Transit time flowmetry in coronary artery bypass grafting-experience at queen alia heart institute, Jordan

To assess the results of transit time flowmetry [TTF] on a consecutive group of coronary artery bypass grafting [CABG] patients at Queen Alia Heart Institute. Intraoperative flow measurements of a consecutive group of 436 CABG patients. The flow pattern for each coronary artery system was assessed including mean flows, pulsatility index [PI] and the need for revision. A total of 1394 grafts in 436 patients were assessed [3.2 grafts per patient], wherein 100 grafts showed inadequate flowmetry results [7.2%]; most of which were in the circumflex and right coronary artery systems with a percentage of 9.4% and the least in the LAD system with a percentage of 4.4%. The mean flow of grafts to the LAD system was 33.4 +/- 5.3 mL/min with a PI of 2.4 +/- 0.4; while the mean for grafts to the circumflex artery system was 35.1 +/- 7.2 mL/min with a PI of 3.5 +/- 0.7. The mean for theright coronary artery was 38.4 +/- 5.9 mL/min with a PI of 2.6 +/- 0.6. Revisions occurred in five patients [1.1%]. Suboptimal grafts to the LAD system exhibited a flow of 14.1 +/- 7.4 mL/min with a PI of 6.9 +/- 1.7. While for the circumflex system a flow of 5.5 +/- 3.6 mL/min was reported with a PI of 10.4 +/- 7.8; and for the right coronary system a flow of 7.2 +/- 5.3 mL/min with a PI of 9.1 +/- 5.7 was reported. Grafts to the LAD system showed the best flowmetry results compared to grafts to the circumflex and right coronary systems. A proportion of poor grafts were revised

Pre-operative carotid doppler ultrasound scanning among patients who underwent cardiac surgical procedures at Queen Alia Heart Institute, is it necessary?

To assess the frequency of significant carotid artery disease among the study group patients who underwent cardiac surgical procedures and highlight the importance of pre-operative Carotid Duplex Ultrasonography Scanning. This is a descriptive study which was conducted on a consecutive series of 102 Jordanian patients who underwent cardiac surgical procedures at Queen Alia Heart Institute between January and December 2009, and were pre-operatively examined for carotid artery disease. Median age of the study group patients was 63 [range 40-78] years, there were 84 males and 18 females, 76[74.5%] were hypertensive, 62[60.7%] diabetics, 67[65.6%] had history of smoking, 45[44%] had a Body Mass Index >30, 13[12.7%] had significant left main disease. Ten patients [9.8%] had a pre-operative history of transient ischemic attack or cerebrovascular accident. Chi-square was used to determine significance of the study variables, P value<0.05 was considered significant. Seventeen patients [16.6%] were found to have 50% or greater stenosis of one or both carotid arteries whereas for an 80% or greater stenosis; it was 6[5.8%]. Frequency of a 50% or greater stenosis of one or both carotid arteries was 3[6.5%] in patients between age 60 and 69 years, increasing to 11[42.3%] for patients age of 70 years and older. Independant risk factors for the presence of >50% stenosis in one or both carotid arteries in this group of patients were a previous history of transient ischemic attack or cerebrovascular accident, left main coronary disease, hypertension, history of smoking. Among 4 patients found to have concomitant significant carotid lesions and were hemodynamically stable with no critically stenotic coronary arteries, management was staged, carotid stenting was performed as a first stage in 2 patients and carotid endarterectomy was performed as a first stage in another 2 patients, cardiac procedures were performed successfully as a second stage in these 4 patients. Concomitant significant Carotid Artery Disease among the study group patients above the age of 70 who underwent cardiac procedures is relatively high, selective pre-operative Carotid Duplex Ultrasonography should be mandatory

Use of magnesium sulphate in the prophylaxis of atrial fibrillation post cardiac surgery, is it effective?

To assess the effectiveness of magnesium sulphate in the prophylaxis of postoperative atrial fibrillation in patients undergoing elective coronary aortic bypass grafting or valvular heart surgery in terms of reducing its incidence and decreasing the length of hospital stay. This study which was conducted at Queen Alia Heart Institute from June 2009 to June 2010 on 308 patients who underwent elective coronary artery bypass grafting or valvular heart surgery. Patients were divided into two equal groups, the magnesium-treated and control groups [154 each]. Then each group was subdivided into patients who underwent coronary artery bypass grafting alone [n = 102], and patients underwent valvular surgery with or without coronary artery bypass grafting [n = 52]. In the treatment group, patients were given 3.0gm of magnesium sulphate intra-operatively, and later on for the first 4 consequent post operative days. About 8.4% developed atrial fibrillation in the treatment group in contrast 23.3% in the control group [P< 0.001]. In the subdivided groups, those patients who underwent only coronary artery bypass grafting, 7.8% and 23.5% developed atrial fibrillation in the treatment and control group respectively. In the group of patients who underwent valvular heart surgery with or without CABG, 5 patients [9.6%] developed atrial fibrillation in the treatment group compared to 15 patients [28.8%] in the control group. Atrial fibrillation developed after 34 +/- 10.52 hours in the treatment group in comparison to 38 +/- 11.23 hours which is statistically non-significant. The length of hospital stay was 6.01 +/- 2.15 days in the treatment group while it was 5.95 +/- 1.85 days in the control group which was also found to be statistically non-significant. Use of magnesium sulphate, both intraoperativley and postoperatively proved to be safe and effective in reducing the incidence of post operative atrial fibrillation in patients undergoing elective coronary artery bypass grafting or valvular heart surgery, but with no obvious significant effect on hospital stay

Does the application of negative suction to the chest drains increase the rate of mediastinal bleeding after coronary artery bypass graft?

