Female Gender is not a Risk Factor for Early Mortality after Coronary Artery Bypass Grafting

Background: The female gender is considered as a risk factor for morbidity and mortality after coronary artery bypass grafting (CABG). Aim: In this analysis, we assessed the impact of female gender on early outcome after CABG. Study Design: This is a retrospective analysis of data from our center situated in South India. Statistical Analysis: Patients were categorized according to gender and potential differences in pre-operative and post-operative factors were explored. Significant risk factors were then built in a multivariate model to account for differences in predicting gender influence on surgical outcome. Methods: 773 consecutive patients underwent first time CABG between January 2015 and December 2016. 96.77% of cases were performed using off-pump technique. 132 (17.07%) patients were females. These patients formed the study group. Results: The in-house/ 30-day mortality in females was similar to that of males (3.03% vs. 3.12%, p value 0.957). Mediastinitis developed more commonly in females (5.35% vs. 1.30%; p value 0.004) compared to males. There were more re-admissions to hospital for female patients (21.37% in females vs. 10.14% in males, p value <0.001). In multivariate analysis using logistic regression; there was a significant association between age (OR 1.08), chronic obstructive airway disease (OR 4.315), and use of therapeutic antibiotics (OR 6.299), IABP usage (OR 11.18) and renal failure requiring dialysis (OR 28.939) with mortality. Conclusions: Early mortality in females was similar to that of males. Females were associated with higher rate of wound infection and readmission to hospital.

Predictors of acute kidney injury in patients undergoing adult cardiac surgery

Background: Acute kidney injury (AKI) after cardiac surgery (CS) is not uncommon and has serious effects on mortality and morbidity. A majority of patients suffer mild forms of AKI. There is a paucity of Indian data regarding this important complication after CS. Aims and Objectives: The primary objective was to study the incidence of AKI associated with CS in an Indian study population. Secondary objectives were to describe the risk factors associated with AKI-CS in our population and to generate outcome data in patients who suffer this complication. Methods: Serial patients (n = 400) presenting for adult CS (emergency/elective) at a tertiary referral care hospital in South India from August 2016 to November 2017 were included as the study individuals. The incidence of AKI-CS AKI network (AKIN criteria), risk factors associated with this condition and the outcomes following AKI-CS are described. Results: Out of 400, 37 (9.25%) patients developed AKI after CS. AKI associated with CS was associated with a mortality of 13.5% (no AKI group mortality 2.8%, P = 0.001 [P < 0.05]). When AKI was severe enough to need renal replacement therapy, the mortality increased to 75%. Patients with AKI had a mean hospital stay 16.92 ± 12.75 days which was comparatively longer than patients without AKI (14 ± 7.98 days). Recent acute coronary syndrome, postoperative atrial fibrillation, and systemic hypertension significantly predicted the onset of AKI-CS in our population. Conclusions: The overall incidence of AKI-CS was 9.25%. The incidence of AKI-CS requiring dialysis (Stage 3 AKIN) AKI-CS was lower (2%). However, mortality risks were disproportionately high in patients with AKIN Stage 3 AKI-CS (75%). There is a need for quality improvement in the care of patients with AKI-CS in its most severe forms since mortality risks posed by the development of Stage 3 AKIN AKI is higher than reported in other index populations from high resource settings.

Tricuspid valve straddling: An uncommon cause of left ventricular outflow tract obstruction in transposition of great artery with ventricular septal defect

Transposition of great arteries (TGA) can be associated with left ventricle outflow tract (LVOT) obstruction. In the presence of ventricular septal defect (VSD), septal leaflet of tricuspid valve may prolapse through perimembranous VSD or rarely tricuspid valve tissue may override to produce LVOT obstruction. Occasionally, this may be mistaken for vegetation due to associated pulmonary valve endocarditis. We report a case of d-TGA with presumptive pulmonary valve endocarditis and LVOT obstruction that was found to be due to tricuspid valve straddling on transesophageal echocardiography, resulting in change in the surgical plan and thus avoiding catastrophe.

Intraoperative localization and monitoring of migrating foreign body using transesophageal echocardiography.

Radiological imaging is often used for the preoperative localization of foreign body following blast injury, but their utility in case of migration during intra‑operative period is limited. Transesophageal echocardiography (TEE) has been used for intra‑operative localization and removal of intra‑cardiac foreign body; however, reports for localization of extracardiac migrating foreign body are few. Preoperative radiological imaging, in a victim of factory blast‑injury, suggested foreign body in the posterior mediastinum. However, the intra‑operative TEE showed it in the left atrium, which later migrated into the left ventricle necessitating a change in surgical approach for its removal.

A proposed method to visualize the ductus arteriosus on transesophageal echocardiography.

The ductus arteriosus occupies a uniquely privileged position in the management of heart disease; it initiated not only the surgical management of congenital lesions but also the percutaneous management of this subset. During trans-thoracic echocardiography (TTE) the ductus is often visualized using ‘high’ parasternal (or the ‘ductal’ view) or suprasternal windows. It is generally agreed that imaging ductus during transesophageal echo (TEE) can be sub-optimal. During TEE imaging, visualization of the ductus arteriosus is obscured by the acoustic impedance offered by the left main bronchus; adjunct techniques such as insertion of a saline filled balloon in this airway have been used. We describe a simple maneuver that allows visualization of the patent ductus arteriosus during TEE imaging without the use of any adjuncts.

Left atrial myxoma, ruptured chordae tendinae causing mitral regurgitation and coronary artery disease.

Mitral regurgitation is uncommon with left atrial myxoma. The echocardiographic assessment of presence of mitral regurgitation and its severity are impaired by the presence of left atrial myxoma. We describe an uncommon association of left atrial myxoma with coronary artery disease and mitral regurgitation. MR was reported as mild on pre‑operative transthoracic echocardiography but found to be severe due to ruptured chordae tendinae during intra‑operative transesophageal echocardiography, which lead to change in the surgical plan to mitral valve replacement in addition to excision of myxoma.

Extradural hematoma following double valve replacement under cardiopulmonary bypass: A rare complication.

The primary mechanisms responsible for acute neurological deterioration following cardiopulmonary bypass (CPB) include cerebral embolism, cerebral hypoperfusion and/or inflammatory process triggered by CPB. Extradural hematoma (EDH) following CPB is rare but associated with significant mortality and morbidity. We present a case of EDH following double valve replacement in an adolescent boy.