Early postoperative outcome in diffusely diseased left anterior descending artery comparative study between endarterectomy and mammary arterial patch reconstruction

The problem of diffusely diseased LAD represents one of the surgical challenges with very few alternative solutions. Some my leave this diffusely diseased vessel without grafting and keep such patients on lifelong anticoagulation with the acceptance of some residual symptoms, others my do surgical grafting of this vessel using either extensive endarterectoy or creating a newly constructed LAD by the use of a long mammary artery graft patch. In this short prospective study we used both techniques in grafting the diffusely diseased LAD and we evaluated the early outcomes in the immediate post operative period [3 months]. This prospective shortterm study was done at Kasr Eleini teaching hospitals in the period between January 2006 and April 2009, 100 patients with severely and diffusely diseased LAD underwent bypass grafting. We used two techniques of LAD grafting. In group "A" [50 patients] we used the internal mammary artery for grafting after conventional endarterectomy [excision of the entire atheromata] while in the other group "B" [50 patients] we employed long mammary patch grafting of the LAD without coronary endarterectomy. In both groups selection of the technique was the surgeon's preference and there was no significant differences in the preoperative and operative criteria of patients. The preoperative data was not significantly different in both groups. The average length of endarterectomy in group A was 2.4 +/- 0.75 cm while the average length of mammary artery patch in group B was 3.2 +/- 0.8 cm. The duration of aortic cross clamp was 68.2 +/- 6.4 mm in group A and 78 +/- 8.5 mm in group B. there was higher postoperative mortality in group A [22%]. and only [8%] mortality in group B. ICU stay was 8.5 +/- 2.8 days in group A and 6.3 +/- 2.6 days in group B. postoperative myocardial infarction was higher in group A [32%] than that in group B [12%]. Also there was 4 cases in group A who needed additional saphenous vein grafting to the distal LAD, while no one needed additional LAD grafting in group B. postoperative bleeding was 540 +/- 86cm2 in group A and 830 +/- 116 cm2 in group B. long mammary arterial patch grafting of the LAD can be used as a surgical technique for grafting the diffusely diseased LAD. This technique provides better early postoperative outcome than that of LAD grafting after endarterectomy, however this study still needs longer evaluation of the graft patency in both groups. Pathological Q wave and positive cardiac biomarkers are predictors for worse prognosis among patients having myocardial infarction post-CABG

Repair of chronic moderate functional ischemic mitral regurge during coronary bypass surgery versus no repair: experience and early results

