extubation time in the hemofiltration group. There was no significant reduction in cytokines. No significant difference was observed in requirement of inotropic agents, hemodynamic status, and intensive care unit stay between the two groups. Small sample size and shorter ultrafiltration time during rewarming phase were limitations of the study.

Keywords: Cardiopulmonary bypass, hemofiltration, tetralogy of Fallot

Abstract

Background: Minimal Invasive Direct Coronary Artery Bypass Surgery (MIDCAB) is becoming popular and an important armamentarium for cardiac surgeons. We aimed to evaluate the result of MIDCAB total arterial revascularization.

Methods: We have evaluated 216 patients who underwent MIDCAB multivessel total arterial revascularization through a left anterolateral mini thoracotomy. LIMA harvested in every patient, RIMA or radial artery used as second conduit. LIMA-RIMA Y or LIMA-RADIAL Y was made to accomplish multivessels total arterial revascularization. Post-operative graft patency was evaluated in all patients by CT coronary angiography at 6 months following discharge.

Results: Mean age of patients was 52.5 ± 9.8 years. Average number of anastomosis performed were 2.34 ± 0.75. Multivessels total arterial CABG was accomplished in all individuals. There was no mortality or deep wound infection. Re-exploration was done in two patients for bleeding. In one patient emergency CPB was required. Average ICU and hospital stay was 1.52 ± 0.77 and 4.92 ± 1.46 days, respectively. Patients were mobilized earlier due to less pain. Wound healing of anterolateral thoracotomy was faster. In the follow up CT angiography 100% of the LIMA grafts were patent.

Conclusions: Multivessels total arterial MIDCAB can be accomplished safely in selected individuals. RIMA can be harvested in long standing diabetic patients with no concern for sternal wound healing. MIDCAB patients experience better cosmetics and early return to daily activities.

Abstract

Objectives

Ebstein anomaly can be managed by single ventricular, bi-ventricular and one and a half ventricular repairs. We present midterm results of Comprehensive Tricuspid Valve repair (CTVR) with bi-directional cavo-pulmonary shunt (BCPS).

Methods

In this prospective observational study (Jan2012–July2018), 69 patients underwent surgery for Ebstein anomaly. In Group I (n = 48; 69.6%), all patients got CTVR and a BCPS (one and a half ventricle repair). Group II (n = 15; 21.8%) consisted of a similar repair without BCPS (bi-ventricle repair). All patients were echocardiographed at six monthly intervals.

Results

Median age of the cohort was 17 years (range 1–68). 12 (17.4%) patients were Carpentier type B, 51 (73.9%) were type C and 6 (8.7%) were type D. There were two early mortalities (2.89%). At a mean follow up of 3.2 ± 1.2 years, there were no late deaths and one delayed repair-failure in each group. Group I had significantly lower mean TR grade (1.2 ± 0.4vs1.6 ± 0.5, p = 0.03) as compared to Group II without a significant difference in the mean gradients (1.5 ± 0.5vs1.6 ± 0.6, p = 0.4). Mean indexed TAPSE (15.0 ± 6.7vs.16.6 ± 5.6 mm/m², p = 0.21), NYHA class (1.2 ± 0.4vs1.3 ± 0.4) and six-minute walk distance (506 vs 507 m, p = 0.7) was similar in both groups.

Conclusion

One and a half ventricle repair of Ebstein anomaly gives a more functionally competent, non-stenotic and durable tricuspid valve as compared to a two-ventricle repair. BCPS doesn’t result in facial swelling or AV malformations. Preload reduction by BCPS may allow the myopathic ventricle to remodel.

Objective: Most of the rheumatic mitral valve repair literature focuses on older patients with burnt out disease. We present our midterm results of rheumatic mitral valve repair in young patients. Methods: In this retrospective-prospective study, 106 consecutive children (<18 years) underwent mitral valve repair for rheumatic etiology (2013-2017). Patients were evaluated at regular intervals.

