Management of a patient with antiphospholipid [Hughes] syndrome undergoing cardiac surgery: a case report

Primary antiphospholipid syndrome is an autoimmune coagulation disorder associated with recurrent arterial and/or venous thrombotic events and the presence of antiphospholipid antibodies. Echocardiography studies have disclosed heart valve abnormalities in about third of patients with primary antiphospholipid syndrome. Valvular lesions associated with antiphospholipid antibodies occur as valve masses [nonbacterial vegetations] or thickening. Both can be associated with valve dysfunction. The predominant functional abnormality is regurgitation, stenosis is rare. The mitral valve is mainly affected, followed by the aortic valve. Antiphospholipid antibodies often inhibit phospholipids dependent coagulation in vitro and interfere with laboratory testing of hemostasis. Therefore, the management of anticoagulation during cardiopulmonary bypass can be quite challenging for those patients. Here, we present a case of mitral valve replacement due to severe mitral regurgitation in a young patient with primary antiphospholipid syndrome

Reopening for bleeding after adult cardiac surgery

To determine the frequency and effects of post operative bleeding among adult cardiac surgery patients at Queen Alia Heart Institute. The medical records, operative and post operative notes of 1000 adult patients who underwent open heart surgery [coronary artery bypass grafting, valvular, ascending aorta and arch repair, and others] between January 2008 and April 2009 were retrospectively reviewed, 45 of them were reopened for bleeding. During the study period, 1000 patients underwent open heart surgery 45 [4.5%] of them underwent reopening for bleeding; 37 [82.2%] were males and 8 [17.7%] females. The average age for those operated upon was 63 years, with an average Body Mass Index of 27.66. The total pump run time was in the range of [54-220] minutes, with an average of 111.89 minutes. 25 [55.5%] patients showed a surgical cause for bleeding, while 19 [42.2%] showed a non-surgical cause. All cases were reopened in the operating theatre except for 1 [2.22%] who had to be reopened in the Intensive Care Unit. The most common cause of surgical bleeding was conduit related, in the form of a slipped ligature or avulsed branch occurred in 6 [13.3%] patients, followed by bleeding from the Left Internal Mammary Artery bed occurred in 5 [11.1%] patients. The most common non surgical cause was related to preoperative medications, Asprin and Plavix [Clopidogrel] being the most common [13.3%], followed by Low Molecular weight Heparin [11.1%]. The average ICU stay was 3.5 in comparison to 2 days for those not reopened, and the total hospital stay was in average 11.5 in comparison to 6 days for those not reopened. Post reopening Atrial fibrillation happened in 8 [17.7] patients and sternal complications in 8 [17.7%] and were the most common morbidities, followed by pleural and pericardial effusions, renal impairment, Intensive Care Unit delirium and psychosis, 2 [4.4%] patients died. Post operative bleeding in cardiac surgery is a serious complication with an increase in both morbidity and mortality. Thus extra care should be taken intraoperatively to limit surgical causes of bleeding, in addition to encouraging policies that promote early return to the operating theatre for exploration once the criteria for reopening have been met

Safety and efficacy of one stage coronary artery bypass grafting and carotid endarterectomy

To review the results of safety and efficacy of one stage coronary artery bypass grafting and carotid endarterectomy. In the absence of clear recommendations, without any bias, and by surgeon preference for the management of individualized cases, between January 1999 and July 2008, only 17 out of around 400 with a concomitant atherosclerotic disease in both vascular territories underwent one stage carotid endarterectomy and coronary artery bypass grafting. The mean age of the studied group was 67 [range: 54-77] years, there were 16 males and one female, all of the 17 patients were at high risk with a mean simple additive EuroScore of eight [range: 7-11]. Twelve out of 17 patients had three vessel coronary artery disease, 4/17 patients had four vessel coronary artery disease, and 1/17 patients had two vessel coronary artery disease. Regarding carotid occlusive disease, 10/17 patients were asymptomatic and only 7/17 were symptomatic, four of these symptomatic patients had an old cerebrovascular accident, 10/17 patients had unilateral significant carotid lesion, 6/17 patients had bilateral significant carotid lesion, while 1/17 patient had unilateral ulcerated unstable carotid lesion. All 17 patients underwent preoperative duplex Doppler carotid ultrasound and/or four-vessel arch arteriography, and standard coronary angiography. The principal indications for the combined procedure were the need for coronary artery bypass grafting and either [1] symptomatic carotid artery disease with unilateral or bilateral stenosis > 50% in 6/17 patients, [2] asymptomatic internal carotid artery stenosis of 80% or more, with or without contralateral disease in 10/17 patients, or [3] an ulcerated, unstable internal carotid artery lesion, regardless of degree of stenosis in 1/17 patient. Simple descriptive statistics were used. The average degree of carotid stenosis on the operated side was 72.5% [range 60-90%]. The average number of bypassed coronary arteries is 3.4 [range 2-4] per patient. There were no postoperative myocardial infarctions or strokes and only one death [5.5%] at a mean follow up period of 2.1 years [range 3 months - 4.5 years]. In our practice, simultaneous carotid endarterectomy and coronary artery bypass grafting seems to be a safe surgical approach for these high-risk patients