An increased attention is nowadays being focused on the surgical management of chronic functional mitral valve regurgitation coexisting with ischemic heart disease [IHD]. The optimum approach as to its management is still under debate as different techniques have been proposed to correct tethering-induced regurgitation caused by derangement in the mitral valve apparatus. This study was carried out to assess the results of surgical repair of isolated chronic moderate functional ischemic mitral regurgitation [IMR] as regards the technique and postoperative left ventricular functions for the first year postoperatively. This comparative prospective-retrospective study was carried out between April 1999 and May 2008 in the Department of Cardiothoracic Surgery of Cairo University as well as the private practice after obtaining the approval of the local ethical committees in these places. The study population included 100 patients who were all diagnosed to have coronary heart disease complicated by moderate degree of ischemic functional mitral regurge. Patients were equally divided to two groups of equal number. Patients of the two groups were chosen to match as close as possible for sex, mean age, and preoperative risk factors. Group A patients contained 50 patients were submitted for mitral valve repair in addition to coronary artery bypass graft [CABG]; whereas group B patients contained another 50 patients were submitted for CABG alone without mitral repair. Perioperative patient evaluation included clinical examination; transthoracic [TTE]; and or transoesophageal [TEE] echocardiography. The surgical times [total operative time, total cardiopulmonary bypass time, and the cross-clamping time] were longer in group A patients [with statistical significance]. The mean number of bypass grafts done in group A was 3.4 +/- 0.4 [range 3-5 grafts]; versus 3.2 +/- 0.6 for group B patients [range 2-5] [p:NS]. Intraoperative IABCP was needed in 5 [10%] of group A patients; versus 14 [28%] of group B patients [p<0.03]. Before going out of the OR, TEE examination revealed trivial or no MR in all of group A patients together with no valve-related complications. The overall mortality was 13 [13%]: 4 [8%] in group A and 9 [18%] in group B [p < 0.05]. Intraoperatively 2 of group A [4%]; versus 2 [4%] of group B died for refractory cardiac muscle failure; while in-hospital mortality occurred in 6 [12%] of group B patients versus 1 [2%] of group A patients within the first 15 days postoperatively, mortality after 6 months was 1 in group A versus 1 in group B. Morbidity occurred in 11 [22%] of group A patients; versus 4 [8%] group B [p <0.04]. In group A, 4 patients [8%] needed prolonged mechanical ventilation with inotropic support; 4 patients [8%] were reoperated for hemostasis; 2 patients [8%] had transient hepato-renal insufficiency and superficial wound infection; while 1 patient [2%] newly-developed transient episode of atrial fibrillation that was medically-controlled. In group B, 3 patients [6%] needed prolonged mechanical ventilation with inotropic support; while another 3 patients [6%] developed prolonged non-fatal low cardiac output symptoms that became controlled on prolonged inotropic support. In both groups, all morbidity were adequately-controlled without fatal consequences. NYHA class has showed a significant improvement in survivors of group A than B with lower percent of patients with NYHA III/IV in group A [7/46] versus [14/41] in group B [p value 0.04]. The group A had a higher LVEF at 6 months 62 +/- 6 than group B 46 +/- 0.9 [p value 0.0001] despite matching of the preoperative LVEF of both groups. Combined CABG and repair of moderate degree of ischemic functional mitral regurge was associated with higher incidence of intraoperative and in-hospital non-fatal morbidity. Performing CABG with no mitral repair was associated with progressive deteroration of the left ventricular dimensions and functions especially in the patient subset with dilated preoperative LV diameters [LA and LVEDD] and compromised functional parameters [LVEF% and FS]. We advocate combining CABG with repair of moderate IMR in specific patient groups for augmenting postoperative LV performance and maximizing surgical results

Effectiveness and value of using free pericardial fat pad to control residual alveolar air leaks after pulmonary resection operations

Residual postoperative air leaks are one of the most common problems following pulmonary resection operations. Many clinical studies were carried out in an attempt to offer solutions for this problem. Our study, aims to investigate the effectiveness and value of using free pericardial fat pad to control air leaks in residual raw parenchymal surfaces following lung resection or pleural decortication operations. This prospective comparative study was done in the Departments of Cardiothoracic Surgery and chest internal medicine of Kasr El Aini University French Teaching Hospital as well as private hospitals after approval of the local ethical committee. The study included 50 adult patients who were submitted to lung resection or pleural decortication operations between 2001 and 2006. There were 27 [54%] lobectomies with incomplete fissure; 5 [20%] wedge resections; .4 [8%] cases of segmentectomy; and 14 cases [28%] of pleural decortication. Patients were divided into two adequately-matched groups: group [I] contained 25 patients in whom residual air leaks were intraoperatively controlled by suturing them to pieces of free pericardial fat pad. In group [II], another 25 patients, in whom residual air leaks were solely managed by conventional manual suturing methods. Data was collected prospectively in group [I] patients but retrospectively in group [II] patients. In both groups, preoperative patient characteristics [age, sex, surgical risk factors], as well as the general standard operative techniques, were matchable. The hospital stay time was longer in group II patients [mean 9 days +/- 1.5 SD] vs. 3 days +/- 0.5 SD][p < 0.05]. In group I, there was no mortality, and no patient showed air leaks beyond 3 days postoperatively. All patients had their chest drains removed [day 3 and 5] after the operation. In none did evidence of space problems occur for 4 weeks postoperatively. In group II, there was no mortality, but shortcomings were noticed in 4 patients [16%] as persistent air leak in 3 patients [12%]; and persistent air leak transforming to empyema in one patient [4%], who needed surgical-reexploration 2 monthes later for pleural decortication. Application of a free pericardial fat pad proved to be effective and useful for controlling air leaks from residual raw parenchymal surfaces after pulmonary resections