Results: The mean age of the cohort was 13.1  3.2 years; 30 (29.6%) patients had recent rheumatic activity (<8 weeks); 80 (78.4%) had mitral regurgitation; 8 (7.8%) had mitral stenosis; 14 (13.7%) had mixed lesions; 11 underwent emergency surgery for intractable heart failure; and 34 (33.3%) patients underwent autologous pericardial augmentation. All patients underwent annuloplasty (ring, band, or other); 40 (39.2%) required chordal procedures. Operative mortality was 1%. Mean follow-up was 25.6  9.5 months and was 100% complete. At last follow-up, mean mitral regurgitation grade was 1.2  0.3, mean mitral valve gradient was 2.96  0.18, and 94.8% of patients were in New York Heart Association class I. Four patients developed recurrent rheumatic carditis (resulting in severe mitral regurgitation), but there were no thromboembolic or hemorrhagic events. Actuarial survival and freedom from reoperation at 2.5 years were 96.2% (number at risk, 38), and 97.1% (number at risk, 38), respectively.

Conclusions: Rheumatic valves in children are eminently repairable. The surgeon who ventures to repair a rheumatic mitral valve should consider all lesions of the various components of the mitral valvular apparatus and must have numerous techniques in the armamentarium to effect a successful repair. (JTCVS Open 2020;1:20-8)     

Abstract

Objective: The ongoing controversy regarding coronary surgery as to perform with or without using cardiopulmonary bypass has not come to a definite conclusion with quite difference between Indian and western scenario. Our objective was to perform a single center, single surgeon prospective observational study to compare clinical outcomes and graft patency in off-pump versus on-pump coronary artery bypass surgery (CABG), to evaluate the current perspective of Indian scenario. Method: 100 patients were selected and divided into two groups, 50 patients in each group. All surgical planning and patient management were standardized for both groups. Various preoperative demographics, intraoperative variables and postoperative outcomes were measured and compared. After one year, follow-up computed tomography (CT) coronary angiography was done to evaluate the graft patency in all patients of both the groups. Results: The number of grafts performed per patient was higher in on-pump group, (3.3 vs. 2.7) however the index of completeness of revascularization was similar in both groups. (96.5% vs. 94%, p = NS). There were significant increase in re-explorations, bleeding, transfusions and hospital stay in on pump group. At one-year follow-up, 64 patients underwent CT coronary angiography. 67 of 86 grafts (77.90%) were in off pump group as compared with 86 of 110 grafts (78.1%) in on pump group were patent. All occluded grafts were saphenous vein conduits to coronary targets other than left anterior descending (LAD) territory. Conclusion: Off pump CABG can provide complete durable and cost effective revascularization comparable with on pump CABG when performed in well experienced hand without compromising completeness of revascularization.

Keywords: Coronary artery bypass surgery,cardio-pulmonary, Bypass, off pump surgery, graft patency.

Background: Popliteal artery injuries have been associated with highest rates of amputations after lower extremity vascular injuries. Early diagnosis of vascular injury, early revascularization of the ischemic limb and management of concomitant injuries are the key factors in preventing morbidity or mortality in such cases. The aims and objective
of this study is to evaluate outcome following civilian popliteal vascular injury and identification of predicting factors for amputation.

Material and methods: Retrospective data of 80 patients over 5 yrs from January 2012 to December 2017 period was collected for patients admitted with popliteal artery injury with or without concomitant bone or other systemic injury. Patient’s age, sex, mode of injury, mangled extremity severity score (MESS), associated venous and or neural
injuries and other physiological parameters assessed. Time to operative intervention, requirement of multiple (more than 2) blood transfusions, other orthopedic or systemic injuries requiring need for concomitant other surgical intervention, timing of orthopedic intervention pre or post vascular interventions and outcome in the form of amputation or in hospital mortality were recorded.

Results: We studied 80 patients with civilian popliteal artery injury with median age of 35 yrs (range 8 to 65 yrs.) the median MESS was 6. Mechanism of injury was blunt for 58% and penetrating for 42%. Fasciotomy was performed in 80% of patients. Out of all 80 patients 56 patients (70%) patients underwent concomitant orthopedic
surgical intervention of which 52 patients had undergone orthopedic intervention prior to vascular surgery. Higher rates of amputation were noted for patients with MESS more than 7, patients with poly trauma and patients presented to surgery after 12 hrs of trauma. Patients requiring multiple blood transfusions, age more than 50 and associated comorbid conditions had highest mortality rates.