There is controversy whether the institution of negative suction for cases of Coronary Artery Bypass Surgery [CABG] affects the rate of Mediastinal bleeding. Consecutive cases of CABG were studied according whether negative suction was applied [Group A] or not [Group B] from October 2003 till May 2004. The 24 hour blood loss, mortality rates, re-opening for bleeding and post-operative pericardial effusions were analyzed. 281 consecutive cases of CABG alone or in combination with other procedures were studied. Negative suction was applied in 78 cases [28%]. Male-to-female ratio was 3.2:1. Pure CABG was done in 92% of the cases. Concomitant procedures included Mitral valve repair and replacement and Aortic valve replacement. Re-do surgery was performed in 16 cases [5.6%]. Left Internal Thoracic Artery [LITA] was utilized in 81%. Average blood loss in group A was 870 +/- 270 ml and group B 630 +/- 215 ml giving a P value<0.05. Re-opening for bleeding occurred in 10 cases in group A [12.8%] and 9 cases in group B [4.4%] with a P value >0.05. There were 11 deaths overall [3.9%] 4 in group A [5.1%] and 7 in group B [3.4%]. Pure CABG had 7 deaths from a total of 258 cases; a mortality rate of [2.7%]. Pericardia! effusion occurred in 2 cases in group A [2.5%] and 9 in group B [4.4%] giving a P value > 0.05. Despite the limitation of not being a randomized study, nonetheless, it shows that negative suction applied to the chest drains after CABG increase Mediastinal drainage but had no effect on reopening rates, pericardial effusion and overall mortality

effect of skeletonization of the left internal thoracic artery on rates of sternal wound infection: experience at queen alia heart institute

To study whether skeletonization of the internal thoracic artery has any beneficial effects on the rate of sternal wound infection after Coronary Artery Bypass Surgery and to compare this with the results of the classical pedicled form. A total of 212 patients were reviewed between October 2005 and February 2006 and divided into two groups according to the method of harvesting the left internal thoracic artery. Group I comprised 158 patients, 102 males and 56 females with a mean age of 59 +/- 2 years. Group II comprised 54 patients, 41 males and 13 females with a mean age of 57 +/- 2 years. In group I, the Left Internal Thoracic Artery was harvested in the classical pedicle form [preserving the vasa vasorum, venous drainage] using cautery and clips. In group II another method of harvesting was adopted using forceps and scissors and depriving the Left Internal Thoracic Artery from all the accompanying structures. The overall rate of sternal wound infection was 9.5% in Group I and 3.7% in group II [P<0.05].In Group I, 10 males and five females were infected [males 9.8% and females8.9%] while in group II only two male patients were infected. Harvesting the Left Internal Thoracic Artery in the skeletonized form takes longer time and is more difficult to do due to our developing learning curve; nonetheless it has a beneficial effect on decreasing the rate of sternal wound infection. The overall outcome was improved but other issues such as the overall patency and post operative pain should be studied more thoroughly

complication of the amplatzer PDA occluder requiring surgical correction

Trans-catheter occlusion of patent ductus arteriosus is the standard of care. We present a case of aortic coarctation secondary to Amplatzer PDA occluder [PDO] deployment treated surgically by device explantation. An eighteen month old boy had an Amplatzer PDA occluder implanted at the age of one year; presented with aortic coarctation; where the aortic disc of the PDA occluder was protruding into the aorta.He then underwent successful surgical retrieval of the PDA occluder and correction of aortic coarctation with ligation of patent ductus arteriosus

Sternal wound complication following upper midsternotomy incision. the experience at Queen Alia Heart Institute

To assess wound-related complications in patients undergoing open-heart surgery through minimally invasive approach, and to assess an alternative safer access to standard sternotomy. Over 30 months period ninety patients underwent elective open heart surgery via upper sternotomy incision risk factors for wound infection. Sternal wound complications were classified according to the seriousness and the extent of wound infection. Patients were followed-up for one month after hospital discharge. Of the 90 patients, 73 [81%] were males and 17 [19%] were females. Age ranged between 19-72 years [mean 40 years]. The procedures performed were valve surgery, coronary artery by-pass grafting and septal myomectomy in 86 [95.6%], 2 [2.2%] and 2 [2.2%] patients, respectively. Simple wound dehiscence occurred in 2, superficial wound infection in 6. None had deep wound infection or sternal wound dehiscence. One patient died from prosthetic valve endocarditis without sternal wound complications. Upper median sternotomy significantly reduces the serious complication of sternal wound closure and hence the hospital stay of the patients as well as the utilization of the medical resources