An Observational Study of Patients with Significant Coronary Artery Disease after Acute Coronary Syndrome on Medical Management

Introduction: Surgery is accepted as a traditional and standardtreatment of significant coronary artery stenosis with historyof an episode of acute coronary syndrome. This study involvesprognostically important descriptors to identify the factorsleading to functional improvement on medical managementin these patients who were at potential risk of majorcardiovascular and cerebrovascular events (MACCE). Thisongoing study attempted to find out whether the improvementof functional status are due to antianginal effect or more thanthat reversely remodelling coronary atherosclerosis.Material and methods: Between1st January 2016 and 31stJuly2017, the detailed investigations of 29 such patients wereobtained, who were on waiting list for CABG after beingreferred from cardiology department, many with history ofAMI. The improvement or deterioration of their functionalstatus while on treatment with guideline directed optimalmedical therapy (OMT) with atorvastatin (40 to 80 mg),aspirin(75mg) and clopidogrel (75mg), metoprolol succinate(12.5 to 50mg) with amlodipine (2.5 to 20mg), ramipril (1.25to 10mg) or telmesartan (20 to 80mg) for hypertension andheart failure prescribed at the discretion of the physicianalong with medications for diabetes and hypothyroidism, wereanalysed.Results: The first year follow-up was for the 29 patientsrecruited over 6 months. 17 patients with CCSA class III and1 with II had a baseline SYNTAX score of 29±6.2, while 11with class II had 20.3±3.2. The functional class improvedwith OMT medications was noted to be improving after 3 to 4weeks and by 12 months 62% were in class I. Duke ActivityStatus Index (DASI), improved from 19.3±3 to 23±2 at 6months and to 30.8±2 by 1 year in 18 patients. The associatedperipheral vascular disease symptoms also improved Mortalitywas 6.7%.Conclusion: In clinically stabilized patients with severe CAD,after ACS, with or without myocardial infarction, conservativemanagement with OMT, has been observed to improve cardiacfunction with reduced odds of mortality and improved qualityof life with lifestyle modification, some dietary and physicalrestriction.

​A Comparative Study of Changes in Left Ventricular Function after Mitral Valve Replacement in Patients with Severe Rheumatic Mitral Regurgitation with and without Mild Mitral Stenosis

Introduction: Presently off- pump CABG has proved itself tobe a safe, cheaper and effective alternative of on- pump CABG.However, it requires manipulation, displacement, positioning& mechanical stabilization of the heart during grafting whichmay cause haemodynamic alteration. Study was done withthe objective of finding out the changes in Central VenousPressure (CVP); Mean Arterial Pressure (MAP); MeanPulmonary Arterial Pressure (MPAP); Right Ventricular EndDiastolic Pressure (RVEDP) & Left Ventricular End DiastolicPressure (LVEDP) while grafting the anterior, lateral &inferior surfaces of heart during off-pump CABG.Material and methods: Over one year time, 50 patients withLVEF ≥40%, undergoing off-pump CABG were monitoredfor the above parameters at various stages of their operation,namely:- 1. During manipulation & shunt introduction,2.During anastomosis without shunt, 3.During anastomosiswith shunt & 4.After anastomosis; while grafting the anterior,lateral & inferior surfaces of heart. These results werecompared with the baseline values of CVP, MAP, MPAP,RVEDP & LVEDP, to look for statistical significance.Results: During manipulation & shunt introduction; CVP(mmHg) significantly increased during Ramus grafting - 12±1.8(p<0.047); and also during OM grafting – 12.6±1.9 (p<0.045),when compared to a baseline value of 9±1.8. The MAP(mmHg) was significantly decreased during manipulation &shunt introduction in Diagonals - 70±5.8 (p<0.046), Ramus- 70±5.8 (p<0.048), OMs - 65±5.8 (p<0.028) & in the Rightterritory - 69±5.9 (p<0.032); as compared with baselineMAP of 76±11.7. During anastomosis without shunt also, theMAP(mmHg) significantly decreased while grafting LAD- 70±3.8 (p<0.048), Diagonals - 68±3.8 (p<0.039), OMs –71.8±4.8 (p<0.039) & Right sided arteries 70.8±4.6 (p<0.039),as compared with baseline MAP values. The MPAP(mmHg)was significantly increased – 18.3±3.7 (p<0.047) as comparedto the baseline value of 16±2.4 during manipulation & shuntintroduction in the OMs.Conclusion: During OPCABG there will be significantalterations in haemodynamics mostly due to mobilizationof the heart, which is necessary to visualise the targetvessels properly & stabilisation of the concerned areawith stabiliser. However, by observing the haemodynamicvariations constantly & by making necessary mechanical &pharmacological adjustments, unnecessary conversion to Onpump technique can be avoided.

