Off-pump Bidirectional Glenn shunt using clamp and sew technique

To evaluate the efficacy of performing Bidirectional Glenns [BDG] using "clamp and sew technique". Quasi-experimental study. Armed Institute of Cardiology / National Institute of Heart Diseases, Rawalpindi from 1[st] January 2011 to 31[st] December 2013. All patients subjected to BDG using clamp and sew technique during study period were included. The salient operative steps included. 1] Dissection of superior vena cava, azygous vein and pulmonary arteries 2] Clamping and division of superior vena cava at cardiac end 3] Clamping of ipsilateral branch pulmonary artery and its anastomosis to the divided superior vena cava. Observed variables included oxygen saturations and internal jugular venous pressure before, during and after the procedure, postoperative ventilation requirements, ICU stay, neuro-cognitive assessment, pleural drainage and mortality. A total of 27 patients were included. 85.2% patients had unilateral BDG while 14.8% patients had bilateral BDG. Mean internal jugular venous pressure on clamping superior vena cava was 29.21 +/- 6.13 mmHg [range 19-23 mmHg] and mean clamp time was 14.32 +/- 3.39 minutes with a range of 11-21 minutes. Mean Glenn pressure was 14.29 +/- 2.53 [range 12-18 mmHg]. Mean postoperative Oxygen saturation was 86.07 +/- 2.71% which was significantly increased as compared to preoperative oxygen saturation of 71 +/- 5.16% [p < 0.001]. Mean ICU stay was 70.45 +/- 8.94 hours [38-210 hours]. No neuro-cognitive impairment was observed and there was no 30 day in hospital mortality. Off-pump BDG with clamp and sew technique is a safe procedure in selective patients. It avoids the need for cardiopulmonary bypass and high cost associated with it

Surgical closure of ventricular septal defect - experience at Armed Forces Institute of Cardiology

To evaluate the results of surgical closure of ventricular septal defect [VSD] with special focus on immediate complications and mortality. Quasi experimental study. Pediatric cardiac surgical department of Armed Forces Institute of Cardiology / National Institute of Heart Diseases [AFIC/NIHD] from 1stJanuary 2011 to 31st Dec 2012. All patients undergoing surgical closure of VSD were included in the study. All patients underwent detailed pre-operative assessment including detailed examination, blood tests, chest x-ray, echocardiography and doppler. The surgery was performed under general anesthesia. VSD was closed using polytetrafluoroethylene [PTFE] patch with prolene interrupted sutures. Good post operative care was ensured. The patients were discharged on 7[th] post-operative day and advised follow up after one week. A total of 230 consecutive patients underwent VSD closure with male to female ratio of 2.2:1and mean age was 5.7 +/- 6.5 years. Mean height was 94.8 +/- 31.4 cms and mean weight was 15.3 +/- 12.6 kgs. Per membranous VSDs were most common accounting for 67.4% of cases. Indications for surgery were moderate to large VSDs [77.8%], associated with other congenital heart diseases [CHDs] [8.3%], coronary cusp prolapse with or without aortic regurgitation [13.5%] and infective endocarditis [0.4%]. In one case aortic valve replacement was also done for severe aortic regurgitation due to gross right coronary cusp prolapse. There were 10 [4.3%] deaths in study population and their mean age was 3.5 +/- 5.5 years. In 02[0.9%] patients, permanent pacemaker was also implanted. Open heart surgery for VSD is safe with low mortality in experienced hands

Short head-up tilt test. Evaluation of time to syncope in nitroglycerine potentiated

The aim of the present study was to evaluate the time to syncope in Nitroglycerine potentiated short Head-up tilt test. This was a descriptive cross sectional study conducted in Armed Forces Institute of cardiology from May 2006 to May, 2007. A total number of 90 patients with orthostatic intolerance both male and female were studied. Head-up tilt test protocol consisted of a Stabilization phase which lasted for five minutes Passive tilt phase: Patients were tilted at 70 [degree sign] for orthostatic stress for 15 minutes. In case of no symptoms the test continued with the drug provocation phase which lasted for 15 minutes. The patients were administered 400 micro g of nitroglycerine sublingually in aerosol preparation. Development of symptoms were noted at 5, 10 and 15 minutes. A total number of 90 patients were examined during the study period. The tilt table test was classified as positive in 58.9% of patients and was negative in 41.1%. The test was positive in five patients without the drug provocation [9.4%]. The responses were classified as positive vasodepressor in 35.8%, 15.09% as mixed and cardioinhibitory 15.09% in patients of neurally mediated syncope. The total time to display of symptoms to positivity in HUTT was 17.89 +/- 6.99. The mean time to syncope after the administration of nitroglycerine was 5.61 +/- 4.17 minutes. Our study concludes that the drug administered phase can be reduced to 12 +/- 3 minutes

Double flap patch closure of VSD with elevated pulmonary vascular resistance: an experience at AFIC/NIHD

