Outcome of Early Surgical Intervention in Acute Lower Limb Ischemia due to Thromboembolism.

Background: Acute lower extremity ischemia is a common vascular disease and considered limb- and life- threatening. The present study evaluated and compared the outcome of early and late surgical intervention in acute lower limb ischemia due to thromboembolism. Methodology: This non randomized comparative parallel study was conducted at the Department of Cardiovascular Surgery, NICVD, Dhaka, Bangladesh from January 2007 to December 2008 for duration of two year. Total 80 patients were enrolled in this study. The patients were divided into equal two groups, Group A, for early surgical intervention (with in 24 hours) and Group B, late surgical intervention (more than 24 hours). Results: Mean (±SD) age of both Group A and Group B was 51.93 (±11.73) and 47.00 (± 11.01) years. Male and female ratio of the total study population was 1.76:1 Pain and absence of pulse distal to occlusion was common for all. Cold extremity, sensory deficit, motor deficit, diminish vascular flow was the commonest findings of both group. In Group A, 57.5% had superficial femoral artery occlusion, 22.5% had iliac artery and 20.0% popliteal artery occlusion. In Group B, 42.5% had superficial femoral artery occlusion, 32.5% had popliteal artery occlusion and 25.0% had iliac artery occlusion. Fasciotomy was performed in 15.0% patients of Group A and in 22.0% patients of Group B. After Fogarty embolectomy in group A and group B had warm extremity (80.0% vs. 65.0%), pulsation distal to occlusion (90.0% vs. 75.0%), intact sensory function (82.5% vs. 67.5%), intact motor function (80.0% vs. 65.0%), and normal vascular flow by Doppler US (80.0% vs. 65.0%). During postoperative period history of bleeding, infection, reperfusion injury, muscle necrosis and limb amputation were 12.5% vs. 10.0%, 5.0% and 7.5%, 17.5% vs. 35.0%, 15.0% vs. 12.5% and 37.5% vs. 32.5% respectively. Conclusion: Duration of embolism may be the significant factor determining the outcomes of the management of acute arterial embolism in the lower extremities. The 24- hour duration of arterial embolism is a crucial factor influencing the surgical the management and early diagnosis and shifting of patients to specified centre as early as possible to save limb as well as life.

Evaluation of Pulmonary Function after Off- Pump Coronary Artery Bypass Graft Surgery with Thoracic Epidural Analgesia.

Background: A substantial reduction of lung volumes and pulmonary function follows cardiac surgery. Pain may prevent effective breathing and coughing, as thoracic epidural analgesia may reduce post operative pain and improve early post operative pulmonary function. We tested the effect of thoracic epidural analgesia (TEA) on pulmonary function after off- pump coronary artery bypass (OPCAB) graft surgery. Methods: 60 patients undergoing off- pump coronary artery bypass (OPCAB) graft surgery were nonrandomized in to two groups. Group-I (30 patients) receiving thoracic epidural analgesia along with general anaesthesia (G/A) but Group-II (30 patients) receiving general anaesthesia alone. Total ventilation time, intensive care unit (ICU) stay, spirometric data, arterial blood gas (ABG) and X-ray chest (CXR) were recorded in postoperative follow-up period. Results: Thirty patients were enrolled in each group. The demographics of the groups were similar. Patients in the epidural group had significantly less pain on the operative day and for the next 2 days. Total ventilation time in hours in Group-I was 6.4±1.0 and in group-II was 10.1±1.8 hours respectively. FVC and FEV1 were significantly different in group-I than group-II. On the postoperative period, ABG was done pre and postoperative period in both groups of patients. Significant differences was found in pao2 and paco2, half an hour after extubation, 1st postoperative day, 2nd postoperative day (p<0.05). Postoperative CXR revealed significant pulmonary complication in group-II than group-I, higher in the epidural group on the first and second postoperative days. There were no complications related to epidural hematoma and no permanent neurologic squeal. Conclusion: Thoracic epidural analgesia yields a slight, but significant improvement in pulmonary function most likely due to a more profound postoperative analgesia.

Left Atrial Myxoma in a Child: An Uncommon Presentation of a Rare Tumour in Early Age.

Myxomas are rare tumours but are the most common benign tumours of the heart. They can arise from any heart chamber. However, they arise more frequently from the left atrium. They have rarely been described as originating in early age. A case of left atrial myxoma successfully removed using cardiopulmonary bypass in a 8-year-old child is presented. Review of the literature emphasizes the rarity and clinically aggressive behavior of this tumor in this age group. The object of this case report is to present myxoma in children and to evaluate possible differences between young and adult patients.

Left Atrial Myxoma in a Child: An Uncommon Presentation of a Rare Tumour in Early Age.

Myxomas are rare tumours but are the most common benign tumours of the heart. They can arise from any heart chamber. However, they arise more frequently from the left atrium. They have rarely been described as originating in early age. A case of left atrial myxoma successfully removed using cardiopulmonary bypass in a 8-year-old child is presented. Review of the literature emphasizes the rarity and clinically aggressive behavior of this tumor in this age group. The object of this case report is to present myxoma in children and to evaluate possible differences between young and adult patients.

Improved Preservation of Saphenous Venous Conduits by the Use of Papaverine mixed heparinized blood Solution during Harvesting.

