Comparison of post-operative atelectasis in patients undergoing coronary artery bypass grafting with and without pre-operative incentive spirometry

Objective: To see the effect of pre-operative incentive spirometry on postoperative atelectasis in patients undergoing Coronary Artery Bypass Grafting

Methodology: This was a randomized prospective study. The duration of study was 05 months from 01-02-2015 to 31-06-2015. A total number of 170 patients were included in this study. In Group I, there were patients in whom incentive spirometry was done before surgery [Study group]. While in Group II patients pre-operative spirometry was not done [Control group]. There were 85 patients in each group. Data was analyzed using SPSS Version 19. Chi-square test and independent sample t-test were used for analysis of qualitative and quantitative variable respectively. P-value < 0.05 was taken as a significant difference

Results: There were 42.4% patients who have positive smoking history in group I as compared to only 24.7% smoker patients in group II [p-value 0.02]. Ventilation time was significantly less in group I patients, it was 5.49 +/- 2.28 hours versus 6.74 +/- 5.46 hours in group II patients [p-value 0.05]. Incidence of post-operative atelectasis was 14.10% in group I and 27.10% in group II patients [p-value 0.04]. So we found that pre-operative incentive spirometry results in considerable reduction in incidence of post-operative atelectasis and it also can reduce ventilation time as well

Conclusion: Pre-operative incentive spirometry helps to reduce and prevent post-operative atelectasis in patients undergoing coronary artery bypass grafting

Early outcomes of on-pump versus off-pump coronary artery bypass grafting

Objectives: To see the early post-operative outcomes of off-pump versus on-pump coronary artery bypass graft surgery

Methods: This retrospective analytical study was conducted at Ch. Pervaiz Elahi Institute of Cardiology Multan, Pakistan. Our Primary outcome variables were; necessity of inotropic support, nonfatal myocardial infarction, ICU stay, nonfatal stroke, new renal failure requiring dialysis and death within 30 days after operation. There were two groups of patients; Group-1 [On-pump group] and Group-11 [Off-pump Group]. SPSS V17 was used for data analysis. Independent sample t-test and Mann Whitney U test were used to compare quantitative Variables. Chi-square test and Fisher's exact test were used to analyze qualitative variables. P-value < 0.05 was considered significant

Results: Three hundred patients were included in this study. There were no significant difference regarding risk factors except hyper-cholestrolemia which was high in off pump group [p-value 0.05]. Angiographic and Echocardiographic characteristics e.g. preoperative ejection fraction, LV function grade and severity of CAD was same between the groups. Mortality risk scores and Priority status for surgery were also same. Regarding post-operative outcomes; Post-op CKMB Levels, need and duration of inotropic support, mechanical ventilation time and ICU stay was significantly less in Off-Pump group [p-value 0.001, <0.0001, 0.006, 0.025 and 0.001 resp.]. Peri-operative chest drainage was significantly high in On-pump CABG group [p-value 0.027]. Incidence of post-op complications was not statistically different between the groups

Conclusions: At 30 days follow-up, Incidence of myocardial infarction, necessity and duration of inotropic support, ICU stay period and peri-operative bleeding were significantly less in off-pump group. The incidence of neurologic, pulmonary and renal complications was same between the off-pump and on-pump groups

Post-operative atrial fibrillation; incidence after coronary after bypass graft surgery

Atrial fibrillation is the most common arrhythmia observed following Coronary Artery Bypass Graft surgery

Objectives: To determine the incidence of post-operative atrial fibrillation in patients undergoing coronary artery bypass grafting

Materials and Methods: Study Design: Non-randomized prospective

Setting: Cardiac Surgery Department of Multan Institute of Cardiology, Multan. Period: 20-1-2014 to 01-05-2015. A total number of four hundred and ninety [490] patients having age more than 40 years undergoing isolated coronary artery bypass graft surgery were included in the study. Data was analyzed in SPSS V20 software. Frequency and percentages were used for Atrial Fibrillation. To see the impact of AF on morbidity, patients developing AF was compared with those who do not develop Atrial Fibrillation post-operatively using independent sample t-test for quantitative variables. Chisquare test and Fischer's Exact test [whenever appropriate] was used to compare qualitative variables

Results: A total number of four hundred and ninety [490] patients were included in this study. There were more 431 males [88.0%] in this study. of the patients 71.6% were in LV Grade I before surgery. Incidence of post-operative atrial fibrillation was 13.5%. In 4.5% patients IABP was inserted due to hemodynamic instability. Ventilation time and hospital stay time was significantly higher in patients with AF postoperatively [p value 0.03 and 0.02 respectively]. But duration of inotropic support, post-op CKMB levels and IABP use were not significantly different in both groups

Conclusion: The incidence of post-operative Atrial Fibrillation is 13.5% according to this study. And these patients were associated with increased risk of morbidity