Cystectomy With or Without Capitonnage: Analysis of Outcome of 73 Cases in the Management of Hydatid Cyst of Lung

Introduction: Sporadic cases of lung hydatid cyst is commonin India apart from its endemicity in Mediterranean regionsand other rural areas of developing countries. The patients ofHydatid cyst (HC) of lungs are often diagnosed incidentally.The definitive treatment of such lesions is surgery. Lungpreserving surgery in such cases is generally the preferredtechnique unless there is considerable destruction ofpulmonary parenchyma. Cystotomy and capitonnage arethe two preferred techniques and generally followed. In thisretrospective observational study it was attempted to analyzeoutcomes of cystotomy and capitonnage with regard topostoperative morbidity and mortality.Material and Methods: Between 1st May 2014 and 31stMay 2019, a total of 73 patients with lung Hydatid cyst wererandomly selected from all the hydatid cyst cases operated in atertiary centre and the results and outcome analyzed. Out of 73cases 39 (Group A) were operated by Cystotomy and closureof bronchial opening and 34 (Group B) were operated withCystotomy, closure of bronchial opening and Capitonnage.Results: The mean chest tube removal time for Group A andB was 5.94 ± 3.17 and 3.41 ± 2.61 days respectively. Themean hospital stay was 10.02 ± 4.53 days for group A and7.55 ± 2.66 days for group B. Prolonged air leak (>7days)was found in 15 patients in group A, 14 of which requiredprolonged chest tube drainage and 1 required surgical closure.4 patients in group B had prolonged air leak and all closedwith prolonged chest tube drainage. No abscess formation ormortality was observed in any group in this study. There wasa significant difference between group A and group B withregard to chest tube removal time (P=0.000836), hospital stay(P = 0.047585), and all complications (P= 0.008214).Conclusion: In surgical management of pulmonary Hydatidcyst, capitonnage is superior to cystotomy without capitonnagebecause it reduces morbidity and hospital stay.

Analysis of Surgical Resection and Prognostic Factors of Primary Chest Wall Chondrosarcomas

Introduction: Primary chest wall tumours are very rare.Chondrosarcoma represents 40% of all chest wall tumours.Wide local excision with tumour free margins has been thegold standard therapy. We evaluated this therapy in relationto various prognostic factors for anticipating the recurrenceof the tumour.Material and methods: 22 cases of Primary chest wallchondrosarcoma was operated upon from 2009 to 2019 withwide local excision with adequate margins. Male constituted77.27% and females 22.73% with the tumour size rangingfrom 5 to 30 cm in size(median 7cm).Results: 19 patients were subjected to lateral chest wallresection. 3 cases underwent partial sternectomies. Resectionwas extended to lungs in 7 cases, diaphragm in 2 cases,vertebral body in 2 cases and clavicle in 2 cases. Reconstructionwas done with polypropylene or titanium mesh and a muscleflap coverage. There was no perioperative mortality. Postoperative complications occurred in 13.6%(n=3). Therewas recurrence in 4 cases within 5 years. 5year disease freesurvival rate was 81.81%.Conclusions: Wide local excision with tumours free marginsstill remains the standard form of therapy. The reconstructiveprocedures have evolved largely to cover the huge defectsfollowing surgery. Post operative adjuvant therapy is guidedby various prognostic factors.