Conclusion: Popliteal artery trauma is a major source of patient morbidity and is important cause of amputation after injuries to the lower extremity. Blunt trauma, Higher MESS, associated bony injuries requiring surgical intervention are important predictors of amputation but associated venous or neural injuries have no role as predictor of amputation. Higher blood transfusion requirement and concomitant other systemic injuries requiring surgical interventions have high risk of in hospital mortality. Timing of orthopedic intervention pre or post vascular
repair does not impact clinical outcome.

Keywords: Popliteal artery injury; Blunt trauma; Amputation; MESS.

Background: Our aim of this study was to find the prevalence of CAD and various CAD risk factors in RHD patients < 50 years.

Materials and Method: It was a single center observational retrospective study of 6324 rheumatic heart disease patients, who underwent Coronary Angiography (CAG) prior to surgical valvular replacement from January 2011 to December 2017. Among them 3920 patients were < 50 years of age; they were included in this study. Patients with age > 50 years (2404) were excluded. Among them significant CAD group patients (stenosis ≥50% -Group A), were compared with similar age group matched patients of RHD without CAD (Group B).

Results: The overall prevalence of CAD in the patients undergoing valvular intervention was 5.68% (61.88% males, 38.12% female). The CAD incidence in patients with mitral, aortic and both valve replacement were 8.20%, 62.5%
and 29.3% respectively. The prevalence of smoking (41.7% vs. 27.48%), diabetes (18.83% vs. 3.62%), hypertension (69.05% vs. 13.52%), family history of CAD (78.02% vs. 3.8%) and aortic valve disease (62.5%) was significantly higher in group A as compared to group B. Conclusion: Prevalence of CAD in patients with Rheumatic valvular heart disease in western population of Asian Indians with age < 50 years is 5.68%. Thus Coronary angiography should be performed in such patients only when there are associated CAD risk factors. No need of doing prophylactic angiography for those rheumatic heart disease patients who do not having any CAD risk factors in young patient’s age < 50 years.

Keywords: Rheumatic Heart Disease; Coronary Angiography; Coronary Artery Disease; Incidence; Risk factors.

Abstract

Introduction: Open heart surgery is one of the most common surgical procedures performed in developed countries; Coronary Artery Bypass Grafting (CABG), Aortic Valve Replacement (AVR), and Mitral Valve Repair (MVR) being the most common procedures. Our aim of the study is to find out the incidence of DSWI among the patients in of coronary artery bypass grafting during the hospital stay at our institute and risk factors associated with this complication and to formulate a protocol for management of this group of cardiac surgical patients and for minimizing such complications.

Methods: The is aretro prospective single center observational study. The study consists of 2772 patients who underwent coronary artery bypass grafting surgery between October 2016 and September 2019 at our institute. Patients were divided in two groups based on the CABG and CABG with DSWI. In Group 1 (2706 patients), while in group 2 (66 patients). All the preoperative baseline, intraoperative and postoperative data were collected.

Result: In our study we have found that Preoperative parameters PAD (p<0.0001) and Smoking (p<0.001) were significantly higher in group 2 (CABG + DSWI). Higher weight was associated with increased incidence of DSWI 42.4% of patients having BMI ≥ 30 kg/m2. (p=0.0082). Bypass Grafting with LIMA-RIMA had significantly high development rate for DSWI, LIMA-RIMA CABG performed in Group 1 in 372 (13.7%) patients and in Group 2 in 15 (22.7%) (p=0.0375). In addition, significant difference to develop DSWI is also founds in High drainage Output (≥ 1 lit), Re-exploration, Reintubation in Group 1 (Non DSWI) with 4.5% (122) patients, 3.88% (105) patients and 4.1% (112) patients while in Group 2 have only 27.2% (18), 28.7% (19) and 24.2%(16) respectively (p<0.0001). It had been seen that increase in ICU stay and increase in ventilation stay are again two chief factors to lead DSWI.

