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 post-operative atelectasis in patients undergoing coronary artery bypass grafting with and without pre-operative incentive spirometry

Objective: To see the effect of pre-operative incentive spirometry on postoperative atelectasis in patients undergoing Coronary Artery Bypass Grafting

Methodology: This was a randomized prospective study. The duration of study was 05 months from 01-02-2015 to 31-06-2015. A total number of 170 patients were included in this study. In Group I, there were patients in whom incentive spirometry was done before surgery [Study group]. While in Group II patients pre-operative spirometry was not done [Control group]. There were 85 patients in each group. Data was analyzed using SPSS Version 19. Chi-square test and independent sample t-test were used for analysis of qualitative and quantitative variable respectively. P-value < 0.05 was taken as a significant difference

Results: There were 42.4% patients who have positive smoking history in group I as compared to only 24.7% smoker patients in group II [p-value 0.02]. Ventilation time was significantly less in group I patients, it was 5.49 +/- 2.28 hours versus 6.74 +/- 5.46 hours in group II patients [p-value 0.05]. Incidence of post-operative atelectasis was 14.10% in group I and 27.10% in group II patients [p-value 0.04]. So we found that pre-operative incentive spirometry results in considerable reduction in incidence of post-operative atelectasis and it also can reduce ventilation time as well

Conclusion: Pre-operative incentive spirometry helps to reduce and prevent post-operative atelectasis in patients undergoing coronary artery bypass grafting

Analytical solution of orthogonal flow impinging on a wall with suction or blowing

In this paper, we have studied the effect of suction and injection on flow and shear stress in case of orthogonal flow. The emerging non-linear differential equation doesn't contain any small or large parameter called the perturbation quantity. Therefore, to solve the non-linear equation we have used the homotopy analysis method [HAM] to obtain the explicit analytic solution of the emerging non-linear equation. The comparison of numerical results with HAM results is also presented. It is noted that the behavior of the HAM solution for velocity profile and skin friction parameter is in good agreement with the numerical solution. It is also noted that the region of convergence can be increased by a better choice of the auxiliary linear operator

Total arterial myocardial revascularization: analysis of initial experience

Total arterial myocardial revascularization is an attempt to overcome the problems of late vein graft atherosclerosis, occlusion and need for coronary re-operations. Despite increasing evidence of efficacy, the use of arterial conduits has not been accepted as a primary practice in most of the centers in Pakistan for various reasons. We analyze our initial experience to assess the feasibility of total arterial revascularization as a primary strategy in patients requiring first time coronary artery bypass grafting. METHODS: Two hundred patients undergoing first time CABG at our institution, from January 2000 to April 2001, were studied. Group 1 consisted of 100 patients undergoing total arterial revascularization [using bilateral internal thoracic and radial arteries] and Group 2 consisted of 100 patients undergoing conventional CABG [using one internal thoracic artery and supplemental veins]. Thirty-day mortality and early morbidity with particular reference to resternotomy for bleeding, cerebrovascular accidents, renal failure, and sternal dehiscence were the main outcome measures. Patients in Group 1 were younger [56.2 +/- 10.4 vs. 60.3 +/- 9.8 years; P<0.001], had lower Parsonnet scores [4.8 +/- 0.4 vs. 9.6 +/- 1.8; P<0.001], and had better left ventricular function. Both groups received a similar number of grafts. The percentage of patients undergoing total arterial revascularization rose from 20% in the first three months to over 65% in the three later three-month periods. Overall 30-day mortality was 1.5%, one patient [1%] in Group 1 and two patients [2%] in Group 2. There was a similar incidence of postoperative complications and length of median postoperative stay in both groups. Total arterial revascularization can be adopted as a primary strategy in most patients undergoing CABG with no increase in mortality or morbidity

