ABSTRACT
Objective: To determine the accuracy of peripheral [radial] arterial access as compared to central [femoral] arterial access for measurement of invasive blood pressure [IBP] in critically ill patients after cardiopulmonary bypass
Methods: Sixty patients [60] who required high inotropic/vasopressor support on weaning from cardio-pulmonary bypass and weaned off in 2nd attempt were included in this study. The duration of this study was from June 2015 to August 2016. Radial and femoral arterial access was achieved in all patients for simultaneous measurement of blood pressure. Arterial pressures were noted after 5, 15 and 30 minutes of weaning from cardiopulmonary bypass for both radial and femoral artery simultaneously
Results: Mean age of study patients was 56.48+/-11.17 years. 85% patients were male. There was significant difference in systolic blood pressure, diastolic blood pressure and mean arterial pressures between the radial artery and femoral artery cannulation. Mean arterial pressures were significantly high in femoral artery as compared to the radial artery. The mean arterial pressures after five minutes of weaning using central access were 76.28+/-10.21 mmHg versus 64.15+/-6.76 mmHg in peripheral arterial access [p-value <0.001]. Similarly we also found significant difference in mean arterial pressures after 15 minutes of weaning from cardiopulmonary bypass 78.70+/-10.12 mmHg in central access versus 72.03+/-6.76 mmHg using peripheral arterial access [p-value <0.001]. The difference in arterial pressures were less marked as compared to the previous differences after 30 minutes of weaning from cardiopulmonary bypass as compared to the earlier readings [p-value 0.001]
Conclusion: Peripheral arterial pressures are unreliable in critically ill patients after cardiopulmonary bypass receiving high dose of inotropic drugs. Central arterial access should be used in these patients to get accurate estimates of patients' blood pressure in early periods after cardiopulmonary bypass
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Background and Objective: Recent meta-analysis reports have called for more randomized trials to evaluate the effectiveness of GIK solution in patients of cardiac surgery. So this study was conducted to evaluate the effectiveness of Glucose-insulin-potassium [GIK] solutions in non-diabetic patients undergoing coronary artery bypass grafting
Methods: A total number of one hundred and sixty [160] patients were randomized into two equal groups; GIK Group and non-GIK group. In GIK group, 5% dextrose containing 70 IU/L regular insulin and 70 meq/L of potassium was administered. The infusion was started at a rate of 30 ml/hour after induction of anesthesia and before the start of cardiopulmonary bypass. The infusion was started again after removal of aortic cross clamp and was continued for six hours after the operation
Results: In early post-operative period, peak CKMB levels were high in non-GIK group 48.50+/-19.79 IU/L versus 33.40+/-14.69 IU/L in GIK group [p-value <0.001]. There was no statistically significant difference in requirements of inotropic support between the groups. The mean duration of inotropic support in GIK group was only 5.50+/-6.88 hours in GIK group and 8.64+/-7.74 hours in non-GIK group [p-value 0.008]. Mean ventilation time in GIK group was 5.06+/-2.39 hours versus 6.55+/-3.58 hours in non-GIK group [p-value 0.002]. Similarly, ICU stay period was also shorter in GIK group [p-value 0.01]. We did not found any detrimental effect of GIK infusion on non-cardiac complications e.g. renal, pulmonary and neurologic complications
Conclusion: Glucose-insulin-potassium [GIK] infusion has a beneficial role in myocardial protection and is associated with better post-operative outcomes without increasing the risk of non-cardiac complications
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Objective: To find out risk factors of heart failure after ST Elevation Myocardial Infarction [STEMI] and to see the most commonly involved vessels in myocardial infarction responsible for heart failure
Methodology: This cross-sectional study was conducted from June 2013 to November 2013. 225 patients of heart failure [HF] following STEMI who came in the emergency department of the hospital were included. The selected patients were followed till the angiography reporting. Statistical analysis was done in SPSS version 16