Conclusion: The present study confirms that preoperative parameters like age > 60 years, uncontrolled DM II, HTN, PAD, Smoking, Obesity (BMI ≥ 30) increase the risk of deep sternal wound infection. Intraoperative risk factors like LIMA-RIMA grafting, high rate of blood transfusion (PCV > 3 unit) have prompt to increase incidence of DSWI in postoperative period while postoperative parameters like High drainage output (≥ 1 lit), Re-exploration, Reintubation, Longer mechanical ventilation time have also predispose to develop DSWI.

Abstract

Objective: To study the in-hospital outcome and short term outcomes in patients undergoing delayed total surgical correction for Tetralogy of Fallot.

Methods: A retrospective descriptive study with the above objective was conducted at our institute using data from the hospital records. Study included all the patients above the age of 13 year undergoing surgery for Tetralogy of Fallot from January 2016 to December 2017.

Results: A total of 85 patients, 56(65.9%) males and 29(34.1%) females, undergoing complete repair of TOF were identified with a mean age of 17.53±4.59 years. Two patients had undergone previous Modified Blalock- Taussig Shunt. Complications noted in the postoperative period were low cardiac output syndrome 17.64%, re intubation 2.4%, reoperation for bleeding 10.6% and free pulmonary regurgitation in 34 (40%) patients recieveing Transannular patch without monocusp. On follow up, only 6 patients (7.1%) had significant pulmonary regurgitation. 30–day mortality was 2.35%. The postoperative outcomes depend mainly on the degree of preexisting cyanosis (p=0.048) and degree of right ventricular outflow obstruction(p=0.042).

Conclusion: Complete correction of Tetralogy of Fallot must be performed irrespective of the age at presentation. Long-term studies are required to study the late outcomes in this group of patients.

Keywords: Tetralogy of Fallot; Adult; 30 days Mortality; Short-term outcomes.

Abstract

Introduction: Over the past decades minimally invasive cardiac surgery has grown in popularity. This growth has been driven by desire to translate many observed benefits like less pain, better cosmesis, less surgical trauma as compared to traditional cardiac surgery. This study’s objective is to evaluate safety and effectiveness of minimally invasive cardiac surgery in a teaching hospital with respect to learning curve, quality of life, and mid term outcomes.

Material and methods: In this study 50 patients diagnosed having mitral or aortic valve disease requiring replacement of the valve and atrial septal defect requiring surgical closure operated between 1/08/2011 to 31/12/2018 are included.

Results: 38 patients were operated by right thoracotomy while 12 patients were operated by mini sternotomy. In our institution femoral platform is utilized for establishing cardio pulmonary bypass. Cardiopulmonary bypass time for mitral valve surgery was 116+–18.7, min, for aortic valve surgery was 138+–19.6.8 min and for ASD closure was 95+–15.4.4 min. no significant early or mid term complication including re exploration, long duration of surgery or other systemic complications pertaining to respiratory, pulmonary or nervous systempertaining to surgery. All patients showed improvement in NYHA class from their pre operative period in follow up stage.

Conclusion: Minimally invasive cardiac surgery is the upcoming boom and it can be safely performed with the available newer cannulae, anesthesia techniques and surgical instruments.

Keywords: Minimally invasive cardiac surgery; Sternal sparing cardiac surgery

Abstract

Objective: To evaluate outcome following On pump Coronary artery bypass grafting for Coronary artery disease without addressing associated Chronic ischemic mitral regurgitation. To find out the efficacy and adequacy of On pump Coronary artery bypass grafting and factors affecting the outcome in these patients.

Methods: This study was conducted in 30 patients of CAD with trace, mild or moderate MR and treated with coronary artery bypass grafting from January 2012 to December 2012. Group I (n=19) included patients of CAD associated with trivial (1+) or mild (2+) ischemic MR and Group II (n=11) included patients of CAD associated with moderate (3+) ischemic MR. Pre and postoperative data related to clinical profile, ECG, 2D Echocardiography along with preoperative CAG and LV angiogram data, collected. All patients underwent conventional on pump CABG.
Patients were followed up at 2 and 6 months after surgery.

