Is declotting a better procedure than Redo MVR for stuck mitral valve?

To evaluate and compare the outcome of declotting versus Redo Mitral Valve replacement for stuck mitral valve in the early postoperative period. Retrospective interventional study. Armed Forces Institute of Cardiology and National Institute of Heart Diseases [AFICNIHD] Rawalpindi from 1[st] Jan, 2010 to 31[st] Oct, 2013. A total of 36 patients were selected. Group A [n = 28] underwent declotting and group B [n = 08] were treated by redo mitral valve replacement [MYR]. Diagnosis of prosthetic valve obstruction was made on the basis of history, clinical examination, echocardiography and fluoroscopy. All patients were operated under general anesthesia and cardiopulmonary bypass [CBP]. Total clamp and CPB time were recorded. Post operatively, patients were evaluated with daily progress parameter. The hemodynamic status, isotropic support, ventilation time, intensive care ward and total hospital stay were also recorded for comparison. Two-dimensional echocardiography was done before extubation and at discharge. Mortality rate was also compared in the two groups. No statistical difference was found on the basis of gender, age, interval between initial mitral valve replacement [MVR] and redo operation or decloting, anticoagulation status, New York Heart Association NYHA] functional class, international normalized ratio [INR] level, trans thoracic echocardiography and luoroscopy. The mean CBP time and cross clamp time was significantly less in group A than group B. Similarly mean ventilation time in group A was significantly less than in group B. The mean ITC stay was and mean hospital stay was not statistically significant. The mortality rate in group A and B was 7.14% and 50% respectively which was statistically significant. Prosthetic valve thrombosis is a life threatening complication after mechanical mitral valve replacement with high mortality without timely and effective surgical intervention. Declotting, being a less aggressive surgical technique is recommended because of better outcome in terms of morbidity and mortality in the early post-operative period

Effects of hot shot [non cardioplegic blood based] on cardiac contractility and rhythm as parameters of myocardial protection in CABG surgery

To compare the effects of warm blood cardioplegia along with hot shot [non-cardioplegic blood based] at the end of ischemic time to warm blood cardioplegia without hot shot to assess resumption of effective electromechanical activity and need for internal electrical cardioversion as indicators of myocardial protection and preservation. Randomized control trial. The study was conducted at Armed Forces Institute of Cardiology [AFIC], Rawalpindi for a period of 10 months [March 2009 - Dec 2009]. Total 100 patients of coronary artery disease having coronary artery bypass grafting [CABG] surgery were equally and randomly divided into two groups using random numbers table. Group A [n=50], consisted of warm blood cardioplegia with non cardioplegic blood based hot shot and group B [n=50], consisted of warm blood cardioplegia only. The adequacy of myocardial protection techniques was assessed by noting the time interval [in seconds] between declamping of the ascending aorta and patient regaining electromechanical activity. Additional parameters were rhythm, use of internal cardiac defibrillation, inotropes, IABP requirement and ECG evidenced peri-op MI. Average age in group A was 56.98 +/- 9.47 years and in Group B it was 59.14 +/- 9.35 years. In group A there were 48 [96%] males and group B there were 43 [86%] males with p-value of 0.081. Comparison of preoperative variables of both the groups revealed no difference in cross clamp time [p=0.52], CPB time [p = 0.68] and endarterectomy [p=0.55]. The electromechanical activity [contractility of heart] returned within 7.53 +/- 2.09min in group A as compared to 9.81 +/- 2.6min in group B [p<0.001]. Significantly high frequency was observed for defibrillation [p=0.025], inotropic support [p=0.045] and IABP insertion [p=0.041] in group B as compared to group A. In CABG surgery the additional use of hot shot [non cardioplegic blood based] during cardiopulmonary bypass [CPB] is effective in myocardial protection and preservation by resuming early contractility of heart, benefit of no detrimental effects like dysrhythmias and less requirement of chemical or mechanical cardiac support

Effects of papaverine and sodium nitroprusside solution as topical vasodilators for internal mammary artery