Results: Mean age of patients was 51.42 +/-11.78 years. 49.0% patients were hypertensive, 37.3% patients were diabetic, 44.0% were smokers and 18.2% had positive family history. In this study, anterior wall MI was predominant and found in 30.7% patients. 46.7% patients had triple vessel disease [TVD]. There was 33.7% involvement of Left main stem [LMS]
Conclusion: Hypertension and smoking are most common risk factors of heart failure. The patients who present with heart failure are most who have involvement of triple vessel coronary artery disease. Left main stem [LMS] is most commonly involved vessel in these patients
ABSTRACT
Objective: To determine the frequency of post-operative pulmonary complications [PPCs] after cardio-pulmonary bypass and association of pre-operative and intraoperative risk factors with incidence of PPCs
Methods: This study was an observational analysis of five hundred and seventeen [517] patients who underwent cardiac surgery using cardiopulmonary bypass. Incidence of PPCs and risk factors of PPCs were noted. Logistic regression was applied to determine the association of pre-operative and intraoperative risk factors with incidence of PPCs
Results: Post-operative pulmonary complications occurred in 32 [6.2%] patients. Most common postoperative pulmonary complication was atelectasis that occurred in 20 [3.86%] patients, respiratory failure in 8 [1.54%] patients, pneumonia in 3 [0.58%] patients and acute respiratory distress syndrome in 1 [0.19%] patients. The main risk factor of PPCs were advance age > 60 years [odds ratio 4.16 [1.99-8.67], p-value <0.001], prolonged CPB time > 120 minutes [odds ratio 3.62 [1.46-8.97] p-value 0.003], pre-op pulmonary hypertension [odds ratio 2.60 [1.18-5.73] p-value 0.016] and intraoperative phrenic nerve injury [odds ratio 7.06 [1.73-28.74], p-value 0.002]. Operative mortality was 9.4% in patients with PPCs and 1.0% in patients without PPCs [p-value 0.01]
Conclusion: The incidence of post-operative pulmonary complications was 6.2% in this study. Advanced age [age > 60 years], prolonged CPB time [CPB time > 120 minutes], pre-op pulmonary hypertension and intraoperative phrenic nerve injury are independent risk factors of PPCs after surgery
Subject(s)
Humans , Female , Male , Adult , Middle Aged , Aged , Aged, 80 and over , Postoperative Complications , Lung Diseases/epidemiology , Risk Factors , Incidence , Logistic Models , Respiratory InsufficiencyABSTRACT
Objective: To see the effect of pre-operative incentive spirometry on postoperative atelectasis in patients undergoing Coronary Artery Bypass Grafting
Methodology: This was a randomized prospective study. The duration of study was 05 months from 01-02-2015 to 31-06-2015. A total number of 170 patients were included in this study. In Group I, there were patients in whom incentive spirometry was done before surgery [Study group]. While in Group II patients pre-operative spirometry was not done [Control group]. There were 85 patients in each group. Data was analyzed using SPSS Version 19. Chi-square test and independent sample t-test were used for analysis of qualitative and quantitative variable respectively. P-value < 0.05 was taken as a significant difference
Results: There were 42.4% patients who have positive smoking history in group I as compared to only 24.7% smoker patients in group II [p-value 0.02]. Ventilation time was significantly less in group I patients, it was 5.49 +/- 2.28 hours versus 6.74 +/- 5.46 hours in group II patients [p-value 0.05]. Incidence of post-operative atelectasis was 14.10% in group I and 27.10% in group II patients [p-value 0.04]. So we found that pre-operative incentive spirometry results in considerable reduction in incidence of post-operative atelectasis and it also can reduce ventilation time as well
Conclusion: Pre-operative incentive spirometry helps to reduce and prevent post-operative atelectasis in patients undergoing coronary artery bypass grafting
ABSTRACT
Objectives: Comparison of effects of propofol and isosorbide dinitrate during rewarming on cardiopulmonary bypass in patients undergoing coronary artery bypasses grafting
Methods: it was randomized prospective clinical trial. One hundred and twenty patient [120] undergoing CABG surgery were included in this study. Group-1 [Study group, n=60]: in which only propofol infusion used during rewarming and Group-ll [control Group, n=60] in which isosorbide dinitrate and propofol infusion combination was used during rewarming. The data was entered and analyzed through SPSS Version 19