Vacuum-assisted closure technique fastens the healing of deep sternal wound infection

To compare the Vacuum-Assisted Closure technique to the conventional wound management in the treatment of patients with deep sternal wound infection after cardiac surgery. A total of 4400 patients underwent open heart surgery at Queen Alia Heart Institute between July 2001 and July 2005.Thirty six patients developed poststernotomy deep sternal wound infections [0.8%].These patients were treated by two different modalities. Twenty patients [group I] were treated by the conventional wound management. The other [group II] 16 patients were treated by Vacuum Assisted Closure Technique. The two groups were comparable with regards to age, sex, weight, associated diseases, presenting postoperative day, infecting organism, and risk factors for deep sternal wound infection. Patients treated by Vacuum Assisted Closure [group II] had a lower mean duration treatment time 10.5 days while the mean duration treatment time was 32 days in group I .Mean hospital duration stay was 17.6 days in group II, however it was 40 days in group I. Mean long term follow up period of both groups was six [range 2-14] months. Re-admissions and repeated surgical procedures was 30% in group I and 12.5% in group II. Perioperative mortality was higher in group I [10%] than in group II [6.25%]. The Vacuum-Assisted Closure Technique for deep sternal wound infection management has many advantages over conventional methods. Vacuum Assisted Closure offers the benefits of an optimal physiological environment of closed technique and the efficient removal of necrotic debris seen with the open technique. Moreover, Vacuum Assisted Closure shortened wound healing and hospital stay, cost-effective, and safe

royal medical services experience in vascular injuries during the Palestinian uprising

This report summarizes the experience of two vascular surgeons in dealing with vascular injuries at Rafidia surgical hospital- Nablus during the bloody conflict between the Palestinians and Israel. Between January 2000 and June 2001 thirty-nine Palestinians with vascular injuries were received alive at Rafidia Hospital in the city of Nablus. All patients were received in profound shock and underwent emergency surgery. Massive blood transfusion was given almost to all patients. We retrospectively evaluated the outcome and the surgical results. There was one operative death in a patient with injury to the vertebral artery. There were serious complications in 14 patients related to other injuries but all of them were discharged alive from Hospital with no limb loss. War vascular injuries are lethal. However, the presence of an experienced vascular surgeon and anesthesiologist, unlimited supply of blood and blood products combined with the young age of patients who tolerate the state of shock better can tremendously improve the outcome

Minimally invasive valve surgery Queen Alia Heart Institute experience

To assess the results of minimally invasive cardiac valve surgery at Queen Alia Heart Institute. The medical records and operative notes of 60 consecutive patients, who underwent minimally invasive valve surgery with or without other concomitant surgical cardiac procedures at Queen Alia Heart Institute between February 1997 and August 2003, were retrospectively reviewed. A satisfactory valve repair and/or replacement were performed in 58 cases through a minimally invasive approach. Conversion to classical midsternotmy was done in two cases [3.3%]. Mean incision length was 6 cm [rang 5-7]. Mean duration of operation, cardiopulmonary bypass, and cross clamp time was 150, 70, and 35 minute respectively. Mean duration of intensive care unit stay was 30 hours [range 24 to 36 hours] and mean duration o hospital stay was 4 days [range 3 to 5 days]. All patients were discharged from hospital. Postoperative wound infection and neurological deficits were not noticed All patients had a speedy recovery with less pain and trauma. At mean follow-up of 12 months [range 1 month to 1 years] all patients were alive and in NYHA functional class I. Minimally invasive valve surgery is technically feasible, safe and provides adequate exposure for valve repair and/or replacement in selected cases. It allows rapid recovery and early hospital discharge. Case selection an more technical experience are needed to further evaluate the early and long-term outcome of this procedure