To compare the effects of topical sodium nitroprusside [SNP] and papaverine solutions to treat left internal mammary artery spasm. Randomized Control Trial [RCT]. AFIC / NIHD Rawalpindi from Jan 2009 to March 2009. Fifty consecutive patients undergoing elective coronary artery bypass graft surgery [CABG] were randomly assigned to two groups: group N [n=25, Sodium Nitroprusside solution], and group P [n=25, Papaverine]. In each patient, pedicled left internal mammary artery was harvested, five minutes after heparin administration, left internal mammary artery was divided distally; flow per minute was calculated after measuring the free flow for over 15 seconds; this is named [Flow 1.]Then, the pedicled left internal mammary artery was sprayed with the randomized solution, and covered with the test solution soaked sponge. The second flow measurement [Flow 2] was done before commencing cardiopulmonary bypass. A third flow measurement [Flow 3] was recorded just before left internal mammary artery to left anterior descending coronary artery anastomosis, while the patient was on cardio pulmonary bypass. Analysis of variance was applied to detect differences among groups; paired-sample t test was used for left internal mammary artery topical free flow in both groups. Mean left internal mammary artery free flows were as follows: group N, flowl=32.72 +/- 27.67 ml/min, versus group P flowl=23.44 +/- 15.16 ml/min [p<0.148], group N flow2=63.92 +/- 33.40 ml/min versus group P flow2=38.88 +/- 24.54 ml/min [p<0.004], and group N flow3=62.44 +/- 38.38 ml/min versus group P flow3=49.52 +/- 30.29 ml/min [p <.170]. Topical free flow difference amongst the two groups was statistically significant in the flow2 [p< 0.004]; whereas topical mean free flow difference was statistically significant when the groups were individually compared group N flowl:flow2, flow 1: flow 3and flow 2: flow 3 group N [p<.000, .000, .846] and group P [p<.001, .000, .001] respectively. Sodium nitroprusside [SNP] and papaverine solutions are able to treat vascular spasm and increase the flow of left internal mammary artery, when they are used topically. However sodium nitroprusside allows early and better relief of vascular spasm

Does intact pleura during internal mammary artery harvesting decreases pleuropulmonary complications?

To evaluate the effects on postoperative pulmonary function of pleural integrity versus opened pleura, in patients who receive a left internal mammary artery graft. Randomized control trial. Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi from June 2009 to Feb 2010. The study was conducted on 62 patients who underwent elective coronary artery bypass grafting. The patients were divided into 2 groups: Group A consisted of patients who underwent internal mammary artery harvesting with opened pleura [n=31] while Group B consisted of patients having internal mammary artery harvested with intact pleura [n=31]. To monitor pleuro-pulmonary complications, chest radiography was performed routinely 1 day before operation and on the 2nd, 4th and 6th postoperative days. The preoperative, after extubation, and 1st postoperative day values of partial oxygen pressure [PaO2], partial carbon dioxide pressure [PaCO2], oxygen [O2] saturation and haematocrit were recorded for comparison. The effect of intact pleura on IMA traction was also recorded by serial cardiac enzymes measurement and electrocardiography in the immediate postoperative period. Pleural effusion occurred more often in patients of Group A [35.5% versus 12.9%] which was statistically significant [P 0.038]. However, no significant differences were recorded in postoperative respiratory complications. Reoperation for postoperative bleeding and tamponade was done in 6.5% and 3.2% of cases in Group B respectively but none Group A; however it was not statistically significant [P 0.076]. The mean postoperative hospital stay was 7.84 days for Group A and 7.58 days for Group B. Pleural integrity during IMA harvesting decreases pleural effusion. Although, no significant differences were recorded in postoperative lung complications, intact pleural technique of IMA harvesting is recommended because of the added advantage of decreasa rate of pleural effusion

Radial artery as a grafting surgery: Early experience at AFic / NIHD

The long-term patency of vein grafts in the coronary circulation has been poor. By contrast, the left internal thoracic artery [LITA] graft to left anterior descending coronary artery [LAD] has been associated with excellent patency and good clinical results. The revival of radial artery [RA] as a graft has offered another source of arterial conduit in addition to the use of right internal thoracic artery [RITA]. We evaluated our early experience with the use of RA as a conduit for coronary artery bypass grafting [CABG] surgery to establish its safety and efficacy. we studied 606 consecutive patients from January 2003 to December 2003 who underwent CABG surgery at our institute. Radial artery was used as a conduit 'in 214 patients. Data was collected prospectively. In the radial artery group, the age range was 27 - 72 years, mean age 49.5 years. 136 [64%] of the patients had diabetes, only 7 [3.27%] patients were females. 8 [3.73%] patients had left ventricular ejection fraction of less than 30%, 146 [68.22%] patients had EF of 30-45% and rest were with good left ventricular function. 23 [10.74%] patients were classified as unstable/urgent. The conduits included were 206 left internal thoracic arteries, 26 right internal thoracic arteries and 214 radial arteries and 170 were vein grafts. Average number of grafts per patient was 2.87. Top ends of the free arterial grafts as well as all the vein grafts were anastamosed directly to the ascending aorta. Patients were followed up to 6 weeks, 24 weeks and then 6 monthly thereafter. Complications included intra operative or post operative myocardial infarction in 6 [2.8%] patients, sternal wound infection in 4 [1.86%] patients, reoperation for excessive bleeding 17 [7.94%] patients. 14 [6%] patients required intra aortic balloon pump support, 46 [21%] required inotropic support. The incidence of hand complication was 7% [15 patients]. The overall mortality rate in radial artery group was not much different from the non-radial artery group of patients undergoing CABG surgery in our settings. Conclusions: Radial artery may be used as a conduit for coronary artery bypass grafting operation with confidence as regards its safety