Results: There was similar downgrade of congestive heart failure NYHA class, in both the groups. In Group I, there was significant improvement in echocardiographic parameters like LVEDD, LVEF, LVESD, EPSS and ESV. In Group II, there was significant improvement in echocardiographic parameters like LVEDD, LVEF, EPSS and ESV. Postoperative echo revealed downgrading of MR. Mean MR of Group I downgraded from 1.8 to 1.4, postoperatively. Mean MR of Group II downgraded from 3.0 to 2.6, postoperatively. There was no incidence of readmission due to congestive heart failure or mortality in either of the groups.

Conclusion: Revascularization alone for trivial to moderate ischemic MR achieves low operative mortality, leads to EF improvement, decreases MR and improves NYHA class but longer follow up could shed more light on long term outcomes and survival benefit.
 

Keywords: CIMR; CABG; CAD

Abstract

Objective: To compare the outcome of continuous and interrupted surgical technique of Ventricular Septal Defect (VSD) closure with respect to the time taken for VSD closure, incidence of residual VSD and conduction abnormality. Methods: Randomized case control study was done with Pre-operative TTE and intraoperative TEE before instituting CPB to confirm the type of VSD. Patients were put on Cardio pulmonary bypass using standard technique, all VSDs were approached though Right atrium. VSD closure was done using PTFE patch in all the patient. 5–0 polypropylene double arm sutures were used in a total of 60 patients, 30 in each group with respect to continuous and interrupted technique of VSD closure. Residual VSD and conduction abnormality were assessed intra-operatively after termination of CPB, immediately post operatively in Intensive Care Unit (ICU) and after 1 month.

Results: The study included total 60 patients, 30 in each group as continuous and interrupted. The mean agegroup was 6.5 years. Most common cardiac abnormality detected in the study group was Tetralogy of Fallot (40%),25% patient had isolated VSD. Most commonly encountered VSD type was Perimembranous (86.67%). We observed that 3 patients had residual VSD, out of these 2 were of continuous group with residual VSD size of less than 2 mm and 1 was of interrupted group with residual VSD of 3 mm. All residual VSDs were detected immediately after CBPbut there were no residual leaks seen in the post operative period. Only 58 patients were followed for 1 month with no residual VSD. Only one patient of continuous group had complete heart block requiring pacemaker.

Conclusion: All types of VSDs can be closed by either of the technique. The residual VSD detected in the post bypass period in both the groups were statistically insignificant. In isolated VSD continuous technique is better in terms of less time required for VSD closure, less number of cardioplegia and lesser cardiopulmonary bypass (CPB) time hence less myocardial damage due to ischemia and reperfusion, where as it does not give added advantage in patients with VSDs as well as associated anomalies as the total CPB time and number of cardioplegia delivered is unpredictable.

Keywords: VSD Closure; TTE; PTFE Patch

Objective

Re-exploration after cardiac surgery still remains a troublesome complication. There is still a scarcity of data about the effect of re-exploration after off-pump coronary artery bypass grafting (OPCABG). We here represent our experience on re-exploration following OPCABG.

Method

A total of 5990 OPCABG were performed at our center, out of these patients, 132 (2.2%) were re-explored in the operation room and were included in this study. The medical records of these patients were retrospectively reviewed.

Results

The most common cause of re-exploration was bleeding (83.3%) and the most common site of bleeding was from graft/anastomosis (53.8%). The mean time to re-exploration was 9.75 ± 8.65 hours. The thirty-day mortality was 1.41%. On univariate and multiple regression analysis, emergency surgery, preoperative low platelet count, and the number of grafts were found to be independent risk factors for re-exploration. On multiple regression, emergency surgery, Euroscore II, low platelet count, low ejection fraction, re-exploration, time to re-exploration, blood products used, and high postoperative serum creatinine and bilirubin were found to be independent factors (P < .001) for mortality. On receiver-operating characteristic analysis, the optimum cutoff for time to re-exploration was 14 hours with a sensitivity of 81.3%, specificity of 80%, and area under the curve of 0.798. Patients who re-explored late (>14 hours) had significantly high mortality (30.55% vs 7.3%) and morbidity.

Conclusion

Delaying re-exploration is associated with a three fold increase in mortality and morbidity. So, a strategy of minimizing the incidence of re-exploration, like the use of minimally invasive surgery and early re-exploration with the judicial use of products, should be used to improve outcomes after re-exploration following OPCABG.

