ABSTRACT
Introduction: Surgery is accepted as a traditional and standardtreatment of significant coronary artery stenosis with historyof an episode of acute coronary syndrome. This study involvesprognostically important descriptors to identify the factorsleading to functional improvement on medical managementin these patients who were at potential risk of majorcardiovascular and cerebrovascular events (MACCE). Thisongoing study attempted to find out whether the improvementof functional status are due to antianginal effect or more thanthat reversely remodelling coronary atherosclerosis.Material and methods: Between1st January 2016 and 31stJuly2017, the detailed investigations of 29 such patients wereobtained, who were on waiting list for CABG after beingreferred from cardiology department, many with history ofAMI. The improvement or deterioration of their functionalstatus while on treatment with guideline directed optimalmedical therapy (OMT) with atorvastatin (40 to 80 mg),aspirin(75mg) and clopidogrel (75mg), metoprolol succinate(12.5 to 50mg) with amlodipine (2.5 to 20mg), ramipril (1.25to 10mg) or telmesartan (20 to 80mg) for hypertension andheart failure prescribed at the discretion of the physicianalong with medications for diabetes and hypothyroidism, wereanalysed.Results: The first year follow-up was for the 29 patientsrecruited over 6 months. 17 patients with CCSA class III and1 with II had a baseline SYNTAX score of 29±6.2, while 11with class II had 20.3±3.2. The functional class improvedwith OMT medications was noted to be improving after 3 to 4weeks and by 12 months 62% were in class I. Duke ActivityStatus Index (DASI), improved from 19.3±3 to 23±2 at 6months and to 30.8±2 by 1 year in 18 patients. The associatedperipheral vascular disease symptoms also improved Mortalitywas 6.7%.Conclusion: In clinically stabilized patients with severe CAD,after ACS, with or without myocardial infarction, conservativemanagement with OMT, has been observed to improve cardiacfunction with reduced odds of mortality and improved qualityof life with lifestyle modification, some dietary and physicalrestriction.
ABSTRACT
Introduction: Surgical approaches to closure of postmyocardial infarction ventricular septal defect (PIVSD) areassociated with high morbidity and mortality. Timing ofintervention for its closure remains controversial. Severalstudies advocate early operative intervention, after diagnosisof PIVSD but these are associated with high mortality.However, the strategy of delayed closure around 14 to20 days or higher has been advocated in certain subsets ofpatients who can be stabilized from cardiogenic shock (CS)with pharmacological means with or without temporarymechanical circulatory support (tMCS). This helps to allowtissue fibrosis around PIVSD which increases the chance ofoperative success. Results of 5 such patients in whom surgerywas moderately delayed, and 2 in whom early operation wereperformed are reported in this paper.Material and methods: Between May 2012 to April 2016,7 consecutive patients of PIVSD had operative closure undercardio pulmonary bypass in our hospital. 5 patients had diureticand inotrope responsive CS and had delayed closure of PIVSDwithin 12 to 20 days, while 2 with severe CS, who weresupported preoperatively with tMCS like intra aortic balloonpump (IABP), had early closure within 72 hours. Patient dataof these seven subjects were retrospectively collected, and thecurrent status of the survivors was ascertained by out patientfollow up.Results: 4 of 5 patients from delayed surgery group withsmall PIVSD survived while 1 patient had early mortalitydue to severe right ventricular dysfunction post operativelyresulting in LCOS. 1 patient out of the 2 early surgery groupwith a large PIVSD survived while the other patient with asmall PIVSD and an extensive MI had early post operativemortality. 1 had from late surgery group had delayed mortalityafter 3 years. 4 patients are living at present.Conclusion: We advocate delayed elective repair of PIVSD,in patients with CS who responded to aggressive conservativemanagement maintaining hemodynamic stability, to allowinflammatory state to subside. In those patients with severeCS, additional rescue therapy with temporary mechanicalcirculatory support is needed to prevent further deteriorationof systemic perfusion. If the severe CS is due to high left toright shunt rather than infarct size, prognosis after repair ofPIVSD is better than in patients with CS due to extensivemyocardial damage.