Surgical Treatment of Cardiac Tumors: A Single Institutional Experience Over 12 Years

Introduction: Tumors of the heart represent an exceedinglyrare entity in cardiac surgery and literature regardingmanagement and outcome is less in comparison to other fieldsof cardiac surgery. 12 years of our experience in both diagnosisand optimal surgical treatment of this small but rare collectionof patients was formed into a detailed analysis of patientprognosis, mean survival and risk of tumor relapse matchedto the corresponding pathology. The overall objective of thepresent study was a thorough characterization of both primarycardiac tumor or tumor like mass and secondary malignanttumor mass in cardiac chambers, their nature as well as ageand gender distribution and management.Material and methods: 17 patients with cardiac tumors,who underwent open-heart surgery at Medical College andHospitals, Kolkata, for tumor excision between 2007 and2019 were analyzed retrospectively. Mean follow-up wasfrom 11 to 1 years.Results: There were 2 males and 15 female patients rangingin age from 7 years to 60 years, median age being 47 years.12 of these tumors were primary left atrial myxoma, 2 wereright atrial myxoma, 1 was right ventricular fibroma, 1 wasintravenous extension into right atrium of renal cell carcinomaand 1 was multiple inflammatory pseudo tumors in leftventricle. Overall operative survival was 88.3%. Operativemortality was 11.7%.Conclusion: Cardiac tumors remain challenging in theclinical setting. Early operation is recommended afterechocardiographic diagnosis as such patients can have suddendeath or severe cardiac failure during preoperative waitingperiod. Follow up should be maintained based upon thehistopathological diagnosis.

A Retrospective Comparative Study of Del Nido Versus Intermittent St Thomas Hospital Blood Cardioplegia Solutions in Aortic-Mitral Double Valve Replacement

Introduction: It is not uncommon in patients, havingrheumatic mitral and aortic valve disease, to undergo mitralvalve replacement with aortic valve replacement that is,double valve replacement (DVR) operation who oftenhave severe cardiac dysfunction optimized with medicalmanagement before surgery. In this retrospective studywe investigated 60 such patients, who underwent DVRoperation with either conventional cold blood cardioplegiawith St Thomas 2 solution (STH), or del Nido cardioplegia(DN) over five years and compared the effects of the twotypes of cardioplegia during perioperative and postoperativeperiod with simultaneous comparative study betweenchanges of cardiac performances in the patients with largerleft ventricle as compared to those with less enlargedones.Material and methods: For this retrospective study, the dataof 60 patients of DVR over five years, in Medical College,Kolkata, India, were retrieved for study. The cases wereplaced into 2 groups: STH and DN according to cardioplegiaused during DVR. Demographic, echocardiographic, andseveral perioperative and postoperative data of the two groupsof patients, were collected. Differences between perioperativebehaviour between STH and DN groups and post operativechanges in the echocardiographic parameters betweenpredominantly mitral stenosis (MS) and mitral regurgitation(MR) patients, were analyzed.Results: The aortic cross clamp (CC) and cardiopulmonarybypass (CPB) time in both predominant MS and MR patientswas shorter in the DN than the STH groups. There was lessarrhythmia, less inotropic and ventilator support in the DNgroup. There was 10% mortality in the series with majoritybeing in the STH and MR predominant patients. Postoperativeimprovement of LVEF, reduction of LVIDS and LVIDDwere also observed in MS predominant in comparison toMR predominant patients after DVR in both STH and DNgroups.Conclusion: Use of DN has been found to have a betteroutcome and survival when compared to STH cardioplegiasolution. DVR could reversely remodel depressed heartswith relatively smaller LV volume and restore LV functionof relatively smaller LV of predominant MS patients betterin comparison to MR predominant patients with relativelydilated hearts.