Aortic valve replacement; relation of aortic annulus measured by echocardiography and prosthesis size required

Precise determination of the size of aortic annulus is very important for the preoperative evaluation before aortic valve replacement

Objectives: to determine the preoperative prosthesis size using echocardiography in patients undergoing aortic valve replacement

Study Design: prospective observational study

Setting: Ch. Pervaiz Elahi Institute of Cardiology [CPEIC] Multan. Period: January 2013 to October 2014

Methods: [100 patients] Aortic annulus sizes were measured with TTE one week before surgery and with the help of sizer per-operatively. The data was analyzed by using SPSS V16. Quantitative variables were analyzed using mean and standard deviation and percentages were used for qualitative variables. Dependent sample t test was used to see accuracy of TTE in measuring aortic annulus size

Results: out of hundred patients, 84[84%] were male. Mean age of the patients was 33.77 +/- 13.17 years. 51% patients underwent isolated Aortic valve replacement; redo-operations were done only in 4% patients. In 96% patient's mechanical prosthesis was used and in 4% patient's boiprosthesis was used for valve replacement. We found no significant difference in Aortic annulus measured pre-operatively with the TTE [23.54 +/- 3.54] and measured per-operative with the sizer [23.96 +/- 3.36] with highly insignificant p-value 0.58.Aortic annulus size was almost same measured by these two techniques. Conclusion: Aortic annulus size measured with TTE helps to arrange the optimum size prosthesis before aortic valve replacement surgery

New modification of modified bentall procedure [a single centre experience]

Background and Objectives: Modified Bentall procedure has become a gold standard in the treatment of combined aortic root and aortic valve diseases. Bleeding is an important predictor of morbidity and mortality after the Bentall operation. Our objective was to evaluate the early outcomes of Modified Button-Bentall procedure with cuff technique for aortic root replacement surgery regarding hemostasis

Methods: A total number of 32 patients who underwent elective Bentall operation from January 2008 to December 2014 were included in the study. In 18 patients [Group I] modified Button-Bentall procedure with formation of cuff was used and in 14 patients [Group II] Modified Button technique without cuff formation was used for aortic root replacement. Data was analyzed using SPSS V16. Chi-square test, Fisher's Exact test and independent sample t-test was used to analyze Qualitative and Quantitative variables

Results: Three patients in Group II and two patients in group I was in congestive cardiac failure pre-operatively. Out of thirty two patients two patients were having Aortic root dissection one in each group. Total bypass time and cross-clamp time were significantly high in Group I. There was no significant difference regarding duration of inotropic support, ventilation time, ICU stay and hospital stay time in patients of Group I and Group II. But post-op Chest drainage was very high in Group II 1158+451.25 ml versus 488.89+168.27 ml in group I [p-value <0.0001]. There was one in hospital death in Group II

Conclusions: Formation of cuff of remnant of aorta during proximal anastomosis results in significant reduction in post-operative bleeding and was better in hospital outcomes

Mitral valve replacement on beating heart; safety an evaluation

Cardiac reperfusion injury is a well-described complication occurring after ischemia or following cardioplegic arrest. The primary aim of this study was to evaluate and compare safety of Mitral valve replacement on beating heart without using cross clamp with the conventional Mitral valve replacement. It was a retrospective observational study for study duration from 2012-2014. A total of 50 patients were randomly selected and were divided in 2 groups, 25 patients in each group. This study was conducted at the Department of Cardiovascular Surgery of Choudhry Pervaiz Elahi Institute of Cardiology, Multan. We divided the patients in two groups. All operations were carried out by team led by a consultant surgeon in our institution. Our patients had the age range from 12 to 65 years [Mean ages=32.5 years +/- 13.9000] the mostly this study included males 60%. The study included Group A and Group B [beating heart versus conventional heart surgery] both groups contained randomized controlled patients with purposeful sampling. Minimum operative time 100 minutes or maximum operative time 160 minutes [Mean 195 +/- 95.75] The P value remained non significant that P <0.001. The CPB time was 22 to 388 minutes [104.8 +/- 97.4. Cross Clamp time, ICU stay intubation time, drainage, inotrope remained almost same in both groups. With P <0.001 Outcome variables of the patients. The hazards of cardiopulmonary bypass and Cardioplegia are well known. Various studies have demonstrated decreased accumulation of extra cellular fluid, diminished lactate production and greater preservation of high energy stores when a strategy of myocardial protection simultaneous antegrade/ retrograde continous normothermic, normokalemic blood perfusion was used. These findings were the basis for using beating heart technique for mitral valve replacement, Aortic cross-clamping, Cardioplegia, and reperfusion injury leads to myocardial ischemia and is a critical issue in mitral valve surgery despite novel approaches to myocardial protection. Myocardial edema induced by the lack of myocardial contractions and impaired lymphatic flow due to Cardioplegia in the heart remaining in diastole is another cause of myocardial dysfunction. Outcomes obtained using this strategy of myocardial protection seem to compare favorably to those of historical series in which conventional myocardial protection with cardioplegic arrest were used

