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

Predictive value of euroscopre in Pakistani cardiac surgical patients

To evaluate the predictive value of European System for Cardiac Operative Risk Evaluation [EuroSCORE] of early mortality in Pakistani cardiac surgical population in a single cardiac center. A prospective, single institution, observational cohort study. Department of Cardiac Surgery AFIC Rawalpindi from 1st January, 2009 to 31st December 2009. A total of 1064 consecutive adult patients undergoing cardiac surgical intervention at department of adult cardiac surgery from 1st January 2009 to 31st December 2009 were included in the study. The logistic EuroSCORE score was estimated for all the patients and compared with the observed 30 day mortality. The patients were divided into three risk groups on the basis of their EuroSCORE. The Hosmer-Lemeshow goodness-of-fit test was applied to assess the calibration of the EuroSCORE model and the area under the receiver operating characteristic [ROC] curve was measured to analyse the EuroSCORE discriminative power on individual death prediction. Expected mortality was compared to observed or actual mortality. Mortality was defined as death from any cause within 30 days of operation or within the same hospital admission. The Hosmer-Lemeshow test revealed a good calibration power [p = 0.73] and the area under the ROC curve was 0.753, suggesting a good discriminative power. The predicted mortality was similar to observed mortality in low- and moderate-risk patients but the observed mortality in high-risk patients [18.18%] was very high as compared to predicted mortality [8.14%]. EuroSCORE is a reasonably good relevant predictor of immediate post-operative mortality in low and intermediate risk groups after cardiac surgery in Pakistani population, but is less predictive for high-risk patients

Follicular dendritic cell sarcoma of the neck with pulmonary metastases

We present a case of follicular dendritic cell sarcoma in a 48 years old Saudi female who reported with slowly progressive right sided extranodal neck mass associated with pulmonary metastasis. Clinical examination, histopathologic features including distinct immunostains combine together to make the rare diagnosis of follicular dendritic cell sarcoma. This entity is often misdiagnosed due to non-consideration in differential diagnosis of sarcoma. It carries a significant potential for regional as well as distant spread and hence categorized as intermediate risk malignancy. Clinical, histopathological and immunohistochemical aspects and therapeutic options of this unusual case are discussed

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

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]

Double flap patch closure of VSD with elevated pulmonary vascular resistance: an experience at AFIC/NIHD

To determine the 30 days outcome measured in terms of morbidity and mortality in cases of ventricular septal defect [VSD] with increased pulmonary vascular resistance [PVR] managed with double flap patch closure. Case series. Armed Forces Institute of Cardiology [AFIC/NIHD], Rawalpindi, from December 2005 to December 2008. Forty patients with VSD having PVR 9.58 + 4.33 wood units underwent double flap patch closure. The patch was fenestrated as one half of the expected aortic annulus diameter. A separate flap patch 5 mm larger than fenestration was attached to superior upper one third margins of fenestration. The patch was placed with flap to open towards the left ventricular apex. Modified ultra filtration [MUF] was employed in every case and sildenafil was given postoperatively. The age of patients ranged from 1 to 28 years with a mean of 6.66 + 5.70 years. There were 22 males and 18 females. All patients were weaned off from inotropic and ventilatory support as earlier as possible postoperatively with intensive care unit [ICU] stay of 77.15 + 54.56 hours. Postoperative pulmonary artery pressures were reduced to 42.63 + 10.86 mmHg as compared to pre-operative pulmonary artery pressures of 88.3 + 15.2 mmHg. Postoperatively 11 patients with suprasystemic pulmonary artery pressures and desaturation went into pulmonary hypertensive crisis in which immediate 2D echo evidenced the functioning flap valve with right to left shunt. There was only one death [early] out of 40 patients with an overall mortality of 2.5% along with limited morbidity. Double flap patch is an inexpensive, easy to construct technique with low morbidity and mortality in cases of VSD with raised PVR

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

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

Role of neo-adjuvant chemoradiation in locally advanced rectal cancers

To determine the radiologic downstaging and histological response after neo-adjuvant concurrent chemoradiation in locally advanced rectal cancers. Case series. Radiation Oncology department of Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, from December 2004 to November 2005. Thirty patients with histopathologically confirmed locally advanced carcinoma rectum who had not received any treatment [chemotherapy, radiotherapy or surgery] prior to presentation were enrolled. Radiation therapy was delivered with a three-field technique to a dose of 50.4 Gy over 5 weeks at the rate of 1.8 Gy/day. Two cycles of chemotherapy were given synchronously, which comprised of 5-fluorouracil 350 mg/m[2] and folinic acid 20 mg/m[2] continuous intravenous infusion over first five days and last five days of radiotherapy. Surgery was planned 4-6 weeks later to chemoradiation after radiologic post therapy staging. Viable specimens were identified and toxicity was observed. All patients completed treatment without modification. Radiologic downstaging was found in 56.7%, stable disease was seen in 30.0% and progressive disease was present in 13.3% of the patients. Radiologically complete resolution of tumour was not observed. Pathological complete resolution of tumour was achieved in 3.3% and near complete resolution was observed in 13.3% of the patients. In 86.6% cases, a total gross tumour resection with no macroscopic residual disease was possible. All the patients tolerated the treatment well. Neo-adjuvant chemoradiation for locally advanced rectal cancers is associated with high resectability rate and is relatively safe with acceptable morbidity which favours its use in future

