Outcomes of Bilateral Internal Thoracic Arteries in Minimally Invasive Coronary Artery Bypass Grafting With Analogy to the SYNTAX Trial.

OBJECTIVES: Minimally invasive CABG is making positive strides in the evolution of coronary artery bypass surgery. We carried out a retrospective study of the efficacy and outcomes of the usage of bilateral internal thoracic arteries in MICS CABG patients over a 6 year period using primary (MACCE) and secondary outcome measures and also carried out a subgroup analysis of patients with diabetes and methodology of revascularization, and with analogy to the SYNTAX trial of the relative risk. METHODS: Nine hundred and forty patients underwent multivessel MICS CABG via a left mini-thoracotomy from August 2011 to September 2017 and complete revascularization was done using the left internal thoracic artery-right internal thoracic artery Y (LITA-RITA Y) composite conduit. Efficacy and outcomes were evaluated by primary (MACCE) and secondary outcome measures including total length of stay, return to full physical activity, and quality of life. Propensity score matched analyses were carried out in diabetics, in the methodology of revascularization (MICS OPCABG vs. MICS ONCABG), and by comparison to the SYNTAX trial for relative risk. Mean follow-up was 2.9 years (maximum was 5.6 years). RESULTS: Out of the 940 patients, 843 (89.6%) were diabetic and 97 (10.4%) were nondiabetic. Average grafts were 3.2. There were 9 mortalities (0.9%). The average ICU and hospital stay was 40 ± 12 hours and 3.1 days. Ten patients (1.06%) required reintervention by angioplasty. A total of 99.3% patients were free from major adverse cardiac and cerebrovascular events (MACCE) at follow-up. Mean follow-up was 33 months and 846 (90%) of the patients were followed up. Based on propensity score-matched groups, patients who had their surgery done by MICS ONCABG (beating heart technique) had greater mean number of grafts and hospital length of stay and had significantly longer ICU stay, extubation in OR and blood loss in comparison to patients who had their CABG done by the MICS OPCABG technique. The new technique has shown favorable risk reduction in comparison to both the arms of the SYNTAX trial. CONCLUSIONS: The safety, efficacy and outcomes of minimally invasive CABG evaluated by primary (MACCE) and secondary outcomes and quality-of-life measures have been good in this study, especially in diabetics, and have shown results better than conventional CABG. The learning curve can be safely negotiated by using peripheral cardiopulmonary bypass assistance and comparison with the SYNTAX trial has shown a relative reduction in all-cause risk.

Minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries: Will this be the future?

OBJECTIVE: The aim was to show that total arterial revascularization via a left minithoracotomy using bilateral internal thoracic arteries was not only feasible but also a safe and reproducible procedure with excellent midterm outcomes. METHODS: From August 2011 to August 2016, 819 patients underwent off-pump minimally invasive multivessel coronary artery bypass grafting using bilateral internal thoracic arteries harvested through a 2-inch left minithoracotomy incision, and complete revascularization of the myocardium was performed using the left internal thoracic artery-right internal thoracic artery Y composite conduit. RESULTS: A total of 819 patients underwent minimally invasive total arterial myocardial revascularization using bilateral internal thoracic arteries (left internal thoracic artery-right internal thoracic artery Y composite conduit) via a left minithoracotomy. The average number of grafts was 3.1. A total of 171 patients (21%) had 4 grafts, and 557 patients (68%) had 3 grafts. There were 6 mortalities (0.7%), and 4 patients (0.4%) had an elective conversion to sternotomy because of hemodynamic instability. The average hospital stay was 3.1 days. Coronary angiograms were performed in 195 patients (23%), and computed tomography angiograms were performed in 172 patients (21%) at 12 months; the grafts were patent. Four patients (0.4%) required reintervention with angioplasty. CONCLUSIONS: Multivessel total arterial revascularization was performed using the left internal thoracic artery-right internal thoracic artery Y composite conduit via a left minithoracotomy and showed that it was safe and reproducible. The midterm outcomes have been good, and coronary angiograms showed widely patent grafts. This novel technique may help optimize minimally invasive coronary surgery and the use of bilateral internal thoracic arteries. Further, this technique has the potential for decreased morbidity, shorter hospital stay, cosmesis, and earlier return to active life.

A case of tetralogy of Fallot associated with left anterior descending coronary artery to pulmonary artery fistula.

Presence of coronary to pulmonary artery fistula is generally a feature of pulmonary atresia with ventricular septal defect. We present a rare case of left anterior descending coronary artery to pulmonary artery fistula in a patient of tetralogy of Fallot.

Supravalvular aortic stenosis in William's syndrome.

We report supravalvular aortic stenosis in a 12 year old patient who presented with mental retardation, malformed teeth, broad lower lips, pectus carinatum, clinodactyly, kyphoscoliosis with symptoms of shortness of breath. On examination presence of better volume pulse in right radial artery with ejection systolic murmur best heard in right 2(nd) intercostal space were noted. Patient was diagnosed as having William's syndrome with investigations demonstrating Supravalvular aortic stenosis with a gradient of 170 mm Hg.

Diaphragmatic palsy after cardiac surgical procedures in patients with congenital heart.