To determine the 30 days outcome measured in terms of morbidity and mortality in cases of ventricular septal defect [VSD] with increased pulmonary vascular resistance [PVR] managed with double flap patch closure. Case series. Armed Forces Institute of Cardiology [AFIC/NIHD], Rawalpindi, from December 2005 to December 2008. Forty patients with VSD having PVR 9.58 + 4.33 wood units underwent double flap patch closure. The patch was fenestrated as one half of the expected aortic annulus diameter. A separate flap patch 5 mm larger than fenestration was attached to superior upper one third margins of fenestration. The patch was placed with flap to open towards the left ventricular apex. Modified ultra filtration [MUF] was employed in every case and sildenafil was given postoperatively. The age of patients ranged from 1 to 28 years with a mean of 6.66 + 5.70 years. There were 22 males and 18 females. All patients were weaned off from inotropic and ventilatory support as earlier as possible postoperatively with intensive care unit [ICU] stay of 77.15 + 54.56 hours. Postoperative pulmonary artery pressures were reduced to 42.63 + 10.86 mmHg as compared to pre-operative pulmonary artery pressures of 88.3 + 15.2 mmHg. Postoperatively 11 patients with suprasystemic pulmonary artery pressures and desaturation went into pulmonary hypertensive crisis in which immediate 2D echo evidenced the functioning flap valve with right to left shunt. There was only one death [early] out of 40 patients with an overall mortality of 2.5% along with limited morbidity. Double flap patch is an inexpensive, easy to construct technique with low morbidity and mortality in cases of VSD with raised PVR

Experience of Fontan surgery at Armed Forces Institute of Cardiology /National Institute of Heart Diseases [AFIC-NIHD]

To assess the overall outcome and success of Fontan surgery at our institute. AFIC-NIHD Rawalpindi. 01 September 2005 to 31 March 2010. For this retrospective study, institute's cardiac surgery database was used. Patients of single ventricle physiology, who had normal Left Ventricular End-diastolic Pressure and pulmonary artery pressures, were included. Data was analyzed using SPSS version 16. A total of 34 Fontan procedures were done. The mean age at operation was 4.83 +/- 1.37 years. There were 22 [64.7%] males and 12 [35.3%] females. Twenty five [73.5%] had a staged Fontan [successful previous Bidirectional Glenn's shunt, BDG]. Nine [26.5%] were primary Fontan procedures [no successful previous Bidirectional Glenn's shunt, BDG]. Thirty two [94.8%] were Extra Cardiac Conduit Fontan [ECCF] and 2[5.8%] were Intra Cardiac Fontan. Mean Bypass time was 132.65 +/- 48.44 minutes. Aorta was cross clamped in intracardiac Fontan and its mean time was 43.31 +/- 5.85minutes. Fenestration was employed in 14 [41.2%] patients. Mean pre-operative oxygen saturations were 77.41 +/- 10.27%, which significantly increased to 93.94 +/- 3.96% post-operatively [p<0.001]. In-hospital mortality was 2 [5.8%]. Fontan surgery has acceptable morbidity and mortality in our set up

Bidirectional Glenn shunt without cardiopulmonary bypass

To determine the efficacy of bidirectional Glenn shunt [BDG] without cardiopulmonary bypass [CPB]. Quasi experimental study. The Armed Forces Institute of Cardiology and National Institute of Heart Diseases [AFIC- NIHD], Rawalpindi. Thirty one patients underwent BDG without CPB between January 2006 to December 2007. Subjects for off pump BDG were those who did not require any intracardiac repair, had good sized branch pulmonary arteries, had acceptable PA pressures [< 16 mm Hg], and did not have any significant atrio-ventricular [AV] valve regurgitation. The off pump BDG was performed using veno-venous shunt between the superior vena cava [SVC] and right atrium [RA] following heparinization. All patients underwent discharge echocardiography to assess BDG patency. Statistical significance was determined using t-test with statistical significance at p < 0.05. There were 18 males and 13 females. All patients survived. Twenty seven [87.09%] patients received BDG and 04 patients [12.90%] received bilateral BDG. Atrial septectomy with inflow occlusion was performed in 5 patients. Antegrade pulmonary blood flow was left in 24 [77.41%] of 31 patients. There was significant improvement in postoperative SpO[2] [p = 0.000] in all the cases. There were no postoperative neurologic complications. Sepsis occurred in 2 patients who ultimately recovered. One patient had chylothorax which stopped after three [03] days in ICU. No SVC/PA distortions were noted by discharge echocardiography. Eliminating CPB reduced the cost of the procedure substantially and saved the patients from its inherent complications. BDG without CPB is a safe procedure in selected patients. It avoids CPB related problems and is cost effective, with excellent results

Effects of modified ultrafiltration on blood products requirement in children undergoing open heart surgery