Independent sample T-test and chi-square test were used for data analysis. P value of < 0.05 was taken as significant
Results: Mean arterial pressures during rewarming were 63.41 +/- 3.61 mmHg in propofol group versus 60.80 +/- 4.86 mmHg in control group [p-value 0.001]. Core temperature on weaning from cardiopulmonary bypass was 37.11 +/- 0.49 °C in propofol group and 37.00 +/- 0.18 °C in control group. After drop in core temperature was little more in propofol group [1.02 +/- 0.36 °C] versus 0.96 +/- 0.37 °C in control group but this difference was not statistically significant [p-value 0.41]. Mean Ventilation time after surgery in propofol group was 4.65 +/- 0.65 hours versus 5.03 +/- 0.81 hours in control group [p-value 0.006]
Conclusion: Propofol alone is capable of fulfilling the requirements of adequate rewarming during Cardiopulmonary bypass and can produce more hemodynamic stability and early post-operative recovery
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Objectives: To see the early post-operative outcomes of off-pump versus on-pump coronary artery bypass graft surgery
Methods: This retrospective analytical study was conducted at Ch. Pervaiz Elahi Institute of Cardiology Multan, Pakistan. Our Primary outcome variables were; necessity of inotropic support, nonfatal myocardial infarction, ICU stay, nonfatal stroke, new renal failure requiring dialysis and death within 30 days after operation. There were two groups of patients; Group-1 [On-pump group] and Group-11 [Off-pump Group]. SPSS V17 was used for data analysis. Independent sample t-test and Mann Whitney U test were used to compare quantitative Variables. Chi-square test and Fisher's exact test were used to analyze qualitative variables. P-value < 0.05 was considered significant
Results: Three hundred patients were included in this study. There were no significant difference regarding risk factors except hyper-cholestrolemia which was high in off pump group [p-value 0.05]. Angiographic and Echocardiographic characteristics e.g. preoperative ejection fraction, LV function grade and severity of CAD was same between the groups. Mortality risk scores and Priority status for surgery were also same. Regarding post-operative outcomes; Post-op CKMB Levels, need and duration of inotropic support, mechanical ventilation time and ICU stay was significantly less in Off-Pump group [p-value 0.001, <0.0001, 0.006, 0.025 and 0.001 resp.]. Peri-operative chest drainage was significantly high in On-pump CABG group [p-value 0.027]. Incidence of post-op complications was not statistically different between the groups
Conclusions: At 30 days follow-up, Incidence of myocardial infarction, necessity and duration of inotropic support, ICU stay period and peri-operative bleeding were significantly less in off-pump group. The incidence of neurologic, pulmonary and renal complications was same between the off-pump and on-pump groups
ABSTRACT
Objective: Pulmonary dysfunction is considered to be the most important complication after open heart surgery. Different maneuvers like intermittent or continuous positive pressure ventilation, low tidal volume ventilation and different vital capacity maneuvers have been used for reducing the incidence of pulmonary dysfunction after cardiac surgery. In this study we evaluated the effects of low tidal volume ventilation versus no-ventilation during cardiopulmonary bypass [CPB] in patients undergoing conventional CABG surgery
Methodology: This randomized clinical trial was conducted in a tertiary care cardiac hospital. One hundred patients who were planned to undergo conventional CABG surgery were divided into two groups by using draw randomization procedure. In Group A patients [ventilation group] ventilation was continued at low tidal volume of 3 ml/kg, respiration rate of 12 breaths/min and PEEP of 5 cmH[2]O. In Group B patients [non-ventilation group] ventilation was arrested during CPB. For data analysis Statistical Package for Social Sciences [SPSS] V17 was used. Parametric variables were compared using unpaired t-test and non-parametric variables were compared using o[2]-test
