Neurological complications are avoidable during CABG

Objective: To review the incidence of stroke in patients undergoing CABG and the impact of a preventive strategy adopted at tertiary care unit of cardiac surgery

Methods: The data of all patients who underwent isolated CABG [N= 722] from July 2016 to August 2017 at Faisalabad Institute of Cardiology was retrieved for this retrospective study. All operations were done on cardiopulmonary bypass and cold blood cardioplegia. Numeric data was summarized as Mean +/- Standard Deviation while categoric variables were summarized into frequency and percentage

Results: Mean age of patients was 53.83 +/- 8.8 years. Mean Parsonnet and Logistic EuroScore were 4.3 +/- 3.2 and 3.3 +/- 0.9 respectively. Forty nine patients [6.78%] had significant carotid artery disease. Mean number of grafts was 2.8 +/- 0.82. Diabetes was present in 27.8% patients. Neurological complications were noticed in 14 patients [1.94%] who included 12 permanent paralyses. Further subgroup analysis revealed that 67 patients who were operated by single clamp technique remained free of neurological complications. This is clinically remarkable finding but due to small population size it is statistically non- significant

Conclusion: The incidence of neurological complications can be reduced significantly by adopting the appropriate preventing measures. Use of Single Clamp technique may be the reasons of such a low incidence of stroke in this study

Surgical repair of post-infarction ventricular septal rupture: determinants of operative mortality and survival outcome analysis

Background and Objective: Ventricular septal rupture [VSR] is one of the fatal complications of myocardial infarction [MI]. Surgery provides the maximum survival benefit. Our objective was to investigate the risk factors of surgical mortality and to do the survival analysis in the past six years at our hospital

Methods: All the patients operated at CPE Institute of Cardiology Multan Pakistan, between 2009 and 2015 for repair of post MI VSR were analysed retrospectively for demographics, comorbidities, operative and post operative outcomes. The primary outcome was 30 days mortality. The follow up was done till April 2017 and the follow up data was obtained from hospital records and by telephoning the patients. SPSS was used for statistical analysis. P value < 0.05 was considered significant

Results: A total of 31 patients were operated for VSR repair with a mean age of 57.19 +/- 7.73 years. Eighteen patients also had a concomitant coronary artery bypass grafting [CABG]. The operative mortality in this series was 25.8% Univariate analysis showed that pre-operative ejection fraction [E.F] [p value 0.010] and cardiogenic shock [p value 0.031] were a significant risk factors for operative mortality while on logistic regression analysis only the cardiogenic shock was found to be an independent risk factor for operative mortality with the odds ratio of 2.17. Low ejection fraction only acted as a confounding variable. The mean survival at six years was 34 months with a survival rate of 28.6%. The additional CABG did not confer any survival benefit

Conclusion: The patients in cardiogenic shock pre-operatively have a high operative mortality. Low ejection fraction [E.F] acts as a confounding factor. Concomitant CABG does not confer any survival benefit

Risks and benefits of giving early aspirin within 6 hoursof CABG: a retrospective analysis

Background and Objective: Antiplatelet drugs are frequently used after coronary artery bypass graft [CABG] surgery to prevent venous graft occlusion. The fear of bleeding complications prevents them to be given early post operatively, which is the time when antiplatelets use confers maximum benefit. Our objective was to determine the effect and influence of early aspirin therapy on fatal and nonfatal bleeding complications and blood requirements after coronary bypass surgery [CABG]

Methods: The patients who only underwent coronary artery bypass surgery for the first time in the past three years and did not have any bleeding diathesis were retrospectively analyzed from the cardiac surgery database of CPEIC Multan. The patients either received aspirin within six hours of CABG or had it given after 12 hours. The patients were analyzed for mean blood loss and number of blood units transfused. SPSS was used for statistical analysis. P value < 0.05 was considered significant

Results: Total 281 patients received aspirin within six hours while 326 patients did not. Mean blood loss in early aspirin group was 727ml as compared to 767ml in the other group [p value 0.74]. The median number of blood units transfused was 2 [p value 0.98]. Our results did not show any statistical difference in both the groups

Conclusion: Aspirin can safely be given early after CABG without the fear of bleeding complications thus conferring the advantage of increased graft patency

Comparison of neurological outcomes in patients undergoing conventional coronary artery bypass grafting, on-pump beating heart coronary bypass, and off-pump coronary bypass

