Multiplane transoephageal echocardiography [TEE] advantages in assessment of prosthetic mitral and aortic valves intraoperatively [IOTEE], early and late after open surgical replacement follow up of complications

Two-dimensional echocardiography can identify gross [cardiosurgeon] structural abnormalities of a prosthesis, such as dehiscence, vegetation, thrombus, or degeneration of a tissue prosthesis, but its sensitivity for cardiac prosthetic dysfunction is hampered by the difficulty with visualizing structures around and behind the cardiac prosthesis. TEE has become an integral part of cardiovascular surgery for identifying a previously unrecognized abnormality that may affect the surgical procedure or the patient's Outcome and for assessing the result of the operation [1, 3]. lntraoperative transesophageal echocardiography [IOTEE] has become a routine addition to most cardiac operations [12-21]. Although epicardial scanning is still used in a few specific situations[12], IOTEE has become the more commonly used method for visualizing cardiac structures in the operating room. Adults and adolescence undergoing mitral or aortic valve replacement or both were subjected to IOTEE, early or late TEE after surgery to clearly assess the prosthetic valve function and detect complications. Randomized study in 25 cases 13 females and 12 males with mean age 31 years youngest 19 years old and eldest 41 years old, referred to the National Heart Institute for surgical replacement of the mitral or aortic valve or both. Patients with resistant heart tailure were excluded from the study. 6 patients had atrial fibrillation. All patients were excluded from rheumatic activity or infective endocarditis. Transthoracic echocardiography was used to assess the mitral and aortic valves by apical 4 chamber, apical 2 chamber, parasternal and subcostal views, and blood flow by Doppler. Transoephageal echocardiography was done before surgery in all patients to further assess the valves [valve stenosis and valve regurge], absence of thrombi or vegetations. IOTEE was done during surgery and prosthetic valve was assessed for valve opening and valve closure, paravalvular leak. TEE [early 6 weeks and late 6 months] is useful in the evaluation of dehiscence, endocarditis, abscess, and intracardiac [especially atrial] mass or thrombi in the presence of a prosthetic valve. Intra-operatively the prosthetic valve is considered successful with good opening and closure and absence of paravalvular leak. Early after surgery [6 weeks], success was considered if there is no or minute paravalvular leak and no thrombi, vegetations, valvular leak or obstruction. Late after surgery [6 months] success considered no or minute paravalvulaj leak and no thrombi, vegetations, valvular leak or obstruction beside we searched for dehiscence, endocarditis, abscess, and intracardiac [especially atrial] mass or thrombi in the presence of a prosthetic valve, All patients have done IOTEE and no complications were detected during surgery namely valvular or paravalvular leak and prosthetic valve obstruction. After 6 weeks, 3/25 significant paravalvular leak, 2/25 fresh thrombus, 0/25 vegetations, 0/25 valvular leak, and 0/25 prosthetic valvular obstruction. Late after surgery [6 months], 5/25 significant paravalvular leak, 2/25 fresh thrombus, 1/25 vegetations, 1/25 valvular leak, and 4/25 prosthetic valvular obstruction, 3/25 valve dehiscence, 0/25 abscess, and 2/25 intracardiac [especially atrial] mass or thrombi in the presence of a prosthetic valve. All results were statistically non significant p>0.001, however, all complications must be considered and correlated to medical treatment especially anticoagulation. Multiplane TEE remains the gold standard in proving efficacy of prosthetic valve function and detection of complications both intraoperatively [IOTEE], early and late alter surgery. All complications may be related to anticoagulation

Non-invasive assessment of secundum atrial septal defect [ASD] versus patent foramen ovale by the use of transthoracic echocardiography [TTE] and 12 lead ECG in adults and adolescence. Efficacy of the procedure and results compared to transoesphageal echocardiography [TEE]