To find out the effects of modified ultrafiltration on blood products requirement for transfusion in congenital heart disease children after open heart surgery.This was a quasi-experimental study between two clinical groups. Patients were assigned to both groups by using convenient sampling; to do Modified Ultrafiltration or not was surgeon's preference who was unaware whether the patient is participating in any study or not. The study was carried out at Armed Forces Institute of Cardiology/National Institute of Heart Diseases [AFIC/NIHD] Rawalpindi between August, 2005 and September, 2006. Total 200 patients were included in this study and were divided equally into two groups; study group [MUF] and control group [non MUF] keeping hundred patients in each group. Significantly increased level of hemoglobin after MUF [9.7 +/- 1.4 gm/dl before MUF versus 13.6 +/- 1.6 gm/dl after MUF, p<0.001] and significantly decreased volume of blood products required for transfusion in study group [24.1 +/- 24.5 ml/kg versus control: 43.81 +/- 42.4 ml/kg, p<0.001]. Significantly increased hemoglobin level was observed during first three days of ICU stay [12.6 +/- 1.8 g/dl versus control: 11.6 +/- 2.1 g/dl, p=0.001on first postoperative day, 11.3 +/- 1.8 g/dl versus control: 10.8 +/- 1.9 g/dl, p=0.039 on second postoperative day and 11.3 +/- 1.5 g/dl versus control: 10.5 +/- 1.8 g/dl, p=0.022 on third postoperative day]. From this study we concluded that use of MUF is well tolerated in all the patients and due to removal of extra water from patients circulation after separation from CPB resulted in hemodynamic benefits, significantly less use of blood products and better postoperative hemoglobin and hematocrit management

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

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

Intra-aortic balloon counterpulsation in the management of low cardiac output syndrome after coronary artery bypass surgery

To assess the efficacy of pharmacological management as compared to early and primary institution of Intra-aortic balloon counterpulsation in the management of low cardiac output syndrome after coronary artery surgery. Postoperative Intensive Care Unit of a tertiary care cardiac hospital. It is a retrospective study of 124 patients who developed post operative low cardiac output syndrome after coronary artery bypass surgery. These patients were treated either with multiple inotropes, plus vasodilators [GP-I, n = 65] or with single inotrope and IABP support within 02 hours after hemodynamic compromise [GP-II, n = 59]. Different hemodynamic variables were compared among both the groups by Statistical Package for Social Sciences [SPSS] Outcome studied: Mean arterial pressure [MAP], Cardiac index [CI], Pulmonary capillary wedge pressure [PCWP], Central venous pressure [CVP], Urine output and ICU stay were compared. Overall survival in both the groups was also noted. Both groups showed improvement in CI, MAP, Urine output, CVP and PCWP, however the improvement was more pronounced in GP-II which was statistically significant after 24 hours. Mean duration of IABP support and stay in ICU was less in GP-II. Survival in GP-I was 24/65 [36.9%] as compared to 34/59 [57.6%] in GP-II. Early initiation of IABP support results in better hemodynamic profile, reduced mortality, reduced ICU stay in patients developing low cardiac output syndrome after coronary artery bypass surgery as compared to pure pharmacologic support or late addition of mechanical support

Abdominal aortic aneurysm and coexisting coronary artery disease: a case report and review of literature

Patients presenting with severe and/or unstable coronary artery disease along with an acutely enlarging or very big abdominal aortic aneurysm are best managed by simultaneous myocardial revascularization and abdominal aortic repair procedures. An experience of a patient who had severe triple vessel coronary artery disease and leaking abdominal aortic aneurysm is presented here. He was managed by combined coronary artery bypass graft surgery and prosthetic replacement of abdominal aortic aneurysm. CASE REPORT The patient, an average built man of 54 years and a diagnosed case of CAD was referred for CABG in cardiac surgery out patient department on 3rd March 1998. He complained of progressively worsening effort angina for the last one year [CCS-II] with aggravation of symptoms for the last three months [CCS-III]. There were no complaints suggesting any other significant medical or surgical illness. His vital signs were within normal limits. Systemic examination was unremarkable. ECG was suggestive of old inferior infarction. Exercise tolerance test was positive for ischemia in six minutes with 2mm ST depression in anterior and lateral chest leads. Echocardiogram showed moderate left ventricular functions and 45% ejection fraction with inferio-basal hypokinesia. Angiocardiography revealed severe triple vessel disease with critical lesions in proximal left anterior descending [LAD] and circumflex [CX] artery and totally blocked right coronary artery [RCA]. Left ventricular end diastolic pressure was 18 mmHg. Patient was scheduled for CABG after three month. On 29th May patient reported with severe abdominal pain radiating to the back. Abdominal examination revealed a 4-6 cm globular pulsatile and tender swelling in the epigastric region. Patient was admitted and investigated. X-ray of the abdomen was normal. Abdominal ultrasonography revealed an infra-renal AAA with an anterio-posterior diameter of 6.2 cm, extending up to the aortic bifurcation. CT scan confirmed the presence of a 6.9-9.8 cm oblong in shape infra-renal AAA. Since patient had severe triple vessel CAD and a large AAA with clinical evidence of rapid enlargement of the aneurysm it was decided to simultaneously perform CABG and AAA replacement which was done on 6th June 1998