Mitral valve repair in a rheumatic population: an experience at AFIC/ NIHD

Objective: To analyze the outcome of mitral valve repair in rheumatic heart disease

Study Design: Retrospective analytical

Place and Duration of Study: Armed forces institute of cardiology/National institute of heart diseases Rawalpindi from Jan 2011 to June 2013

Material and Methods: In this retrospective study of 28 patients [15 females]. The mean age was 20.2 +/- 11.2 years [range, 11 to 55 years]. The cause of mitral regurgitation was rheumatic in all patients, with no congenital myxomatous, infective or ischemic cases. About 68% patients were in New York Heart Association [NYHA] functional class III or IV. In all the cases posterior ring annuloplasty was done with flexible C- Shape rings with size ranging from 20 to 26 mm. Repairs included anterior leaflet repair with cusp shortening and resuspension [n=17], posterior leaflet repair with quardranguloplasty and transpositioning [n=6], commissuroplasty [n=2] and mixed anterior posterior leaflet repair [n=3]

Results: There was no operative mortality. Follow-up was carried out for 10 months. The trivial mitral regurgitation was found in 3 cases [10.7%]. Four [14.2 %] patients required mitral valve replacement due to valve dysfunction

Conclusion: Mitral valve repair in rheumatic patients, with current techniques, can effectively correct functional and hemodynamic abnormalities with satisfactory results

Skeletonization of left internal mammary artery in coronary artery bypass grafting

Objective: To compare mean per-operative flow capacity between skeletonized and pedicled left internal mammary artery [LIMA] in patients undergoing coronary artery bypass grafting [CABG] surgery

Study Design: Randomized control trial

Place and Duration of Study: Department of Cardiac Surgery, Armed Forces Institute of Cardiology and National Institute of Heart Diseases [AFIC-NIHD], Rawalpindi, Pakistan from February to August, 2013

Methodology: Patients undergoing CABG for coronary artery disease, under 80 years, excluded by the exclusion criteria; and fulfilling the inclusion criteria were randomly assigned to two groups of 70 each. One group underwent skeletonized and the other underwent pedicled technique of LIMA harvesting. Free flow was checked just before anastamosis of each LIMA to the LAD, manually in blood flow in ml per minute during cardiopulmonary bypass by allowing it to bleed into a 100 ml container over 20 seconds. A specialized proforma was used to record the age, gender, weight, disease, type of IMA used, and free flow of the IMA. Data was analyzed using SPSS 18

Results: The mean age of the patients was 57.16 years in 40 patients, ranging from 36 to 75 years. Disease pattern analysis showed 5%, 10.7% and 84.3% single, double and triple vessel coronary artery disease, respectively. There was significantly higher free flow in the skeletonized group than the pedicled group [p=0.04]

Conclusion: Skeletonized IMA had superior flow to pedicled IMA in addition to its traditional proven advantages, which justifies its further use as a conduit for myocardial revascularization

Comparison of topical use of protamine and tranexamic acid in surgical patients requiring cardio-pulmonary bypass

To determine the effectiveness of local protamine in reducing post-operative blood loss compared to loca1 tranexamic acid. Randomized controlled trial. Armed Forces Institute of Cardiology/National Institute of Heart Diseases Rawalpindi from January 2011 to September 2011. One hundred and twenty cardiac surgrcal patients were randomly divided into two equal groups, one receiving local protamine while the other group receiving local tranexamic acid before chest closure. The efficiency was measured as post-operative blood loss and requirement of blood and blood products in the post-surgical ICU. RAverage blood loss in protamine group was significantly less [252.97 ml] compared to tranexamic acie group [680.67 ml]. hTumber of patients requiring no post-operative blood transfusion was sigruficantly higher in protamine group [76.7%] compared to tranexamic acid group [53.3%]. Local protamine is more effective in reducing post-operative blood loss than local tranexamic acid

Topical application of tranexamic acid reduces postoperative bleeding in open-heart surgery: myth or fact?

To determine the efficacy of topical application of Tranexamic acid in controlling postoperative bleeding in open-heart surgery. Double blind randomized control trial. Departments of Cardiac Surgery and Intensive Care of Armed Forces Institute of Cardiology and National Institute of Heart Diseases [AFIC-NIHD], Rawalpindi, Pakistan, from May to October 2011. A total of 100 consecutive adult patients fulfilling the inclusion criteria undergoing elective on-pump cardiac surgeries were randomly divided in groups [A] and [B]. A study solution that contained 2.5 g of Tranexamic acid in 250 ml normal saline in group-A and equal amount of normal saline [placebo] in group-B was poured in the pericardial cavity over the mediastinal tissues before sternal closure. Postoperative bleeding was measured in both groups for 24 hours in the cardiac surgical ICU. Efficacy of Topical Tranexamic Acid / Placebo was measured in terms of mean postoperative bleeding in ml. Kindly again include these lines which seem to have been omitted in the final proof. There was significant difference in the mean postoperative bleeding within 24 hours among the two groups 340.1 +/- 112.4 ml in Tranexamic acid group vs. 665 +/- 187.28 ml in placebo group [p < 0.001]. Patients who did not have topical Tranexamic acid before chest closure had a significantly higher postoperative bleeding. Topical Tranexamic acid application is an effective and economical way for controlling non-surgical bleeding in patients undergoing cardiac surgery with cardiopulmonary bypass