Outcome Analysis After Surgical Management of Ventricular Septal Defect Complicating Acute Myocardial Infarction

Introduction: Surgical approaches to closure of postmyocardial infarction ventricular septal defect (PIVSD) areassociated with high morbidity and mortality. Timing ofintervention for its closure remains controversial. Severalstudies advocate early operative intervention, after diagnosisof PIVSD but these are associated with high mortality.However, the strategy of delayed closure around 14 to20 days or higher has been advocated in certain subsets ofpatients who can be stabilized from cardiogenic shock (CS)with pharmacological means with or without temporarymechanical circulatory support (tMCS). This helps to allowtissue fibrosis around PIVSD which increases the chance ofoperative success. Results of 5 such patients in whom surgerywas moderately delayed, and 2 in whom early operation wereperformed are reported in this paper.Material and methods: Between May 2012 to April 2016,7 consecutive patients of PIVSD had operative closure undercardio pulmonary bypass in our hospital. 5 patients had diureticand inotrope responsive CS and had delayed closure of PIVSDwithin 12 to 20 days, while 2 with severe CS, who weresupported preoperatively with tMCS like intra aortic balloonpump (IABP), had early closure within 72 hours. Patient dataof these seven subjects were retrospectively collected, and thecurrent status of the survivors was ascertained by out patientfollow up.Results: 4 of 5 patients from delayed surgery group withsmall PIVSD survived while 1 patient had early mortalitydue to severe right ventricular dysfunction post operativelyresulting in LCOS. 1 patient out of the 2 early surgery groupwith a large PIVSD survived while the other patient with asmall PIVSD and an extensive MI had early post operativemortality. 1 had from late surgery group had delayed mortalityafter 3 years. 4 patients are living at present.Conclusion: We advocate delayed elective repair of PIVSD,in patients with CS who responded to aggressive conservativemanagement maintaining hemodynamic stability, to allowinflammatory state to subside. In those patients with severeCS, additional rescue therapy with temporary mechanicalcirculatory support is needed to prevent further deteriorationof systemic perfusion. If the severe CS is due to high left toright shunt rather than infarct size, prognosis after repair ofPIVSD is better than in patients with CS due to extensivemyocardial damage.

Evaluation of Outcome of Non-cemented Total Hip Arthroplasty in Avascular Necrosis of Femoral Head in 25 to 40 Years Age Group

Background: The proper treatment of Avascular Necrosis(AVN) of Femoral Head has become a major challengeworldwide in younger age group as they are main effectiveforce of family and society. The patients who are young andsuffer from AVN of femoral head become immovable, worklessand unproductive. Thus they become burden to family andsociety. The Hip Replacement is a better way of treatment forthis type of patients, making them pain free and movable andimproving their everyday activity.Objective: To evaluate outcome of non-cemented total hiparthroplasty in avascular necrosis of femoral head among theactive younger age group of patients.Method: This was a prospective observational study of 30patients and all the patients had done non-cemented total hiparthroplasty (THA) through lateral approach at the NationalInstitute of Traumatology and Orthopaedic Rehabilitation(NITOR), Dhaka.Results: Mean age of the patients was 32 ±5.12 years,patients were diagnosed as Avascular Necrosis of FemoralHead in which 63% were affected at Right sided Hip 37%patients were at Left sided hip. Final outcome after six monthsof operation evaluated with Modified Harris Hip Score revealedthat, there was significant (p<0.005) improvement in functionalability of the patients after THA. Among the 30 studied cases,21 (70%) patients carried slight pain and 63.4% of them wereable to walk unlimitedly. Outcome of supporting functionanalysis indicated 76.7% patients could walk and climb stairswithout support and 100% patients could sit on chair, 66.7%patients among them could walk without limping. On clinicalassessment of deformity, range of motion before and afteroperation, significantly resolved the deformities and increasedthe range of motion (2100-2300). After evaluation with ModifiedHarris Hip Score showed that 60% excellent (HHS 90-100),30% good (HHS 80-89), 10% had fair (HHS 90-100) outcome.Conclusion: The progressive study of the patients of THAshowed that non-cemented THA has resulted in a better wayamong the younger age group of people

