Coronary endarterectomy for severe diffuse coronary artery disease

To determine the outcome of Coronary Endarterectomy [CE] in patients undergoing Coronary Artery Bypass Graft [CABG] surgery for diffuse Coronary Artery Disease [CAD], in terms of postoperative mortality and morbidity, relief from angina and survival at one year. A case series. Department of Cardiac Surgery, Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi, from January 2003 to November 2005. Included in the study were all patients with such diffuse CAD that conventional bypass grafting was not possible. Those with the diseased coronary artery supplying an akinetic myocardium and a fixed perfusion defect on perfusion scan, or with poor left ventricular function [ejection fraction < 30%] in association with severe chronic hepatic disease and deranged liver function tests, permanent severe immune deficiency state, or poor results at lung function tests were excluded. Cardiopulmonary Bypass [CPB] was used in all patients. All patients were followed up for a mean time of one year, for assessment of postoperative mortality and morbidity, relief from angina and survival. Fifty five patients [3.2%] underwent CE of at least one major coronary artery for severe diffuse atheromatous disease. The mean age was 53.9 +/- 9.5 years. Twenty six [47.3%] had previous Myocardial Infarction [Ml], 16 [29.1%] had unstable angina, 12 [21.8%] had poor Left Ventricular [LV] function, 5 [9.1%] underwent emergency CABG surgery for impending infarction, 39 [70.9%] had angina Canadian Cardiovascular Society [CCS] class II/III, 11 [20%] had critical left main stem disease and 12 [21.8%] required Intra-Aortic Balloon Pump [IABP] for hemodynamic support. There were 2 [3.6%] early deaths and 2 [3.6%] cases of non-fatal infarctions. Three [5.4%] patients had low Cardiac Output [CO] after operation. At one year follow-up, there were no late deaths and 43 patients [91.5% of those reporting for follow-up] did not have angina. CE acted as an adjunct to CABG surgery with acceptable operative risks and satisfactory results at one year in terms of mortality and angina relief

Vascularized bilateral pectoralis major muscle flaps as a primary procedure in patients with sternal necrosis and infection

The current study was conducted to analyze our experience of vascularized bilateral pectoralis major muscle flaps as a primary procedure in patients with sternal necrosis and infection in terms of mortality, functional results and chest stabilization. It is a case - review analytical study conducted at Armed Forces Institute of Cardiology / National Institute of Heart Diseases, Rawalpindi from 1st Jan 1994 to 31st Dec 2001. Patients developing sternal dehiscence subjected to primary repair with vascularized bilateral pectoralis major flaps were studied. Relevant information was retrieved from the medical records. The procedure entails generous excision of all visibly infected soft tissues and bone followed by covering with vascularized bilateral pectoralis major flaps, raised from medial to lateral side based on thoracoacromial vessels. Patients were followed for 01 year postoperatively for complications. Twenty six patients suffered from deep mediastinal wound infection and sternal necrosis requiring bilateral pectoralis major flaps. One patient presented late after three months and all others were fresh cases. Mean age was 57.23 +/- 8.92 and there were 24 males and 2 females. Twenty five patients had coronary artery bypass surgery and 01 had closure of ventricular septal defect [VSD] with aortic valve replacement and right ventricular outflow tract [RVOT] reconstruction. One [4%] patient had complete failure of the repair requiring omentoplasty, while 02 [8%] had partial wound dehiscence needing resuturing. Twenty two [84%] patients were discharged between 8 to 10 days while 01 [4%] patient died of septicemia and mutliorgan failure in the hospital. After one year, all were alive; none had chest instability, breathing difficulty or limitation of shoulder joint movement. Primary repair with bilateral pectoralis major muscle flaps in sternal infection requiring extensive resection gives good results, with early discharge from the hospital good cosmetic results

High altitude illness: experience of one year

Objectives of this study was to analyze symptoms of altitude illness commonly necessitating evacuation of patients from high altitude to the base hospitals in Siachin area by simple clinical screening. This was a prospective observational. Place and duration of study was Northern areas of Pakistan. This study was carried out at altitudes of 3633 meters [GOMA] and 2833 meters [Siksa] from Oct 2003 till Oct 2004. One hundred and thirty eight patients of altitude illness were studied, who were evacuated from altitude above 4000 meters. Out of 138 cases, 103 [74.6%] patients suffered from acute mountain sickness [AMS], while 21[15.2%] patients developed high altitude pulmonary edema [HAPE] and 14 [10.1%] patients developed high altitude cerebral edema [HACE], of which 3 patients were having concomitant HAPE. The most common symptom combination was headache and vomiting which was the presenting feature in 53[38.4%] patients, followed by headache, loss of appetite and insomnia, in 41[29.7] patients. Headache was the most common single symptom present in about 120[86.96%] patients that required evacuation. The next common symptom was vomiting that was found in 51[36.96%] patients while shortness of breath was present in 33[23.91%] patients. We conclude that headache is the most common presenting symptom in all the patients of AMS. Therefore, headache at high altitude should be taken seriously, if does not respond to common medication, then patient should be evacuated to a lower altitude. The incidence of AMS, HAPE, and HACE may be reduced by improving the physical fitness of mountaineers and observing the protocol of acclimatization

Outcome of ventricular septal defect closure

To identify the factors affecting the outcome, measured in terms of morbidity and mortality, after primary ventricular septal defect [VSD] closure. Design: Descriptive study. Place and Duration of Study: Armed Forces Institute of Cardiology / National Institute of Heart Diseases, Rawalpindi, from January 2002 to October 2003. Subjects and Children upto the age of 5 years who had primary VSD closure were studied. Patients were divided into two groups. Group-I included survivors and group-II included non-survivors. There was no difference in the conduct of operation among the two groups. A total of 53 patients were operated of whom 47 survived. Pulmonary hypertensive crisis [p < 0.001], pulmonary infections [p < 0.001] and pleural effusions [p < 0.003] were higher in non-survivor group. Patients in non survivor group were younger [0.75 + 0.34 years vs 2.24 + 1.16 years, p = 0.01] having less body weight [4.91 + 1.56 kg vs 7.94 + 3.35, p = 0.03] and high pulmonary artery to systemic pressure ratio at the time of coming off bypass [0.63 + 0.13 vs 0.43 + 0.09, p < 0.001]. Non survivors had higher association [66.6% vs 19.1%] of additional left to right shunts [p < 0.001]. Body weight less than 5 kg along with young age, high pulmonary artery to systemic pressure ratio at the time of coming off bypass and presence of additional left to right shunt are risk factors for adverse outcome