Urgent aortic valve replacement in severe aortic stenosis with severe left ventricular dysfunction and severe pulmonary hypertension: a perioperative multidisciplinary management approach

Severe aortic stenosis [AS] with reduced left ventricular systolic function and pulmonary artery hypertension [PH] is associated with poor outcome if remained untreated We report a case report of a 62 years old male patient weighing 69 kg had progressive dyspnea for 5 years and was diagnosed cardiac patient, and was scheduled for an urgent aortic valve replacement. He had severely reduced left ventricular [LV] function and severe pulmonary hypertension. The patient was put on bypass with special emphasis on myocardial protection. Tissue valve was placed and patient was successfully put off cardiopulmonary bypass on high inotrope score, which was tapered after some time. The patient was shifted to CICU after chest closure and was extubated on fast track mode. The patient was followed up for three months showing improvement in symptoms and LV function The objective of reporting the case is to highlight the role of multidisciplinary integrated approach in the perioperative period for best patient outcome

Cardiac surgery benchmarking: a quality improvement initiative

Background: Benchmarking programs help in reviewing and validating clinical practice and improves quality of care

Methodology: Fifteen accredited hospitals participated in International cardiac surgery benchmarking [ICSB] project from eight different countries including ours, Aga Khan University Hospital, a "clinical data coordinator" was trained to facilitate data collection, verification and eventual submission. The data was collected prospectively for preoperative characteristics, intraoperative variables and postoperative outcomes. Onsite data validation was also performed by a JCI representative for the accuracy of data. Data analyzed and reported on six quarters starting from October, 2009 to March, 2011

Results: A total of 4761 isolated CABG including 474 from our hospital entered into ICSB. The postoperative complication rate for ICSB and our hospital were calculated showing a higher rate of reopening [2.5 vs. 1.7%], higher postop renal dysfunction [5% vs. 1%] and a higher RBC transfusion [61 vs. 36%] but the incidence of stroke, myocardial infarction and deep sternal wound infection were low at our hospital. Risk factors that predict surgical death for CABG in this model are very similar to those used in New York state hospitals. The overall risk adjusted 30-day mortality was 3.4% at our hospital compared to 1.9% for ICSB

Conclusion: By benchmarking program our practice and data collection methodology has been reviewed and validated. Feedback will serve as regulatory function leading towards self-assessments to improve quality of care

Surviving shot through the heart: management in two cases

Penetrating cardiac injuries after gunshot are usually fatal and are very challenging to manage for surgeons even in fully-equipped centres. Such injuries can cause ventricular septal defect [VSD] or cardiac tamponade depending upon the distance, direction and velocity of the bullet. Stable patients can be subjected to investigations like computed tomography [CT] to avoid unnecessary intervention, but unstable patients should be rushed to the operating room. We discuss management in two cases of traversing bullet injury to the heart. In the first case, traumatic VSD was significant, requiring closure on cardiopulmonary bypass [CPB] along with repair of right and left ventricular injury. In the second case, only the repair of right and left ventricles was performed without CPB. They both had traversing bullet injury through the heart

Carotid cavernous fistula in a patient with coronary artery disease

Carotid cavernous fistulas are abnormal communications between the carotid and cavernous vasculature, with potential for serious neurological and ocular sequelae. There is considerable literature on the neuro-radiological management of carotico-cavernous fistula depending upon their flow status. The coronary artery bypass grafting [CABG] for coronary artery disease [CAD] is a well established method of revascularization. However, the association of carotid cavernous fistula in presence of CAD is an infrequent occurrence. We present a case of coronary artery disease scheduled for bypass surgery, developed spontaneous bilateral carotid cavernous fistulas, highlighting a unique aspect of association between coronary and carotid disease