Does an Early Implantation of Extracorporeal Membrane Oxygenator in High-Risk Emergency Open Heart Surgery Patients Improve the Outcome in Comparison with Elective Patients? A Prospective Cohort Comparative Study.

BACKGROUND: Extracorporeal membrane oxygenator (ECMO) has been implemented in refractory postcardiotomy cardiogenic shock (PCCS) patients to maintain excellent oxygenation and hemodynamic support. The aim of this study is to compare the results of early ECMO implantation to treat refractory PCCS in emergency versus elective patients who developed univentricular or biventricular pump failure. PATIENTS AND METHODS: Between January 2019 and June 2021, 35 patients received ECMO after refractory PCCS. Patients have been categorized into two groups: Group A contains 18 patients who were urgently operated on and Group B, which includes 17 patients who were electively operated on. ECMO was implanted through central cannulation (right atrium and ascending aorta), or through peripheral cannulation (femoral vessels or through axillary artery). RESULTS: There was no statistically significant difference between the two ECMO groups in the preoperative patient's characteristics, complication rate, duration of mechanical ventilation, post-ECMO weaning hospital stay, duration of ICU stay, in-hospital mortality, and number of patients discharged from the hospital or in 1-year survival on follow up. CONCLUSION: Early use of ECMO in high-risk emergency cardiac surgery should be taken into consideration when possible, without hesitance. Emergency and elective patients benefit equally from ECMO implantation and show comparable complication rates.

A Comparative Study Between Different Surgical Techniques For Left Atrial Exclusion in Patients Undergoing Concomitant Cardiac Surgery.

OBJECTIVES: To find out the most successful surgical technique to obliterate left atrial appendage (LAA) in atrial fibrillation (AF) patients who had undergone concomitant cardiac surgery. BACKGROUND: About 10%-65% of patients develop AF following cardiac surgery [Rho 2009; Mathew 2004; Maesen 2012]. Cerebral cardio-embolic stroke remains the most serious complication in AF patients. LAA is the main anatomical source for thromboembolic events. The use of oral anticoagulants (OAG) is considered to be an effective method for reduction of thromboembolic complications [Johnson 2000]. The use of oral anticoagulants is faced by two important facts which are the therapy duration is still unknown [Kirchhof 2017] and importantly that between 30-50% of patients are not candidates for oral anticoagulants due to the high bleeding risk or other contraindications [Johnson 2000; Kirchhof 2017; Kirchhof 2014]. In such patients, LAA obliteration would be an optimal alternative technique as it will reduce the stroke risk by 50% [Go 2014]. Several surgical techniques with variable degrees of success rates have been used.  It still is unclear which surgical technique is optimum to achieve a successful obliteration of the LAA and a considerable reduction of the postoperative stroke events in AF patients. PATIENTS AND METHODS: A total of 100 patients have been subjected to surgical LAA exclusion from April 2017 to April 2019 in two different centers. All patients had postoperative transesophageal echo (TEE) examination to confirm the success of LAA occlusion. All patients included in our study suffered from AF at the time of surgery or in past history, which was confirmed by ECG examination in their previous medical files. A variety of surgical techniques to close the LAA have been utilized, including surgical excision by means of scissors, patch exclusion by means of an endocardial patch, suture exclusion and finally stapler exclusion. TEE examination 16 months postoperatively divided our patients into four groups as follows: successful LAA occlusion, Patent LAA, excluded LAA with persistent flow into LAA, and remnant LAA with a stump connection with LAA more than 1 cm. RESULTS: Out of 100 patients, 30 patients (30%) underwent surgical LAA excision, 24 patients (24%) underwent surgical epicardial suture ligation, eight patients (8%) underwent patch exclusion using autologous pericardial patch, 33 patients (33%) underwent LAA internal orifice purse string suture obliteration, and five patients (5%) underwent stapler exclusion. Forty-two patients out of 100 (42%) showed successful LAA closure. The successful LAA occlusion occurred mostly in LAA excision patients 87%, 24% in LAA internal orifice purse string suture obliteration patients, 21% in epicardial suture ligation patients, and 37.5% in patch exclusion patients. The stapler exclusion was very disappointing as we did not record a single case out of the five patients who showed a successful LAA occlusion. Stroke events were recorded in all surgical techniques except the LAA excision technique. The stroke rate after two years follow up was zero in the surgical excision group, 49% in the suture exclusion group, 20% in the patch exclusion group, and 40% in stapler exclusion group. CONCLUSION: Surgical LAA excision is the most successful technique for LAA occlusion and represents a promising technique for the reduction of thromboembolic events in AF patients who undergo a concomitant cardiac surgery.