Paralysis of diaphragm on one or, exceptionally, both sides is a common cause of delayed recovery and excessive morbidity following pediatric cardiac surgery. The consequences of this complication after all forms of congenital heart surgery in newborns and young infants can be potentially serious. The impact of diaphragmatic palsy on the physiology after single ventricle palliations is particularly significant. It is necessary for all professionals taking care of children with heart disease to be familiar with the etiology, diagnosis, and management of this condition. Early recognition and prompt management of diaphragmatic palsy can potentially reduce the duration of mechanical ventilation and intensive care in those who develop this complication. This review summarizes the anatomy of the phrenic nerves, reasons behind the occurrence of diaphragmatic palsy, and suggests practical guidelines for management.

Pleural effusions in children undergoing cardiac surgery.

Persistent pleural effusions are a source of significant morbidity and mortality following surgery in congenital heart disease. In this review, we discuss the etiology, pathophysiology, and management of this common complication.

Successful aneurysmectomy of a congenital apical left ventricular aneurysm.

Congenital apical left ventricular aneurysm is a rare clinical entity that is different from congenital left ventricular diverticulum. This aneurysm usually occurs as an isolated anomaly. Its clinical presentation varies, and it is usually diagnosed by exclusion. Herein, we report the case of a 54-year-old man who experienced progressively increasing symptoms of congestive cardiac failure. Through the use of contrast echocardiography and angiocardiography, and upon histopathologic examination, he was diagnosed to have a congenital apical left ventricular aneurysm. He was successfully treated by means of left ventricular aneurysmectomy. We discuss the process of diagnosis and surgical correction of the aneurysm, and we briefly review the pertinent medical literature.

Successful surgical correction of a patient with congenital coronary arteriovenous fistula between left main coronary artery and right superior cavo-atrial junction.

The case of a 7-year-old female with a congenital left main coronary arteriovenous fistula to the right superior cavo-atrial junction, presenting with congestive cardiac failure, is reported for its rarity. The surgical importance of this anomaly is highlighted.

The impact of HIV/AIDS on the quality of life: a cross sectional study in north India.

OBJECTIVE: To determine the impact of Human Deficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) on the quality of life (QOL) on such patients in North India. DESIGN: A cross sectional study. SETTING: Outpatient setting and wards, Department of Medicine at a premier tertiary health care center, North India. PARTICIPANTS: Sixty-eight consecutive HIV/AIDS patients attending Medicine out patient department and/or admitted to the wards of All India Institute of Medical Sciences were administered a structured questionnaire by the HIV nurse coordinator. QOL was evaluated using the WHOQOL-Bref (Hindi) instrument. ANALYSIS: One way Analysis of Variance (ANOVA) was performed to find out significant difference between the clinical categories and socio-demographic variables on QOL domains. RESULTS: The overall QOL mean score on a scale of 0-100 was found to be 25.8. Similarly, on the scale of 0-100 the mean scores in the four domains of QOL in descending order were social (80.9); psychological (27.5); physical (17.7) and environmental domain (11.65). There was a significant difference of quality of life in the physical domain between asymptomatic patients (14.6) and patients with AIDS (10.43) defining illnesses (p< 0.001) and asymptomatic and early symptomatic (12) patients (p=0.014). QOL in the psychological domain was significantly poorer in early symptomatic (12.1) (p< 0.05) and AIDS patients (12.4) (p< 0.006) as compared to asymptomatic individuals (14.2). A significant difference in QOL scores in the psychological domain was observed with respect to the educational status (p< 0.037) and income of patients (p< 0.048). Significantly better QOL scores in the physical (p< 0.040) and environmental domain (p< 0.017) were present with respect to the occupation of the patients. Patients with family support had better QOL scores in environmental domain. CONCLUSIONS: In our study, QOL is associated with education, income, occupation, family support and clinical categories of the patients.

Heart rate variability in human immunodeficiency virus-positive individuals.

BACKGROUND: Heart rate variability (HRV) is a marker of cardiac autonomic tone. Depressed HRV has been reported in patients with AIDS. We conducted this study to find out if HRV is depressed in human immunodeficiency virus (HIV)-positive individuals without AIDS. METHODS: We studied prospectively HRV by spectral analysis of short-term electrocardiography (ECG) monitoring in 21 HIV-positives (33+/-11 years) and in 18 healthy volunteers (31+/-9 years). None of the HIV-positives had any clinical evidence of autonomic or cardiac dysfunction. Echocardiography was also performed in HIV-seropositives to rule out left ventricular (LV) systolic dysfunction. All these individuals did not have any evidence of AIDS. RESULTS: Mean CD4+ lymphocyte count was 426+/-166/mm(3). The ejection fraction (EF%) of HIV patients was 62.4+/-6.4. The total power of HRV was reduced significantly in HIV-positive individuals (p<0.00001). All the components of HRV were reduced. CONCLUSIONS: HRV is reduced in HIV-seropositive individuals in early stages of infection as well without any clinical evidence of autonomic dysfunction. This may serve as an early marker of future global sympatho-vagal imbalance.

Profulla Kumar Sen: his contributions to cardiovascular surgery.

One of the most eminent cardiothoracic surgeons of India, Profulla Kumar Sen (1915-1982) had a keen interest in research and in the subsequent clinical application of knowledge gained in the laboratory. His most significant contributions are his pioneering work on a transmyocardial acupuncture technique for treatment of ischemic myocardium, on heart transplantation in canine models and later in human beings, and on a new technique for aortic arch replacement. Transmyocardial laser revascularization of the 1990s was but an extension of his mechanical myocardial acupuncture for the treatment of ischemic heart disease, which he introduced 30 years earlier. On 16 February 1968, after many years of preparation through work with animal models, P.K. Sen and his team performed the 1st cardiac transplantation in India and the 6th in the world.