Results: The mean patient's age in this study was 57.70 +/- 8.57 years in ventilated group and 54.5 +/- 8.33 years in non-ventilated group. PaO[2]/FiO[2] ratio and alveolar-arterial oxygen tension gradient immediately after intubation was same in groups. But PaO[2]/FiO[2] was significantly high in ventilated group after one hours of CPB and even after four hours of CPB [p < 0.001 and 0.002 respectively]. Alveolar arterial oxygen tension [A-a O[2]] gradient after 1 hour and four hours of CPB was significantly low in Ventilated group [p < 0.001 and 0.001 respectively]. Total Mechanical ventilation time was also significantly shorter in ventilated group 5.19 +/- 1.96 hours versus 6.42 +/- 2.60 hours in non-ventilated group [p 0.009]. On 4th post-operative day, incidence of atelectasis was significantly low 20% in ventilated group versus 38% in non-ventilated group [p = 0.04]
Conclusion: Continuous low tidal volume ventilation is associated with better oxygenation after surgery and reduced risk of post-op pulmonary complications during cardiopulmonary bypass in patients undergoing conventional coronary artery bypass graft surgery
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Objectives: To evaluate the frequency of early remodeling in patients of severe aortic regurgitation after aortic valve replacement and to see the incidence of early remodeling in patients with stroke volume >97 ml versus < 97 ml before aortic valve replacement
Method: This was a prospective comparative study conducted from August 2013 to December 2014 in a tertiary care hospital. Fifty seven [57] patients of isolated chronic aortic regurgitation were included in this study. SPSS v23 was used for data analysis. Independent sample t-test was used for analysis of continuous variables and chi-square test for qualitative variables
Results: Out of fifty seven patients, early remodeling occurred in 34 [59.64%] patients after surgery. The mean pre-operative stroke volume of patient in whom remodeling occurred was 110.3 +/- 9.66 ml while mean pre-operative stroke volume of patients who did not undergo remodeling was 86.65 +/- 7.63 ml. There were 28 [82.4%] patients with stroke volume >97 ml in whom Remodeling occurred where as in patients with stroke volume <97 ml remodeling occurred only in 6 [17.6%] patients [p value 0.004]. There was no inhospital mortality
Conclusion: There is an association between stroke volume and early LV remodeling after Aortic valve replacement. Stroke volume >97 ml is a good predictor of early LV remodeling
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Objective: To review the operative results of 55 cases of partial anomalous pulmonary venous connection [PAPVC]
Methods: This retrospective case series of 55 cases of PAPVC operated from January 2011 to June 2016 at CPE Institute of cardiology, Multan. Baseline characteristics of patients, their operative findings and results were retrieved from the hospital record
Results: Operation for PAPVC was performed in 55 patients. Patient's age varied from 3-28 years [mean 12.56 +/- 7.49], their weight was 9-62 kg mean [25.61 +/- 16.28]. There were 41[74.5%] males and 14[25.5%] females. 49[89.0%] patients had right sided PAPVC associated with ASD moreover 3[5.4%] cases had right pulmonary vein draining into right atrium. While there was only one case having left sided PAPVC [1.8%] and two cases [3.6%] of bilateral PAPVC [4%]. Reassuringly, there was not a single mortality. However, one patient developed junctional rhythum, which was successfully controlled on amiodarone. SVC obstruction having 6mmHg gradient was observed in one case however patient is doing well and is on follow up since 9 months
Conclusion: Surgical correction of PAPVC generally carries highly reproducible results with low morbidity
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Background and Objectives: Modified Bentall procedure has become a gold standard in the treatment of combined aortic root and aortic valve diseases. Bleeding is an important predictor of morbidity and mortality after the Bentall operation. Our objective was to evaluate the early outcomes of Modified Button-Bentall procedure with cuff technique for aortic root replacement surgery regarding hemostasis