Leg Wound Complications: A Comparison Between Endoscopic and Open Saphenous Vein Harvesting Techniques.

BACKGROUND: The most common conduit for coronary artery bypass graft (CABG) surgery is saphenous vein graft (SVG). There are two techniques for SVG harvesting: open and endoscopic. Our aim is to evaluate clinical results of endoscopic versus open SVG harvesting. Nowadays, endoscopic vein harvesting (EVH) has become prevalent because of reduced complications with more patient satisfaction. OBJECTIVE: We designed and performed a prospective randomized cohort study of patients undergoing CABG to compare the results of open versus endoscopic harvesting technique. METHODS: Patients who underwent elective CABG at our hospitals were divided into two groups, during the period of January 2019 to March 2021. The EVH group (50 patients) underwent endoscopic technique compared with the open vein harvesting (OVH) group (50 patients) that was underwent open surgical incision for great saphenous vein (GSV) harvesting. The two groups demographically were similar and received identical management. Leg wound was evaluated at discharge, two weeks, and four weeks for evidence of any complications. Early outcomes were recorded, including infection, gaped wound and surgical re-suture, degree of pain, level of cosmetic satisfaction, and early mobilization. RESULTS: In the EVH group, harvesting time increased, and incision closure time decreased in comparison with OVH. The hospital stay was 5.5 ± 2.4 days in the EVH group versus 9.5 ± 2.7 days in the OVH group. Leg wound complications were significantly reduced in the EVH group in comparison with the OVH group. CONCLUSIONS: Endoscopic vein harvesting technique reduced leg wound complications. Conveniently, patients also were cosmetically satisfied.

Aortic Root Enlargement in patients with small aortic annulus undergoing double valve replacement. Is it justified? A retrospective Comparative cohort study.

BACKGROUND: Small Aortic Annulus (AA) is big issue during Aortic Valve Replacement (AVR) necessitating replacement of an undersized prosthetic valve especially with Double Valve Replacement (DVR). Despite that small aortic valve prostheses can lead to Prosthesis-Patient Mismatch (PPM), there remains reluctance to perform aortic root enlargement (ARE) procedures fearing from morbidity and mortality. OBJECTIVE: To evaluate clinical and echocardiographic outcomes in patients with small aortic annulus undergoing double valve replacement. METHODS: The study included 100 consecutive patients underwent DVR for combined rheumatic aortic and mitral valve diseases, between Jan. 2016 and Sept. 2020. Only (50) patients had ARE with DVR.  ARE was performed using an autologous or bovine pericardium or Dacron patch by Nick¢s or Manouguian procedures. The estimated postoperative end-points were mortality, effective orifice areas (EOA), mean aortic pressure gradient and valve-related complications. The least postoperative follow-up period was 6 months. RESULTS: The study included 30 male and 70 female patients with mean age of 35±20 years, body surface area (BSA) of 1.5 ±0.20 m2, aortic annulus diameter was 20±1.4 mm, aortic orifice area was 0.80±0.50 cm2, and aortic peak gradient (PG) 80±40 mm Hg. During follow-up period, there was a mild to moderate paravalvular leak (1%) with, (1%) heart block, and residual PG on prosthetic aortic valve; that was all in DVR alone. CONCLUSION: Enlargement of aortic root by Nick¢s or Manouguian technique is safe and effective in patients with small aortic annulus undergoing double valve replacements.

Experience of Emergency Cervical Tracheal Repair after Non-Iatrogenic Injury.

BACKGROUND: Non-iatrogenic cervical tracheal injury is very rare and challenging for emergency critical care, early diagnosis, and immediate repair. So, emergency repair after early definitive diagnosis is the mainstay to avoid mortality and morbidity. METHODS: A retrospective, observational, cohort study is undertaken with collected data on 50 patients with emergency cervical tracheal repair after non-iatrogenic injury between January 2011 to January 2020 at our accident and emergency department in Minia and South Valley Universities. RESULTS: The non-iatrogenic injury of the cervical trachea is more common in adult males (98%), and blunt trauma (70%) is the predominant type of injury. Subcutaneous emphysema (SE) is the most common presentation (99%). There are associated comorbidities like vascular (4%), maxillofacial (6%), head injury (2%), and esophageal tear (8%). Successful intubation is lifesaving, and early diagnosis and repair avoid complications. CONCLUSIONS: Early diagnosis is a cornerstone for the successful management of cervical tracheal injury, in which successful intubation is a mainstay to reduce mortality. Emergency surgical repair reduces mortality and complications.

