ABSTRACT
Objective: Since the last decade, the notion of minimally invasive cardiac surgery (MICS) has gained worldwide rapid popularity. Bangladesh is not far from mastering this technique due to the increasing interest of both patients and surgeons. Meanwhile, during this COVID-19 era could it help patients, remains the main question. In this context, we have operated on a total of 523 patients from October 2020 to November 2021 including, 89 patients who were MICS and among them, 17 were coronary artery bypass grafting. Method(s): We have included all patients who underwent minimally invasive coronary artery surgery in our hospital from October 2020 to November 2021 irrespective of single (MIDCAB) / multi-vessel disease (MICAS) or combined valve replacement with coronary revascularization. Data were collected from the hospital database, telephone conversations, and direct clinic visits. All data were analyzed statistically and expressed in the form of tables. Result(s): In the last 14 months of pandemics we have operated on a total of 89 MICS patients, among them 10 were Minimally Invasive Direct Coronary Artery Bypass (MIDCAB), 6 were double or triple vessels coronary artery surgery (MICAS), 1 patient underwent upper-mini aortic valve replacement along with coronary revascularization. One of our patients needed re-exploration for chest wall bleeding on the same day. Mean ICU and hospital stay in our series were less than conventional revascularization. There was no in-hospital or 30 days' mortality in our series. Conclusion(s): Cardiac surgery these days is headed toward less invasive approaches with the aid of technology, advanced instruments, and pioneer's lead. But from our in-hospital results we conclude that by avoiding median sternotomy, these minimal invasive revascularization techniques can provide hope to the patients by alleviating symptoms with restored vascularity, reduced morbidity, preventing sudden cardiac death. Health costs reduction with shorter hospital and ICU stay are the added benefits.
ABSTRACT
Background: This case highlights how coronary pathology presents in vasculitis. Case presentation: A 49-year-old male, never-smoker presented to our hospital for a series of Acute Coronary Syndromes (ACS). The first in October 2019;angiogram revealed diffuse aneurysms and clot in the right coronary artery (RCA) and stenosis in the posterolateral branch (PLB). Post aspiration thrombectomy, and drug eluting stent (DES) to the PLB, patient was discharged on standard ACS meds. Coagulopathy workup was unremarkable. Follow up in November 2020, the patient was recommended reducing ticagrelor to 60mg twice daily (bid). The second ACS, one year later, revealed severe in-stent restenosis of the PLB stent. Patient had 2 DES placed in the PLB and was discharged on escalated therapy of rivaroxaban 2.5mg bid, and ticagrelor 90mg bid. Two months later the patient had COVID-19;during that admission he had two ACS events. The first showing mid-RCA stenosis and thrombosis of the same PLB;this was treated with only angioplasty. The next day, he had repeat ACS showing thrombosis of the RCA, but despite multiple attempts RCA recanalization was unsuccessful and discharged on medical therapy only. During clinic follow up, May 2022, the patient revealed that he had Kawasaki's disease as a kid. Conclusion(s): Coronary aneurysms are high risk because of slow flow and endothelial dysfunction that makes balloon dilation, stent sizing, and post interventional medical therapy difficult. Currently no standard guidelines exist to help providers treat this population. It may be beneficial to regularly follow up, monitor inflammatory markers (ESR, CRP correlated well with interleukin 6 and 8), and use CT or PET to follow active vasculitis and changes in aneurysms. Kawasaki's disease is a vasculitis of small and medium-sized vessels and often presents in childhood. Prospective studies show that patients with coronary aneurysms tend to have systemic artery aneurysms, so it is important to screen other arterial beds. Valvular disease has also been found to co-exist in patients with vasculitis, and pre-existing disease should be followed with echocardiography.