To study the differences in the prevalence of neurological complications following coronary artery bypass [CAB] carried out by conventional, on-pump beating and off-pump techniques. A retrospective analysis of all isolated coronary bypass operations [n=127] performed in King Fahad Cardiac Center, Riyadh over a period of one year starting from January 2005. Out of 127 patients, 73 underwent conventional CAB graft [CABG], 33 patents on-pump beating heart coronary bypass, and 21 had off pump coronary bypass grafting [OPCAB]. All patients had preoperative carotid scans and those who developed neurological complications underwent CT-brain and expert neuro-psychiatric assessment. Preoperative characteristics of patients in all 3 groups were similar. The bypass times in the conventional CABG group were significantly longer than the on-pump beating group. The maximum number of grafts was in the on-pump beating group, followed by the conventional CABG, and the least in the OPCAB group. Seven out of 73 cases in the conventional bypass group developed neurological events of various severities. Only one out of 33 patients developed acute confusional state in the on-pump beating group and no neurological events were noticed in 21 patients operated by the OPCAB technique. Low ejection fraction, preoperative congestive cardiac failure, non-elective surgery and preoperative catastrophic state were found to be significant risk factors independent of the bypass technique. This study shows no significant difference in the prevalence of neurological complications among different types of bypass surgery in our institution. There was a trend towards less neurological outcomes in the OPCAB and on-pump beating groups

Coronary artery bypass grafting on beating heart. does it provide superior myocardial preservation than conventional technique?

To compare myocardial injury caused by 3 commonly used methods for coronary artery bypass grafting [CABG]. A prospective randomized study conducted at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. The study started in February 2003 and concluded in April 2004 after including 45 patients [15 patients in each of 3 sub-groups] who fulfilled the inclusion and exclusion criteria. The subgroups included coronary artery bypass surgery performed by: a] conventional technique, b] off-pump technique, and c] on-pump beating-heart techniques. All patients had similar operative risk profiles. Their ages were 70 years or less with an ejection fraction of 30-50%. The creatine kinase, myocardial band [CKMB] levels were determined 2 hours after arrival from the operating room then, at 4 hours, 6 hours, and 12 hours. The comparison of creatine phosphokinase and CKMB levels was carried out using analysis of variance with repeated measures. The p-values were used to evaluate the significance of differences. The pre-operative characteristics including age, gender, ethnic origin, diabetes mellitus, hypertension, and left ventricular function, were similar in the 3 groups. All groups had a median number of 3 bypass grafts. The stay in the intensive care unit and the duration of inotropes were shortest in the off-pump group, but the difference was not significant. There was a peak of CKMB levels at 6 hours in all groups. The trend of CKMB level showed significantly higher values in the conventional CABG group as compared with the other 2 groups. This study indicates that the off-pump technique provides better myocardial preservation than other methods

effect of residual ventricular septal defects on early clinical outcome: Initial experience

Residual ventricular septal defect [VSD] after repair of isolated VSD or Fallot's tetrology is one of the main causes of morbidity and re-operations. In this paper we have presented the results of our initial experience regarding the management of this problem. The data consists of 71 patients [22 isolated VSD and 49 Fallot's tetrology] operated during January, 1991 to July, 1993. The incidence of residual VSD as shown by colour doppler study at the time of discharge from hospital and at three month's follow-up was 43 out of 60 patients [73%] and 12 out of 60 [20%] respectively. Six out of these 12 patients were NYHA class III-IV who underwent cardiac catheterization which revealed patch dehiscence in two patients and residual right ventricular outflow tract obstruction in four patients. The two patients, with patch dehiscence, were reoperated successfully with very good outcome. Simple colour doppler mapping tends to over-diagnose residual VSDs since it can pick up small hemodynamically insignificant leaks around stitches and needle holes which seal off in due course. The findings of colour doppler should, therefore, be correlated with actual clinical outcome in order to proceed with further investigations and re-operation

Surgical approaches to the mitral valve: a prospective comparative study of the trans-septal approach vs standard left atrial approach

Surgical exposure of the mitral valve can be achieved through various approaches depending upon various pathological features of individual case. Each of these approaches has its own merits and demerits. The criteria for selection are not well defined. The left atrial approach is standard and most commonly used approach. The next commonest approach is right atrial trans-septal approach. There is theoretical possibility of rhythm problems following tyhe trans-septal approach as it can damage the atrioventricular conduction system located in the inter-atrial-sepum. We did a comparative prospective study to evaluate the safety of trans-septal approach against the gold standard of left atrial approach. All planned mitral valve operations done between January 1991 to May 1993 were included in the study, which included 237 cases operated through left atrial and 25 through trans-septal approach. The patient characteristics and the operative procedures were similar in both groups. All patients in left atrial group were followed for four years and those in trans-septal group could not be followed beyond two years due to various reasons. The results of both groups were compared statistically. We found no statistically significant differences in post-operative characteristics between both groups. There were no conduction block or arrhythmia in trans-septal group and we therefore consider this approach as useful, safe and convenient