Methods: A total number of 32 patients who underwent elective Bentall operation from January 2008 to December 2014 were included in the study. In 18 patients [Group I] modified Button-Bentall procedure with formation of cuff was used and in 14 patients [Group II] Modified Button technique without cuff formation was used for aortic root replacement. Data was analyzed using SPSS V16. Chi-square test, Fisher's Exact test and independent sample t-test was used to analyze Qualitative and Quantitative variables
Results: Three patients in Group II and two patients in group I was in congestive cardiac failure pre-operatively. Out of thirty two patients two patients were having Aortic root dissection one in each group. Total bypass time and cross-clamp time were significantly high in Group I. There was no significant difference regarding duration of inotropic support, ventilation time, ICU stay and hospital stay time in patients of Group I and Group II. But post-op Chest drainage was very high in Group II 1158+451.25 ml versus 488.89+168.27 ml in group I [p-value <0.0001]. There was one in hospital death in Group II
Conclusions: Formation of cuff of remnant of aorta during proximal anastomosis results in significant reduction in post-operative bleeding and was better in hospital outcomes
Subject(s)
Humans , Male , Middle Aged , Hemostasis , Retrospective Studies , Cardiovascular Surgical Procedures , HemorrhageABSTRACT
Primary objective of this study was to evaluate the impact of significant left main stem [LMS] stenosis on the early outcome of coronary artery bypass graft [CABG] surgery. A Retrospective non-randomized analytical study was conducted in Cardiac surgery department, Chaudhary Pervaiz Elahi Institute of Cardiology [CPEIC] Multan, Pakistan. The data of patients who underwent isolated CABG at our institution from February 2008 to March 2014 were analyzed. Two thousand six hundred two [2602] patients of isolated CABG were divided into 2 groups according to the LMS disease. Group I [n=2088]: without significant LMS disease and Group II [n=514]: with LMS disease. Data was analyzed using SPSS V16. The groups were compared using Student's t-test for numeric variables. Chi-square test and Fishers Exact test were used for categorical variables. P-value ? 0.05 was considered as significant difference. Out of two thousand six hundred two, 2088 patients were in Non.LMS group [Control Group] and five hundred fourteen were in LMS Group [Study Group]. Patients with LMS disease were older. In both groups there was no statistically significant difference regarding gender distribution, risk factors of IHD, pre-operative renal function and preoperative CKMB levels. Significant number 50 [9.7%] of patients were unstable in LMS group and they needed urgent surgery [p-value <0.0001]. Need and duration for inotropic support and intra-aortic balloon counter-pulsation support were significantly high in LMS group [p-value <0.0001, 0.002, 0.003 respectively]. Similarly Mechanical ventilation time and hospital stay were higher in LMS group. Incidence of pulmonary complications and operative mortality were significantly higher in LMS group [p-value 0.005 and 0.001 respectively]. Mortality of CABG patients with significant left main coronary stenosis was 13 out of five hundred fourteen [2.5%] as compared to just 17 out of two thousand eighty eight [0.8%] in control group. This study showed that significant LMS disease is an independent risk factor for early cardiopulmonary morbidity and mortality after CABG surgery
ABSTRACT
Atrial fibrillation is the most common arrhythmia observed following Coronary Artery Bypass Graft surgery
Objectives: To determine the incidence of post-operative atrial fibrillation in patients undergoing coronary artery bypass grafting
Materials and Methods: Study Design: Non-randomized prospective
Setting: Cardiac Surgery Department of Multan Institute of Cardiology, Multan. Period: 20-1-2014 to 01-05-2015. A total number of four hundred and ninety [490] patients having age more than 40 years undergoing isolated coronary artery bypass graft surgery were included in the study. Data was analyzed in SPSS V20 software. Frequency and percentages were used for Atrial Fibrillation. To see the impact of AF on morbidity, patients developing AF was compared with those who do not develop Atrial Fibrillation post-operatively using independent sample t-test for quantitative variables. Chisquare test and Fischer's Exact test [whenever appropriate] was used to compare qualitative variables