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

Bidirectional Glenn shunt without cardiopulmonary bypass

To determine the efficacy of bidirectional Glenn shunt [BDG] without cardiopulmonary bypass [CPB]. Quasi experimental study. The Armed Forces Institute of Cardiology and National Institute of Heart Diseases [AFIC- NIHD], Rawalpindi. Thirty one patients underwent BDG without CPB between January 2006 to December 2007. Subjects for off pump BDG were those who did not require any intracardiac repair, had good sized branch pulmonary arteries, had acceptable PA pressures [< 16 mm Hg], and did not have any significant atrio-ventricular [AV] valve regurgitation. The off pump BDG was performed using veno-venous shunt between the superior vena cava [SVC] and right atrium [RA] following heparinization. All patients underwent discharge echocardiography to assess BDG patency. Statistical significance was determined using t-test with statistical significance at p < 0.05. There were 18 males and 13 females. All patients survived. Twenty seven [87.09%] patients received BDG and 04 patients [12.90%] received bilateral BDG. Atrial septectomy with inflow occlusion was performed in 5 patients. Antegrade pulmonary blood flow was left in 24 [77.41%] of 31 patients. There was significant improvement in postoperative SpO[2] [p = 0.000] in all the cases. There were no postoperative neurologic complications. Sepsis occurred in 2 patients who ultimately recovered. One patient had chylothorax which stopped after three [03] days in ICU. No SVC/PA distortions were noted by discharge echocardiography. Eliminating CPB reduced the cost of the procedure substantially and saved the patients from its inherent complications. BDG without CPB is a safe procedure in selected patients. It avoids CPB related problems and is cost effective, with excellent results

Ventricular septal defect in infants and children with increased pulmonary vascular resistance and pulmonary hypertension - surgical management leaving an atrial level communication

To evaluate the surgical and medical efficacy of the patients operated for Ventricular Septal Defect [VSD] with Pulmonary Hypertension and Pulmonary Vascular Resistance [PVR]. Infants and children with elevated PVR and Pulmonary Hypertension are associated with significant mortality and morbidity after surgical closure. Circulatory assist devices and sophisticated medicines may not be available to help in the management of infants and children with elevated Pulmonary artery pressure and resistance. We left Patent Foramen Ovale [PFO] or made atrial communication to decrease the morbidity and mortality associated with the closure of large VSD in this risky group. Sixteen infants and children were operated with median age of 12 months, operated by the same surgeon [IU], from January' 2004 to December' 2005. They were with large VSD of elevated PVR [3.9+0.3] and underwent VSD closure leaving PFO or artificial ASD [5mm]. Surgical approach was through right atrium. Post operatively, all the patients were electively ventilated for 36 hours. They were given intravenous dilators [Glyceral Trinitrate + Phentolamine] and oral Sildenafil up to 1mg /Kg, six hourly. Five cases went into acute pulmonary hypertensive crisis postoperatively, and were rescued by Prostacycline Nebulization. Sixteen patients had VSD as the primary lesion that underwent operation. The overall early mortality was 6.25% [1/16]. There have been no late deaths. Closure of large VSD with elevated PVR can be performed, leaving PFO or artificial ASD, with acceptable mortality and morbidity

Role of carotid doppler in coronary artery disease

To find out the Intima media thickness [IMT] of carotid artery disease in coronary artery disease and to identify hemodynamically significant stenosis [i.e.>70%] in patients undergoing coronary artery bypass surgery. A descriptive study. The study was conduct at AFIC and MH Rawalpindi from 2003 to 2004. One hundred patients of triple, double and single vessel coronary artery disease were studied. There were 85 male and 15 female patients, ranging from 35 to 77 years. The patients were studied by Toshiba Ultrasound Machine equipped with high frequency linear transducers. In 10 patients having more that 70% ICA stenosis, conventional angiography was done. Intima-media thickness of common carotid artery was increased in 92 patients with mean value of 1.1 mm. Plaques were seen in 92 patients with commonest location at carotid bifurcation with extension into the origin of ICA. 15 patients has >70%, 10 patients > 50% stenosis and 67 patients in the range of 1-50% stenosis. 6 patients showed normal intima-media thickness with no evidence of plaque. In two patients ultrasound could not locate bifurcation of CCA. Doppler ultrasound showed 98% sensitivity in diagnosis of > 70% stenosis. Doppler ultrasound is a non-invasive imaging modality of choice in evaluation of extra-cranial carotid artery disease

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

Outcome of ventricular septal defect closure

To identify the factors affecting the outcome, measured in terms of morbidity and mortality, after primary ventricular septal defect [VSD] closure. Design: Descriptive study. Place and Duration of Study: Armed Forces Institute of Cardiology / National Institute of Heart Diseases, Rawalpindi, from January 2002 to October 2003. Subjects and Children upto the age of 5 years who had primary VSD closure were studied. Patients were divided into two groups. Group-I included survivors and group-II included non-survivors. There was no difference in the conduct of operation among the two groups. A total of 53 patients were operated of whom 47 survived. Pulmonary hypertensive crisis [p < 0.001], pulmonary infections [p < 0.001] and pleural effusions [p < 0.003] were higher in non-survivor group. Patients in non survivor group were younger [0.75 + 0.34 years vs 2.24 + 1.16 years, p = 0.01] having less body weight [4.91 + 1.56 kg vs 7.94 + 3.35, p = 0.03] and high pulmonary artery to systemic pressure ratio at the time of coming off bypass [0.63 + 0.13 vs 0.43 + 0.09, p < 0.001]. Non survivors had higher association [66.6% vs 19.1%] of additional left to right shunts [p < 0.001]. Body weight less than 5 kg along with young age, high pulmonary artery to systemic pressure ratio at the time of coming off bypass and presence of additional left to right shunt are risk factors for adverse outcome