Abstract

Truncus arteriosus (TA) or common arterial trunk is a congenital cardiac anomaly having high association with arch anomalies such as right aortic arch or aortic arch interruption. However, TA with double aortic arch (DAA) is a rare occurrence. We report a case of TA with DAA where the diagnosis of DAA was missed initially

Conclusion

High level of vigilance for vascular rings is needed while evaluating a case of TA with disproportionate respiratory symptoms or stridor. One should not hesitate to confirm an echo-based diagnosis with CT to rule out DAA even though it is a rare association. Also, a single-stage complete repair in the form of division of the minor arch and truncus repair with valved conduit is likely to have most favorable outcome and should be the procedure of choice.

Abstract

Background: Objective: To retrospectively evaluate and compare the outcome of mitral valve thrombectomy (Group A) versus Redo mitral valve replacement (Group B) for acute mitral prosthetic valve thrombosis (PVT).

Methods: 104 patients underwent redo surgery for obstructive mitral PVT in our center from January 2016 to March 2018 were included.  Patients having acute PVT of other valves were excluded. Pre-operative, peri-operative and post-operative parameters affecting the outcome with follow-up data were measured. Group A (n = 26) underwent mitral valve thrombectomy & group B (n = 78) were treated by redo mitral valve replacement (MVR). Diagnosis of prosthetic valve obstruction was made on the basis of history, clinical examination, echocardiography and fluoroscopy. Total cross clamp and CPB time, hemodynamic status, ionotropic support, ventilation time, intensive care, total hospital stay, morbidity and mortality were also recorded for comparison. Echocardiography was done before discharge.

Results: No statistical difference was found on the basis of gender, age, interval between initial MVR and redo operation, anticoagulation status, functional class, international normalized ratio, echocardiography and fluoroscopy. The mean CBP time & cross clamp time was significantly less in group A than group B. Similarly mean ventilation time, Ionotropic support, mean ICU stay and mean hospital stay in group A was significantly less than group B. 

Conclusions: PVT is a dreaded complication after mechanical MVR with high mortality without timely and effective surgical intervention. Mitral valve thrombectomy being a less aggressive surgical technique is recommended because of better outcome in terms of morbidity and mortality.

Introduction

Little is known about the course of aortic valve disease in patients undergoing mitral valve surgery for rheumatic mitral valve disease. In addition, there are no guidelines regarding the appropriate treatment of mild aortic valve disease while replacing the mitral valve.

Aim

To evaluate the long-term outcome of aortic valve disease and the need for aortic valve surgery in patients with rheumatic mitral valve disease who underwent mitral valve surgery.

Material and methods

Twenty patients (6 male, 14 female; mean age: 23.4 years, range: 14–41) were followed after mitral valve surgery for a mean period of 14 years. All patients had rheumatic heart disease. Aortic valve function was assessed preoperatively by transthoracic echocardiography and during follow-up.

Results

At the time of mitral valve surgery, 11 (55%) patients had aortic valve disease with aortic regurgitation. Nine (45%) patients had no evidence of aortic valve disease. At second surgery, all patients had aortic valve disease (either pure regurgitation or with stenosis). Most had mild disease at the time of mitral valve surgery. Aortic valve replacement was needed after a mean period of 14.1 years (range: 3–26 years).

Conclusions

In patients with rheumatic heart disease, a noticeable number of patients have mild aortic valve disease at the time of mitral valve surgery. Only a few progress to severe disease, and aortic valve replacement is rarely needed after a long follow-up period.