Results: A total number of four hundred and ninety [490] patients were included in this study. There were more 431 males [88.0%] in this study. of the patients 71.6% were in LV Grade I before surgery. Incidence of post-operative atrial fibrillation was 13.5%. In 4.5% patients IABP was inserted due to hemodynamic instability. Ventilation time and hospital stay time was significantly higher in patients with AF postoperatively [p value 0.03 and 0.02 respectively]. But duration of inotropic support, post-op CKMB levels and IABP use were not significantly different in both groups
Conclusion: The incidence of post-operative Atrial Fibrillation is 13.5% according to this study. And these patients were associated with increased risk of morbidity
ABSTRACT
Precise determination of the size of aortic annulus is very important for the preoperative evaluation before aortic valve replacement
Objectives: to determine the preoperative prosthesis size using echocardiography in patients undergoing aortic valve replacement
Study Design: prospective observational study
Setting: Ch. Pervaiz Elahi Institute of Cardiology [CPEIC] Multan. Period: January 2013 to October 2014
Methods: [100 patients] Aortic annulus sizes were measured with TTE one week before surgery and with the help of sizer per-operatively. The data was analyzed by using SPSS V16. Quantitative variables were analyzed using mean and standard deviation and percentages were used for qualitative variables. Dependent sample t test was used to see accuracy of TTE in measuring aortic annulus size
Results: out of hundred patients, 84[84%] were male. Mean age of the patients was 33.77 +/- 13.17 years. 51% patients underwent isolated Aortic valve replacement; redo-operations were done only in 4% patients. In 96% patient's mechanical prosthesis was used and in 4% patient's boiprosthesis was used for valve replacement. We found no significant difference in Aortic annulus measured pre-operatively with the TTE [23.54 +/- 3.54] and measured per-operative with the sizer [23.96 +/- 3.36] with highly insignificant p-value 0.58.Aortic annulus size was almost same measured by these two techniques. Conclusion: Aortic annulus size measured with TTE helps to arrange the optimum size prosthesis before aortic valve replacement surgery
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Intermittent antegrade warm blood cardioplegia is routinely used as a mean of myocardial protection since its introduction. There is a considerable debate on the longest time off cardioplegia interval during aortic cross clamping. To see the frequency and extent of myocardial damage in patients undergoing CABG receiving intermittent antegrade warm blood Cardioplegia at LTOC [longest time off cardioplegia] 11-15 minutes [Group I] and 16-20 minutes [Group II]. A randomized prospective study involving 94 patients was arranged to see the safe periods of intermittency. There were two groups of patients having LTOC of 11-15 minutes [Group I] and 16-20 minutes [Group II]. 20 minutes was the upper limit. The duration of study was from 1-09-2013 to 10-02-2014. Data was analyzed using SPSS Version 16. Independent sample t-test and chi-square were applied to see the significance. Mean age was 54.1 +/- 9.36 years. There were more males as compared to females. More than 50% of the patients had Hypertension and Diabetes. There was no urgent surgery. Triple vessel disease [TVD] was present in 48.9% patients and 40.4% had Double vessel disease [DVD]. Average blood flow during CPB was 2.4 +/- 0.14 [L/ min.m-2]. Average body temperatures were 31.7 +/- 2.30 C. Cardioplegia temperature was 36-370 C. According to Left Ventricular Function Classification, 43.6% of the patients were of LV grade II and 10.6% of LV grade III. There was no significant increase in the levels of CK-MB in two groups. 77.8% patient in Group I and 66.7% in Group II gained spontaneous rhythm [p-value 0.16]. IABP was inserted in 5.4% patients in group I and 5.6% in group II [p-value 0.97]. There was no failure to wean off from bypass and no peri-operative mortality. The levels of inotropes viz dopamine and epinephrine on weaning were also almost the same. Perioperative MI occurred only in 7 patients [ruled out by biochemical evidence]. A reasonable margin of safety exists with intermittent antegrade warm blood cardioplegia in these two groups. So the LTOC [longest time off cardioplegia] up to 20 minutes is unlikely to lead to adverse clinical outcomes and is clinically acceptable