Diabetic foot infections and their management in a tertiary care hospital

Diabetic foot is a common complication of diabetes world over. We conducted this study to determine common microbiological pathogens in Diabetic Foot Infections [DFI] at a tertiary care hospital and their management. In this observational study deep wound swabs of all admitted diabetic patients were taken, pathogens isolated, antibiotic used and its response depending on complete resolution of symptoms and biochemical markers were recorded. Data were analysed on SPSS-11. A total of 114 cases were recorded. Sixty-eight [59%] cases had ulcers on forefoot, 28 [25%] mid-foot and 18 [16%] hind-foot. One hundred and four pathogens were isolated from wound swabs after debridement. Commonest pathogen isolated was Staphylococcus aureus [52, 46%] followed by E. coli [11, 10%], MRSA was found in 10 [9%] cases, streptococcus in 6 [5%] and pseudomonas in 5 [4%] cases. Polymicrobial infection was also seen in a few cases. Surgical intervention included superficial debridement in 88 [77%] cases, toe amputation/forefoot amputation in 19 [17%] cases, and below/above knee [major] amputation in 7 [6%] cases. Commonest antibiotic used was Cefoperazone/Sulbactam in 43 [38%] cases, alone or in combination, followed by Ceftraixone 36 [33%] cases. Linezolid was used for MRSA. Ninety-four [82%] patients responded to treatment and were recorded as 'cured'. Diabetic Foot ulcers often present with serious foot infections. Commonest pathogens are Staph. aureus, E. coli, Pseudomonas spp. and MRSA. Treatment was effective with Cefoperazone/Sulbactam and Ceftraixone. MRSA was treated successfully with Linezolid

Awareness diabetic retinopathy amongst known diabetics

To study awareness regarding Diabetic Retinopathy [DR] amongst established diabetics. This cross-sectional observational study was done at Department of Diabetes and Endocrinology, Hayatabad Medical Complex Peshawar, Pakistan with technical support from Hyber Institute of Ophthalmic Medical Sciences, Peshawar. Two hundred and two indoor patients were interviewed and duration of diabetes, drugs taken for the control of diabetes, history of any previous eye examination was recorded. Later dilated fundoscopy was done by endocrinologist and finally all the patients were sent for independent assessment by an ophthalmologist for categorizing DR and if needed laser was done for the affected eyes. Of 202 patients only 9 [4%] patients had optimum diabetic control with HbA[1]C of <7. Ninety four [47%] had previous eye examination while 18 [53%] had never had their eyes examined. Of those examined 77 [81.9%] had been seen by ophthalmologist, 13 [13.8%] by physician/endocrinologist and only 4[4.3%] by general practitioners [G.Ps]. Dilated fundoscopy showed 118[58%] patients had retinopathy. Thirty eight [18.8%] patients were offered laser treatment after appropriate investigations. Screening and awareness of DR amongst patients is particularly low in our setup. We need to increase awareness amongst our patients regarding this complication of diabetes

Trial of scar in patients with previous one caesarean section

To assess the usefulness of trial of scar in patients with previous one cesarean section and to know the frequency of vaginal delivery and repeat caesarean section [CS] in these patients. This descriptive study was conducted from July 2001 to June 2002, at Khyber Teaching Hospital Peshawar on 50 pregnant women with a history of previous one cesarean section and with no contraindication for vaginal delivery. Patients with more than one CS and those with medical disorders were excluded. A detailed history and examination of each patient was done. The clinical data was recorded in proformas and the results were tabulated. Among 50 pregnant women with previous one CS, 36 [72%] patients were successfully delivered vaginally while 14 [28%] had emergency lower segment CS. Out of 36 vaginal deliveries, 27[75%] were normal vaginal deliveries while 9 [25%] were delivered with instrumental support i.e. 7[19.4%] with outlet forceps and 2[5.6%] by vacuum extraction. One patient [2%] developed scar dehiscence and lost her baby which resulted in one still birth [2%] in this study. One [2%] patient with imminent rupture underwent timely CS and baby was saved. A trial of scar may be given to all pregnant women with previous cesarean section except those with absolute contraindications. A woman with one previous cesarean section delivery with a low transverse incision should be counseled and encouraged to attempt labor in her current pregnancy