Management strategy for patients of ventricular septal defect and pulmonary atresia (VSD/PA) with hypoplastic pulmonary arteries presenting in late childhood or adolescence is still controversial. We present our experience with the use of right ventricle-pulmonary artery shunt (RV-PA) in management of this entity. Between January 2014 and April 2018, 25 patients of VSD/PA underwent valveless RV-PA shunt at our center. The size of the RV to PA shunt was calculated as half the expected diameter of the main pulmonary artery. We retrospectively reviewed the data from hospital records. Follow-up data were recorded from outpatient records or via telephone. Mean age of the cohort was 12.25 ± 3.18 years. There was 1 early and 1 interstage mortality. None of the patient developed acute renal failure, ventricular dysfunction, and arrhythmias. At interstage follow-up of 8.28 ± 3.7 months, both Nakata index (from 66.23 ± 24.12 to 185.8 ± 58 mm²/m²) and McGoon ratio (0.9 ± 0.22 vs 49 1.84 ± 0.4) increased significantly compared to preoperative value, whereas RPA-LPA ratio was not significantly changed (1.095 ± 0.39 vs 1.01 ± 0.56, P = 0.63). Prerepair pulmonary vascular resistance in 17 patients, who underwent complete repair, was 2.9 ± 0.69 woods unit/m². Postrepair right ventricle-left ventricle pressure ratio was 0.5 ± 0.14. There was no early or late mortality and none of the patient required conduit revision or VSD fenestration. On follow-up of 25.75 ± 17.94 months, 16 patients were in NYHA I and 1 patient was in NYHA II. Appropriate-sized RV-PA shunt is an effective strategy for achieving balanced pulmonary artery growth in VSD/PA with hypoplastic pulmonary arteries presenting late without the risk of pulmonary over circulation or systemic malperfusion.

Purpose

There has been a shift in the paradigm of management of post-myocardial infarction ventricular septal rupture (MI VSR), with many authors reporting improved prognosis if the surgery can be “optimally delayed.” Timing of the procedure is of critical importance and our management (UPMS), and prognosis scores (UPPS) have proven to be relevant. However, long-term outcomes and their correlation with our scores had not been analyzed. In this study, we present our long-term results of post-MI-VSR repair and their correlation with our prognosis score (UPPS).

Methods

Seventy-one patients with post-MI VSR repair (2009–2017) were retrospectively studied. Patients were managed using standard institute protocols.

Results

The 30-day mortality was 56% (n = 40). During a mean follow-up of 4.91 ± 2.43 years, there were eight late deaths. Actuarial survival of 30-day survivors was 87% at 1 year, 74% at 5 years, 

and 69% at 10 years. Actuarial freedom from major adverse cardiovascular events (MACE) was 82% at 1 year, 72% at 2 years, and 72% at 8 years. The UPPS score predicts late mortality with sensitivity of 75% and negative predictive value of 84%.

Conclusion

Our prognostic score (UPPS) helps not only in predicting early mortality but also in identifying the patients who are likely to live longer. The management score (UPMS) also provides best timing for the procedure, which is helpful in optimal utilization of resources in the developing world. The accuracy of these scores is reasonable and may be helpful in the decision-making in this difficult subset.

Abstract

Purpose

Carpentier’s classification has been used to classify both stenotic and regurgitant lesions. However, given the extreme variability of lesions, a universal nomenclature suggestive of the complexity and the prognosis of the repair procedure for the entire spectrum of the mitral valve disease still remains elusive. We present the predictors of mitral valve repairability with the help of a four-level-based ‘CLAS’ scoring system.

Methods

A total of 394 patients undergoing mitral valve procedure were prospectively studied. The valvular apparatus was divided into four sub-units, namely Commissures (C), Leaflet (L), Annulus (A), and Subvalvular apparatus (S), and the components were scored individually and the summation scores were calculated. Based on our results, three CLAS groups were formulated.

Results

A total of 376 (n = 394) patients underwent successful MVRep (95.43%; on-table failure in 18 patients). A total of 276 were rheumatic, 51 degenerative, 28 congenital, and 16 had infective endocarditis. Thirty-day mortality was 14 (3.72%) while delayed re-intervention rate was 8 (2.12%). The mean follow-up period was 30 months. One hundred percent patients with a CLAS score ≤ 8 had a successful repair as compared to 93.33 and 69.69%, respectively, for patients with scores between 9 and 12 and > 12, respectively. The cardio pulmonary bypass time, aortic-cross-clamp time, and ICU stay also showed a significant correlation with the patient’s ‘CLAS’ groups.

Conclusion

The CLAS score is highly predictive of a successful repair. We thus propose that, in the patients with a score of ≤ 8, repair should always be attempted irrespective of the pathology. The patients expected to be scored > 8 should be referred to a repair reference center.