Atrial fibrillation and early clinical outcomes after mitral valve surgery in patients with rheumatic vs. non-rheumatic mitral stenosis

Atrial fibrillation [AF] is the most common arrhythmia after open heart surgery that can lead to early morbidity and mortality following operation. Mitral stenosis [MS] is a structural abnormality of the mitral valve apparatus that can be resulted from previous rheumatic fever or non-rheumatic fever such as congenital mitral stenosis, malignant carcinoid disease etc. This study was designed to test the hypothesis that type of mitral stenosis can affect the incidence, duration and frequency of AF post mitral valve replacement. We selected fifty patients with rheumatic mitral stenosis and 50 patients with non-rheumatic mitral stenosis who were candidates for mitral valve replacement [MVR] surgery. Pre-operative tests such as CRP, ESR, CBC, UA, ANA, APL [IgM, IgG], ANCA, RF were performed on participants' samples and the type of mitral stenosis, rheumatic or non-rheumatic, was determined clinically. Early post-operative complications such as infection, bleeding, vomiting, renal and respiratory dysfunction etc., were recorded. All patients underwent holter monitoring after being out of ICU to the time of discharge. The mean age of patients was 48.56 +/- 17.64 years. 57 cases [57%] were male, and 43 cases [43%] were female. Post-operative AF occurred in 14 cases [14%]; 3 cases [6%] in non-rheumatic mitral stenosis group, and 11 cases [22%] in the rheumatic mitral stenosis group. There was a significant relationship between the incidence of AF and type of mitral stenosis [P = 0.02]. Renal dysfunction after MVR was higher in rheumatic MS group than in non-rheumatic MS group [P = 0.026]. There was no relationship between the type of mitral stenosis [rheumatic or non-rheumatic] and early mortality after mitral valve replacement [P = 0.8]. We concluded that the type of mitral stenosis affect post-operative outcomes, especially the incidence of atrial fibrillation and some complications after mitral valve replacement

[Effectiveness of oral n-acetyl-cystein in reduction of pulmonary complications in smokers undergoing coronary artery bypass surgery]

Up to 12% of patients undergoing coronary artery bypass graft have pulmonary complications. Smoking can cause a six-time increase in pulmonary complication after major surgery. The most common pulmonary changes after CABG are decrease in FRC, VC and atelectasis. In this study, the effect of oral N-acetyl-cystein in reduction of severity of hypoxemia and atelectasis in current smokers who smoked more than 10 packs/year and had undergone CABG was evaluated. In the study, 54 current smoker patients were selected randomly and allocated to two drug and placebo groups. In the study group, 300mg N-acetyl-cystein [ACC long] containing vitamin C was prescribed two times a day from 4 days before operation up to 3 days after surgery and in control group, effervescent vitamin C tablet was prescribed as placebo. Patients with body mass index more than 35, NYHA class IV, those who needed intra aortic balloon pump and those who needed reoperation due to bleeding were excluded from the study. In all patients, spirometry was done in the preoperative visit and FEV1/FVC was determined. Induction and maintenance of anesthesia was similar in all patients. Arterial blood gas samples were obtained immediately after anesthesia induction and 4 to 6 hours after extubation. Chest X ray was taken before, 6 to 10 hours after extubation and 3 rd postoperative day. Severity of atelectasis was also measured. Quantitative and qualitative data was analyzed by ANOVA and Chi-square tests, respectively. P value <0.05 was considered as statistically significant. Both groups were similar with respect to demographic data including ejection fraction, NYHA class, FEV1/FVC, cigarette smoking and Lima harvesting. The ratio of arterial oxygen pressure to fraction of inspiratory oxygen Pao2/FIo2 was not significantly different after induction but this difference was strongly significant [P value<0.005] after extubation. Duration of mechanical ventilation was significantly shorter in patients who had N-acetyl-cystein, but duration of ICU stay was similar. Linear and segmental atelectasis was significantly less in the study group. N-acetyl-cystein can improve oxygenation and ventilatory parameters in pathological lungs, but further studies with different doses and different situations are needed

[Carotid artery sonography findings in 291 patients undergoing CABG]

Doppler ultrasonography [DUS] is the most preferable method for screening of carotid artery disease in patients undergoing CABG. The purpose of this study was to investigate the frequency of carotid artery disease and determine the relation between known risk factors of atherosclerosis and rate of carotid artery narrowing in order to identify high-risk groups among patients scheduled for isolated elective coronary artery bypass grafting [CABG] procedures. Two-hundred ninety-one patients [222 males and 69 females] undergoing isolated coronary artery bypass grafting were preoperatively evaluated by carotid artery Doppler ultrasomography and the morphology of carotid artery was determined. Age, sex, cervical bruit, diabetes mellitus [DM], hypertension, hyperlipidemia, smoking, history of cerebrovascular event [CVE] and coronary angiographic findings were investigated to define the high-risk group for carotid artery disease. Data were analyzed by SPSS software and P<0.05 was considered significant. Patients ages ranged from 35 to 95 years [mean of 57.6 +/- 10.4 years]. Eleven patients [3.8%] had history of cerebrovascular events [CVE]. 13 patients [4.5%] had cervical bruit. Left main coronary artery involvement was observed in 19 patients [6.4%]. In 127 patients [43.6%] carotid scanning was normal, fifty nine patients [20.4%] had less than 50% stenosis [mild stenosis], ninty seven patiens [33.3%] had 50-70% stenosis [moderate stenosis], and eight patiens [2.7%] had more than 75% stenosis [severe stenosis]. Calcified plaque was observed in 109 patients [37.5%]. Previous cerebral ischemic events [P=0.297], diabetes mellitus [P=0.467], hypertension [P=0.110], hyperlipidemia [P=0.08], smoking [P=0.401], age >60 years [P=0.84], female sex [P=0.730], and left main coronary disease [P=0.390] were not identified as high-risk factors for carotid artery stenosis greater than 50%. But positive MI history [P=0.025], and cervical bruit [P=0.002], were significantly related to 50% carotid artery stenosis. Based on the results of this study, we can not suggest DUS as a routine screening method in all patients undergoing CABG, except for patients with history of MI and cervical bruit. Another important finding was that 56.4% of patients posted for CABG had different degrees of carotid artery stenosis which requires a long term CVA prophylaxis program

[Intrapleural injection of bupivacaine for control of postoperative pain]

Post-operative pain is an unpleasant experience following various stimuli resulting in a response by the body. This process causes physiological disturbances in all of the systems of the body. In this clinical trial, 60 upper abdominal surgery patients were selected post operatively and divided into two groups of 30 patients each. In one group, bupivacaine intrapleural injection and in the other group, opioid injections were administered in the recovery room. Pain intensity with visual analogous scale was measured 6 hours after the operation. There was no difference in VAS according to patient's age, sex, and type of operation, but in the Bupivacaine injected group, VAS score was significantly lower. Intrapleural injection of bupivacaine is more useful and reliable than opioids for controlling post operative pain