Early results of combined coronary artery by-pass grafting and valve replacement

In the era of continously evolving cardiac interventions, the profile of patients referred for coronary artery bypass grafting [CABG] is changing to include older patients with concomitant diseases and co-morbidities. Studies on the results of a specific type of valve pathology operation in combination with CABG are few. This study conducted on 29 consecutive patients who underwent combined CABG and valve operations between January 2002 and December 2006. Follow-up for survival and events continued six months after discharge. All patients underwent cardiac catheterization within 3 months before operation Patients age ranged from 30-72 years, with a mean of 56.3 +/- 9.64 years, of these patients, 21 patients [72.4%] were males, whereas 8 patients [27.6%] were females. They underwent a combination of CABG with either isolated aortic valve replacement [n - 16], isolated mitral valve replacement [n = 9], or double valve replacement [n = 4]. LAD was grafted in 23 patients, RCA was grafted in twelve patients, OM was grafted in ten patients and saphenous vein was used to graft the diagonal branch of the LAD in two patients. It was found that sex, age, the duration of aortic cross clamping, and arrythmias specially atrial fibrillation and heart block are important determinants of early post-operative events suggesting restriction of the number of distal anastomosis to shorten the aortic cross-clamp

Early use of clopidogrel after coronary artery by-pass grafting

A better preserved hemostasis increases the risk of thrombosis, which is of particular importance for the patency of coronary anastomosis. Thromboembolic complications seem to be more frequent following off-pump coronary artery by-pass [OP CAB] than after conventional coronary Artery by-pass grafting [CABG], it is not known whether the conventional antiplatelet treatment, as established for on-pump procedures, is optimal for OPCAB-patients. Clopidogrel is a potent platelet aggregation inhibitor, that has gained widespread acceptance for the treatment of acute coronary syndromes and as an adjunct to percutaneous coronary intervention. Is to detect safety and efficacy of administration of clopidogrel early post-operative. Seventy five patients who underwent primary isolated CABG in Alexandria Forty two patients received dopidogrel after OPCAB or conventional on pump coronary artery bypass grafting according to surgeon's decision. The rest of patients didn't receive dopidogrel. Patients were divided into two groups, dopidogrel group [42 patients 56%] had received dopidogrel post-operatively, the no-clopidogrel group [33patients 44%] didn't receive dopidogrel. Post-operative bleeding, chest tube drainage, blood transfusion was detected. In the dopidogrel group, 38 patients [90.5%] received blood transfusions, and the mean number of packed red blood cells transfused during hospitalization was 3.8 +/- 2.2 units. In the second group, 29 patients [87.8%] received blood transfusions, and the mean number of packed red blood cells transfused was 3.5 +/- 2.6 units. No significant differences were noted in the development of early postoperative [within 30 days] pleural effusions requiring thoracentesis. This study documents the safety of early dopidogrel administration after coronary revascularization when administered according to a defined postoperative protocol. Major gastrointestinal bleeding is considered of most frequent risk and needs to be considered

Surgery of double aortic arch: a new modality for diagnosis [multislice CT angiography]

The vascular rings are defined as congenital anomalies of the aortic arch in which the trachea and oesophagus are surrounded completely or partially by vascular structures that cause respiratory or feeding problems. Double Aortic Arch [DAA] is the most common clinically recognized form of vascular rings and constitutes about 40% of vascular ring anomalies. Is to detect different methods of diagnosis of double aortic arch [DAA] and mode of treatment. Retrospective analysis of 13 infants with DAA was done where clinical presentation, investigations, surgical approach, and early postoperative outcome was studied and analysed. Thirteen patients presented to us with documented diagnosis of double aortic arch as a sub-entity of vascular ring [9 females and 4 males]. All patients presented with respiratory problems mainly dyspnea while dysphagia was encountered only in 9 patients. Age ranged from 4-7 months. Chest radiography was performed for all infants and denoted tracheal narrowing only in 9 patients, while multi slice CT was the gold standard tool for diagnosis of the DAA. Surgical outcome was favourable with postoperative hospital stay ranged from 4-12 days. We encountered only one post-operative mortality. DAA should be suspected in any infant presented with dyspnea or dysphagia. Early investigation is valuable for prevention of morbidity and mortality. Surgical repair of DAA is of favourable outcome

Renewing of Ravitch approach for repair of pectus excavatum deformity: Surgical and anesthetic implications

Pectus excavatum is the most common chest wall deformity referred for surgical correction. As a congenital lesion, it is a highly visible anomaly and is easily diagnosed. Its anatomic severity can be readily assessed by visual measurement. Repair is undertaken to alleviate symptoms of pain, cardiac or respiratory compromise, as well as to diminish significant psychosocial consequences to a child or adolescent. Was to study results of renewing the standard surgical approach to the pectus repair based on the technique described by Ravitch. Several technical modifications in the operative procedure and perioperative management strategy were added. Two post-operative pain management techniques were used following the Ravitch repair of pectus excavatum: continuous intravenous opioid analgesia, and thoracic epidural analgesia using opioid and local anesthetic combination. This study included 15 patients [nine females 60% and six males 40%], their ages ranged from 8-13 years old with a mean of 10.6 +/- 2.7 subjected to pectus excavatum repair in the cardio-thoracic surgery department between 2001 and 2006. A limited transverse submamary skin incision with generous subcutaneous flap over the muscle fascia. Three to four sets of costal cartilages were removed to get optimal remodeling. The xiphoid process was detached from the sternum. An anterior wedge osteotomy was done using the redo sternal saw leaving the posterior table intact. Final stabilization was done using Kirshner wires mounted on drill, passing transversely under the lower segment of the sternum. Asymmetry can be easily dealt with by adjusting the angle of the osteotomy. Thoracic epidural catheter was routinely placed preoperatively by the anesthesiologist at the most appropriate level between T3 and T8, after induction of general anesthesia. No operative mortality or significant infra-operative morbidities were reported. Blood loss was minimal. Two children developed ileus. One patient had a wound infection that required incision and drainage. Seromas developed after discharge in two patients. All patients had extubated before leaving the operating room and were sent to the thoracic surgery ward after leaving the recovery room. Both regimens provided effective analgesia. A low morbidity with excellent short- and long-term results combined with a high level of patient satisfaction were achieved and should be the standard against which the Nuss procedure is compared. Indwelling epidural catheters placed at the time of surgery lead to smooth postoperative course. This strategy has greatly reduced the amount of narcotics required and allowed for more rapid mobilization