Transthoracic echocardiography represents a non-invasive technique for assessment of secundum atrial septal defect. However in some patients it is not always simple to identify the edges of the defect due to technical problems, obesity or echocardiographic experience. Transoephageal echocardiography represents the golden tool in assessment of secundum defects but may represent probable hazards of invasive procedures. Retrograde study in all patients who were diagnosed to have secundum ASD by TEE. All patients were subjected to TTE by different investigator and the results was calculated for sensitivity and specificity. The results were added to 12 lead ECG to assess the efficacy of 12 lead ECG to increased sensitivity and specificity of presence of secundum atrial defect than transthoracic echocardiography alone. All patients were adults and adolescence. Randomized study using 143 cases 96 females and 47 males with mean age 30 +/- 14 years youngest 14 years old and eldest 59 years old, referred to the National Heart Institute with suspected atrial septal defect by echocardiography. All patients were analyzed for clinical problems namely chest pain or dyspnoea and patients with atrial fibrillation were excluded from the study. Transthoracic echocardiography was used to prove the presence of secundum defect by apical 4 chamber, apical 2 chamber, parasternal and subcostal views, and blood flow by Doppler across the defect was analyzed and dimensions of the defect were calculated in millimeter together with the presence of tricuspid regurge +/- paradoxical septal wall motion abnormality. 12 lead ECG was used to prove the presence of right bundle block [RBBB] namely rsR, rSr or qRc. Right axis deviation and right ventricular strain are also detected. Transoephageal echocardiography was used in all patients to prove the secundum defect and analyze the results compared to transthoracic echocardiography and 12 lead ECG. The presence of right bundle block [RBBB] rsR was 48%, rSr 16%, and qRc 8%. All patients had incidence of RBBB in 62% of cases. Transthoracic echocardiography was used to prove the presence of secundum defect by apical 4 chamber, apical 2 chamber, parastemal and subcostal views were effective in only 24%, and blood flow by Doppler across the defect was not possible in all patients. The size of the defect were not calculated in all patients. Tricuspid regurge with different significant grades was present in 18% in of all patients and 75% in patients with secundum defect. Paradoxical septal wall motion abnormality was present in 9.1%. Transoephageal echocardiography was used in all patients, secundum defect were present in 42% of all patients and 100% of all patients with documented transthoracic data of secundum ASD +/- ECG of RBBB. The presence of secundum ASD is more common in females. Transthoracic echocardiography alone is not effective in giving proven data of secundum ASD except in 24% of patients. Combined use of 12 lead ECG of presence of RBBB and experienced non-invasive transthoracic echocardiography increase the possibility of proving the presence of secundum atrial septal defect with sensitivity of 85% and specificity 89%. Right axis deviation is detected in 52% and right ventricular strain in 15%, TEE remains the gold standard in proving the presence of secundum ASD with high sensitivity and specificity

Coronary artery bypass grafting using arterial conduits

The use of arterial conduits in CABG showed better results and higher patency in long term follow-up. Complete myocardial revascularization using only arterial conduits can be accomplished by using multiple arterial conduits with one directed to each distal site, or 3 arterial conduits with the use of sequential anastomoses. Finally, the advent of T- graft or Y- graft has allowed complete revascularization with only 2 conduits. In the last few years, off-pump CABG has progressed and showed more and more popularity. This technique allowed surgeons to operate on high risk groups with better patient outcome. The aim of this study is to assess our results with these new techniques. In addition, different techniques of myocardial protection have been used for comparison. The patient population consisted of 50 patients. Patients' profiles are explained in the text and in table 1. Inclusion criteria include the use of two or more arterial conduits and isolated coronary surgery. On the other hand, exclusion criteria include less than two arterial conduits or associated valvular surgery. We used different techniques of myocardial protection; warm intermittent blood cardioplegia in 14 patients [28 percent], crystalloid cardioplegia in 22 patients [44 percent], fibrillating heart with or without intermittent cross clamping in seven patients [14 percent] and OPCAB in seven patients. These patients were studied immediately after operation by hemodynamic monitoring, complete laboratory investigation, myocardial serum enzymes and daily ECG for 3 days. Three months later, these patients were studied by a complete clinical work-up, Echo and stress ECG. All the patients were stable hemodynamically. They were put on minimal vasopressor support and liberal use of nitroglycerine. Intraaortic balloon pumping was not used. We had few complications; two patients developed preoperative myocardial infarction [4 percent], and two others [4 percent] developed neurological problems, one of them died and this was the only mortality in this series [2 percent]. All techniques of myocardial protection used could be the same in some patients, but there are certainly some subsets of patients need special precautions. Chronic renal disease, elderly patients and redo CABG are better operated upon by off-pump CABG. Patients having bad left ventricular function may need warm blood cardioplegia for better myocardial protection. Therefore, every surgeon should be able to handle different techniques