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

Role of posterior pericardiotomy in prevention of Pericardial Effusion and Atrial Fibrillation after coronary artery bypass grafting surgery

The aim of this prospective study was to evaluate the efficacy of Posterior Pericardiotomy in decreasing the occurrence and development of Pericardial Effusion and related Atrial Fibrillation [AF] Randomized Control Trial [RCT]. Armed Forces Institute of Cardiology and National Institute of Heart Diseases Rawalpindi, from Jan 2009 to Feb 2010. This prospective randomised study was performed in the first 100 patients undergoing coronary artery bypass grafting surgery [CABG] between January 2009 and February 2010. Patients were randomized into two groups, Posterior Pericardiotomy was performed in 50 patients before releasing aortic cross clamp [Group I]; remaining other 50 patients served as the control Group [Group II]. Longitudinal incision was made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm in Group I. The difference between the two treatment groups, with regards to age, sex, number of bypass grafts, duration of cross clamp, total perfusion time and hospital stay time were not statistically significant. Atrial Fibrillation was noted in 02 [4%] patients in Group I and 12 [24%] patients in Group II [p 0.004]. Pericardial Effusion was present in 03 patients in Group I and 16 patients in Group II [p <0.001]. Atrial flutter and other supraventricular arrhythmias were not statistically significant. Posterior Pericardiotomy proved to be technically easy and efficient procedure in decreasing the occurrence and development of Pericardial Effusion and related Atrial Fibrillation [AF]

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

Induced remote ischemic pre-conditioning on ischemia reperfusion injury in patients undergoing coronary artery bypass

To determine the role of remote ischemic pre-conditioning [rIPC] on myocardium, against ischemia reperfusion injury in patients undergoing coronary artery bypass graft [CABG] surgery by measuring CKMB levels. A randomized controlled trial. The Surgical Department of Armed Forces Institute of Cardiology/National Institute of Heart Diseases, Rawalpindi, from January to June 2008. One hundred patients with double and triple vessels coronary artery disease were randomized in two groups of 50 each. rIPC protocol consisted of 3 x 5 minutes of forearm ischemia, induced by a blood pressure cuff inflated to 200 mmHg, with an intervening 5 minutes of reperfusion, during which the cuff was deflated. Patients in the control group were not subjected to limb ischemia. The protocol of induced ischemia was completed before placing patients on extracorporeal bypass circuit. At the end of surgery serum CKMB levels were measured and compared at 8, 16, 24 and 48 hours from both the groups. Written informed consent was taken from patients. Study was approved by the hospital ethical committee. Remote ischemic pre-conditioning significantly reduced CKMB levels at 8, 16, 24 and 48 hours after surgery with p-values of 0.026, 0.021, 0.052 and 0.003 respectively. There was mean reduction of 3 iu/l in CKMB levels, in patients who underwent rIPC protocol prior to CABG surgery, compared to control group. This study showed a significant reduction of enzyme marker CKMB in patients subjected to rIPC prior to CABG surgery. This suggests lesser degree of myocardial damage compared to control group in CABG patients

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

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

Off pump coronary artery surgery and intraoperative safety-experience at AFIC/NIHD, Rawalpindi

Coronary Artery Bypass Grafting [CABG] with cardiopulmonary bypass [CPB] on one hand allows controlled haemodynamics with superior graft quality while on the other hand carries inherent risks of CPB which has renewed interest in Off-pump coronary artery bypass [OPCAB]. Haemodynamic instability and intraoperative dysrythmias are major procedural complications of OPCAB, threatening conversion to emergency on-pump surgery. The purpose of this study was to compare intraoperative dysrythmias and inotropic use for haemodynamic stabilization during OPCAB surgery against conventional CABG. Consecutive CABG cases operated between 1[st] June 2003 and 31[st] May 2006 were included while conversions were excluded. Primary end points were analyzed using chi square and t test and values described in percentages, means and probability [p value]. Six hundred and eighty-four cases were divided in group-A [on-pump, n=574] and B [OPCAB, n=97]. Conversion rate was 11.8%. Intraoperative dysrythmias [A, 3.5%, B, 15%, p<0.0001] and use of inotropic support was higher in group-B [A, 15.3%, B, 30.3%, p<0.0001]. Actual mortality in group-B was higher than the predictive value [A, 3.8%, B, 3.6%, Predictive value 3-5% and 0-3% respectively]. OPCAB leads to higher frequency of dysrythmias and inotropic use intraoperatively, highlighting lower procedural safety over conventional CABG

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

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

Management of postoperative chylothorax

To evaluate treatment modalities of iatrogenic post operative chylothorax and describe our current approach this study was conducted at CMH/AFIC Rawalpindi from Aug 2001 to Aug 2003. It included the causative evaluation and management modalities. 11 patients were operated for cardiac and thoracic pathology, which resulted in chylothorax. Chylothorax was diagnosed based on clinical appearance and chemical analysis of pleural fluid. Out of 11 patients, 9 had cardiac procedures while 2 had thoracic operations. All Patients had chest intubation. 9 had drainage within 24 hours, 1 at 48 hours, and 1 after 72 hrs. Initial tube thoracostomy drainage was 1000 to 2500 ml/day. S patients responded to conservative tube thoracostomy and TPN. 2 were operated with in 48 hours with ligation of the leaking site. 4 had to undergo the supra-diaphragmatic enmass ligation via right thoracotomy