Background: High-pressure distension during harvesting damages the saphenous vein (SV) and may contribute to subsequent coronary artery bypass graft (CABG) occlusion. Application of vasodilator agents to the SV during harvesting may reduce the need for high-pressure distension and improve graft quality. We tested the effects of a vasodilator solution containing the conventional agent papaverine (Pap) mixed with heparinized blood on the pressure necessary to overcome SV spasm and on the structure. Methods: 150 patients undergoing CABG were nonrandomly allocated to receive an application of either intraluminal papaverine (Pap) mixed with heparinized blood(Group-A), or intraluminal heparin mixed normal saline(group-B) to the SV for distension during harvesting. The peak pressures required to distend the vein were recorded. Samples of SV were taken for microscopical analysis just before we performed the anastomosis. Results: The results for mean peak pressures (mm Hg) were: Normal saline 131.77±20.6 (range 85 to199 mmHg); and Papaverine mixed blood solution, 56.4±2.1 (range 40 to 90 mmHg); P<0.001, (Pap mixed blood solution versus normal saline); The results of histological study for endothelial injury were: Normal saline, 52.5 %; Papaverine mixed blood solution , 20%; (P<.02, untreated versus Pap mixed blood solution). Conclusions: Intraluminal use of Papaverine mixed heparinized blood solution during vein harvesting requires low distension pressure and improves endothelial coverage compared with the use of heparin mixed normal saline.

Off Pump Complete Revascularization Through Left Lateral Thoracotomy (ThoraCAB): NICVD Experience.

Background: Conventional coronary artery bypass surgery (CABG) is associated with substantial morbidity caused by cardiopulmonary bypass (CPB) and median sternotomy. Here we described an innovative technique to perform complete revascularization through a left lateral thoracotomy without CPB (ThoraCAB). Methods: From September 2005 to December 2008 a total 83 patients underwent ThoraCAB in National Institute of Cardio Vascular Diseases (NICVD). The patient is positioned with the left side elevated to 45 degree. A 6 to 8 inches long incision is made over the left 4th or 5th intercostal space from just medial to the nipple to the anterior axillary line. The left internal mammary artery (LIMA) is harvested as a pedicle graft under vision. Distal coronary anastomosis is completed first on the beating heart using a stabilizer, followed by proximal anastomoses on the descending aorta. Peroperative and postoperative complication the arrhythmia hypotension wound infection death was observed. Results: Complete revascularization was achieved in all patients. The number of grafts averaged 2.18±1.08 per patients. One patient died (1.2%) due to severe respiratory acidosis. One patient (1.2%) was converted to CPB due to arrhythmia. No strokes were observed. Of these patients, 7.2% developed new onset postoperative atrial fibrillation. Conclusion: ThoraCAB has been feasible in the vast majority of the patients requiring CABG surgery. The prevalence of the post operative atrial fibrillation was low. Left lateral thoracotomy offers an attractive and effective alteration to Off Pump median sternotomy.

Effect of Tranexamic Acid after Cardiac Surgery in Children.

Background: The antifibrinolytic drug tranexamic acid (TA) decreases blood loss in Pediatric patients under going cardiac Surgery. However its efficacy has not been extensively studied in children. Method: We examined 750 children under going cardiac surgery form 2004 to 2007 in National Institute of Cardiovascular Diseases (NICVD), 379 children in the Tranexamic Acid group (TA) and 371 included in placebo (P) group. After induction of anesthesia and prior to skin incision, patients received either tranexamic acid (10mg/kg followed by 1mg/kg/hr) and saline placebo. After admission to intensive care unit total blood loss and transfusion requirements during the first12 hours were recorded. Result: Children who were treated with tranexamic acid had 24% less total blood loss (26±7 vs 34±17 ml/kg) compared with children who received placebo (p<0.05). Additionally, the total transfusion requirements, total donor unit exposure and financial cost of blood components were less in the tranexamic acid group. Conclusion: Tranexamic acid can reduce perioperative blood loss in children undergoing cardiac surgery.

Aspects of Infection in Intensive Care Unit - Prevention and Control.

Intensive Care Unit (ICU) is the most vulnerable area in the hospital premises. Hospital acquired infections in critically ill patients as well as of transmission of infections from a patient to another patient or to the health care workers or vice versa can occur in ICU. ICUs combine physicians, nurses and allied health professionals to manage patients with life threatening single or multiple organ system failure, including stabilization after surgical interventions. It is a continuous management including monitoring, diagnosis, and support of failing vital functions as well as the treatment of the underlying disease. Here we have to discuss the source of infection and their effective control measurement in intensive care unit. Ventilator associated pneumonia (VAP) as well with other sources is most common nosocomial infection having 33% mortality in ICU.

Diagnostic and Therapeutic Value of Cardiac Scan: First Experience of Utility and Prosfect of MPI in Bangladesh.

Background: Cardiac Scan (MP-SPECT) is a widely utilized noninvasive imaging modality for diagnosis, prognosis, and risk stratification of coronary artery disease. In Bangladesh it is a recently introduced test and there is no study upon it. Considering this ground the study is perform on Bangladeshi patients. Methods: 100 referral patients underwent MPI for evaluation of perfusion status of myocardium. The patients either of suspected IHD or diagnosed case of IHD were referred from different cardiology unit or surgery unit of NICVD. Technetium 99m (99"Tc) isotopes and tetrofosmin used in the same day stress and rest protocol. Result: The commonest findings observed in this present analysis were the early age group patients mostly of female having DCM, but the later age group of patients are of both male and female having Angina Pectoris, OMI and ICM. The referral patients by cardiologists or cardiac surgeons are mostly limited to the pre therapeutic evaluation rather than diagnostic indication. The most common indication is the evaluation of myocardial viability and aim of subsequent treatment. Conclusion: Analysis of perfusion status, decision of subsequent treatment either by medicine or CABG, conform the usually described pattern in western literature.