Sternal wound infection following CABG: a review of 1121 patients

To know incidence of sternal wound infection, microbacteria involved and associated risk factors so as practical steps should be made before hand to counter theses problems. Case series study. This study was conducted at Ch. Pervaiz Ellahi, Institute of Cardiology, Multan from 2012-2014. Microbiological testing was conducted under supervision of a consultat microbiologist attached to the hospitals performing cardiac surgery. Infections were classified as in-hospital SSIs if occurring during the hospital stay, or post-discharge. Infections were recorded as sternal or harvest site infections. Associated Potential risk factors were recorded. A proforma was filled which was approved by hospital ethical committee. Over the study period, 1121 patients had CABG. Predominantly patients were male [mostly in age range of 50-76 with median age of 63 years]. ASA score of 3 was recorded in majority of patients. The majority of patients were recorded as having an ASA score of 3 or 4, a clean wound, and antibiotic prophylaxis administered. Antibiotic prophylaxis in almost all cases.97 patients had sternal site infections, with one half of the cases detected in-hospital and the other half post-discharge. Gram-positive bacteria were detected in 56% of cases having infections. 43% had Gram-negative bacteria and fungi [e.g. Candida albicans] 1 case. The incidence of MRSA is increasing and to counter these we had to adopt methods

Prevalence of methicillin-resistant staphylococcus aureus [MRSA] in intensive care unit of CPEIC, Multan

We undertook a study to determine the prevalence of MRSA colonization on admission to our intensive care unit [ICU] and the incidence of MRSA colonization in the ICU. Case series study. This study was conducted in ICUs in Chaudhry Pervaiz Ellahi Institute of Cardiology, Multan from January 2012, to December 2012. We included 1230 patients in which 766 were CABG and remaining 464 were for some congenital heart disesase. All patients were screened within 24 hours after ICU admission. For the intact skin specimen, a single swab was used to sample 4 different sites [the axilla and groin on both sides]. Sternotomywound were sampled also. Pre-moistened swabs were used to collect nasal and skin samples. Swabs were plated on Chapman agar alone. Data were analysed by using spss 11. Descriptive analysis were done along with p value. There were 1230 admissions to the ICU during the study. MRSA was isolated from 80 [6.8%] of 1,185 admission swabs taken, from 42 [7%] of 596 admission swabs where patients had both admission and discharge swabs taken, and from the discharge swabs of 63 [11.4%] of 554 remaining patients who had negative admission swabs. This study confirmed that there is a significant rate of acquisition of MRSA in our ICU. It also raised concerns about trauma patients being at increased risk compared with other patients. We are in the process of conducting a cohort study to assess risk factors for the acquisition of MRSA among trauma patients

Early left ventricular remodeling after aortic valve replacement

Aortic valve disease is associated with eccentric or concentric left ventricular [LV] hypertrophy and changes in the LV mass. The relationship between LV mass and function and the effect of LV remodeling after aortic valve replacement [AVR], in patients with aortic valve disease needs evaluation, that is largely unknown in our population. The aim of this study was to evaluate the effect of AVR on LV remodeling, in patients with aortic valve disease. Fifty patients with aortic valve disease were studied using transthoracic echocardiography to assess LV mass before AVR and compared with early postoperative changes in the LV dimensions and function. LV mass was studied preoperatively and before discharge in 50 consecutive patients undergoing isolated aortic valve replacement. Out of fifty patients, 47[94%] were male and 03[6%] were female. Mean age of the patients was 40.42 years. 22 [44%] had isolated aortic stenosis [AS], 16 [32%] patients had isolated aortic regurgitation [AR] and 12 [24%] patients had mixed aortic valve disease [MAVD]. 02 [4%] patients died. LV mass regression was studied in all the patients. In group A, with aortic stenosis, LV regressed to 69.88 gm [mean] with maximum of 156.88 gms and minimum of 0.00 gms [SD 43.67 gms, p value=0.001]. In group B, with aortic regurgitation, LV mass regressed to 203.96 gms [mean] with maximum 453.79 gms and minimum of 45.65 gms [SD 95.33, p value=<0.001]. In group C, with mixed aortic valve disease, postoperatively LV mass regressed to 122.94 gms [mean] with minimum 9.57 and maximum of 224.75 gms [SD 69.53, p value=0.524]. There was significant early LV mass regression after aortic valve replacement in patients with pre existing aortic valve disease. However, it was noticed that LV mass regressed in all patients except no significant changes in LV wall thickness [hypertrophy]