Emergency off-pump coronary artery surgery / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Off-pump coronary artery bypass grafting is fast-becoming a procedure of choice for elective revascularization in high-risk patients with multi-vessel coronary artery disease. However, the role of off-pump coronary artery bypass grafting for patients with acute coronary syndromes requiring emergency revascularization still requires validation. We present our experience to show the feasibility of off-pump coronary artery surgery as an emergency revascularization technique.</p><p><b>METHODS</b>From April 2001 to September 2003, emergency (operation within 24 hours after hospitalization) coronary artery bypass grafting without cardiopulmonary bypass (CPB) was performed in 66 patients with a mean age of (66.9 +/- 5.4) years (range 49-72 years). They presented acute coronary syndromes with 38 patients on platelet glycoprotein IIb/IIIa receptor antagonists. All patients underwent off-pump coronary artery bypass surgery via sternotomy with the intention of complete coronary revascularization.</p><p><b>RESULTS</b>An average of 2.9 grafts per patient were performed and the posterior descending artery and marginal branches of the circumflex artery were grafted in 83.3% of the patients. There were 4 events of intraoperative cardiac instability, precipitated by occlusion of right coronary artery or positioning of a cardiomegaly heart, leading to immediate conversion to CPB. The mortality rate was 3% (2/66). Two patients suffered postoperative stroke while three needed hemofiltration for acute renal failure. Post surgery elective coronary angiography (n = 46) showed no significant stenosis.</p><p><b>CONCLUSION</b>Emergency off-pump coronary artery surgery with complete revascularization is feasible in patients with acute coronary syndrome with low morbidity and mortality and excellent early results.</p>

Myocardial preservation with intermittent aortic cross-clamping technique during coronary artery bypass grafting

To evaluate the safety and efficacy of intermittent aortic cross-clamping technique for myocardial preservation during coronary artery bypass grafting and to compare the results with other published series using the same technique. Design: An institution-based analytical study. Place and Duration of Study: Study was carried out from July 1995 to December 1997 at Punjab Institute of Cardiology, Lahore. Patients and The data of 100 consecutive patients were analyzed who had coronary artery bypass grafting without cardioplegia using intermittent aortic cross-clamping. All the patients who had emergency or concomitant major surgery, reoperations, and aortic disease with calcification were excluded from this study. Despite minor complications there was no mortality, no rhythm disturbance or perioperative infarction. Inotropic support was needed in 8% of patients. Our results compared favourably with other published series using the same technique. These results provide re-assurance that intermittent aortic cross-clamping provides excellent myocardial protection and operative conditions for primary coronary artery bypass. It also provides a simple and safe option for myocardial protection during coronary artery bypass grafting

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

Mitral valve repair for pure mitral regurgitation and mixed mitral valve disease

Out of all mitral valve salvage cases done at the Punjab Institute of Cardiology, Lahore between 1991 and April 1994, 60 cases operated upon by one surgeon were selected for study. There were 4 [6.67%] hospital and 2 late deaths. Three patients including one late death underwent mitral valve replacement at a later stage. Six patients were lost to follow up. The remaining 46 patients are being followed up to assess the success of the repair or otherwise in terms of the New York Heart Association [NYHA] functional class of the patients and echocardiographic findings. All our patients dad rheumatic involvement of the mitral valve. The associated cardiac lesions were ASD in 2 [3.33%], tricuspid regurgitation in 40 [66.67%] and aortic regurgitation in 23 [38.33%] patients. The age range was between 10 and 50 years. The follow up period was 3-43 months. Forty [86.96%] patients are in functional class I or II while 6 [13.04%] patients are in functional class III or IV. Twenty-five [54.35%] patients have trivial or mild mitral regurgitation on post operative echocardiogram while 14 [30.43%] have moderate mitral regurgitation. We conclude that satisfactory results can be obtained with repair even in cases with rheumatic mitral valve disease

Eruptive syringoma [a case report]

A case of Eruptive Syringoma of a uniquely extensive nature and very early onset has been reported. The success of Dermabrasion in cases like this offers prospects of optimism in such like hopeless cases

Lipoid proteinosis [case reports and review]

LIPOID PROTEINOSIS with its classical manifestations in 4 out of 5 siblings of a family is reported. The occurrence of the disease in more than one member of a family supports the findings of URBACH and WYTH, WISE and REIN, who reported the disease in 2 and 1 such families respectively

Bullous Honoch-schoenlein purpura

A classical case of H.S. purpura with the usual features of purpura, arthritis and G.I.T manifestations and with the un-usual feature of predominantly bullous type of purpuric lesions is reported. The occurrence of cutaneous lesions coinciding in such sharp precision with abdominal features is also worthy of note