Multicenter experience: early outcome of mitral valve repair in patients with ischemic mitral regurgitation.

BACKGROUND: Ischemic mitral regurgitation is associated with poor outcomes. The optimal surgical strategy for management of ischemic mitral regurgitation is still debated. The objective of this study was to evaluate the early mortality and morbidity of mitral valve repair in patients with ischemic mitral regurgitation undergoing coronary artery bypass grafting. METHODS: We performed a retrospective, observational, cohort study on prospectively collected data on 136 consecutive coronary artery bypass graft patients with ischemic mitral regurgitation undergoing mitral valve repair between January 2016 and January 2020. Perioperative echocardiogram findings, operative procedures, and outcomes were analyzed. RESULTS: The overall mortality rate was 4.4%. Mitral valve repair with a low ejection fraction had a 4-fold increase in the risk of death compared to mitral valve repair with preserved ejection fraction > 30%. However, after adjusting for preoperative risk factors, the number of grafts was not an independent risk factor for mortality (odds ratio = 0.18, 95% confidence interval: 0.03-2.81, p = 0.84). Multivariable analysis showed that preoperative ejection fraction (odds ratio = 1.14, 95% confidence interval: 0.82-4.86, p < 0.01), preoperative left ventricular end-systolic dimension (odds ratio = 1.03, 95% confidence interval: 0.65-3.51, p < 0.01) and preoperative left ventricular end-diastolic dimension (odds ratio = 0.99, 95% confidence interval: 0.64-3.28, p = 0.04) were independent risk factors for mortality. CONCLUSIONS: Mitral valve repair can be performed safely concomitantly with coronary artery bypass grafting in patients with moderate, moderately severe, and severe ischemic mitral regurgitation.

Factors Associated with Early Adverse Events after Coronary Artery Bypass Grafting Subsequent to Percutaneous Coronary Intervention.

BACKGROUND: A previous percutaneous coronary intervention (PCI) may affect the outcomes of patients who undergo coronary artery bypass grafting (CABG). The objective of this study was to compare the early in-hospital postoperative outcomes between patients who underwent CABG with or without previous PCI. METHODS: The present study included 160 patients who underwent isolated elective on-pump CABG at the department of cardiothoracic surgery, Minia University Hospital from January 2010 to December 2014. Patients who previously underwent PCI (n=38) were compared to patients who did not (n=122). Preoperative, operative, and early in-hospital postoperative data were analyzed. The end points of the study were in-hospital mortality and postoperative major adverse events. RESULTS: Non-significant differences were found between the study groups regarding preoperative demographic data, risk factors, left ventricular ejection fraction, New York Heart Association class, EuroSCORE, the presence of left main disease, reoperation for bleeding, postoperative acute myocardial infarction, a neurological deficit, need for renal dialysis, hospital stay, and in-hospital mortality. The average time from PCI to CABG was 13.9±5.4 years. The previous PCI group exhibited a significantly larger proportion of patients who experienced in-hospital major adverse events (15.8% vs. 2.5%, p=0.002). On multivariate analysis, only previous PCI was found to be a significant predictor of major adverse events (odds ratio, 0.16; 95% confidence interval, 0.03 to 0.71; p=0.01). CONCLUSION: Previous PCI was found to have a significant effect on the incidence of early major adverse events after CABG. Further large-scale and long-term studies are recommended.

Open Transthoracic Plication of the Diaphragm for Unilateral Diaphragmatic Eventration in Infants and Children.

BACKGROUND: To evaluate our experience of early surgical plication for diaphragmatic eventration (DE) in infancy and childhood. METHODS: This study evaluated infants and children with symptomatic DE who underwent plication through an open transthoracic approach in our childhood development department between January 2005 and December 2012. Surgical plication was performed in several rows using polypropylene U-stitches with Teflon pledgets. RESULTS: The study included 12 infants and children (7 boys and 5 girls) with symptomatic DE (9 congenital and 3 acquired). Reported symptoms included respiratory distress (91.7%), wheezing (75%), cough (66.7%), and recurrent pneumonia (50%). Preoperative mechanical ventilatory support was required in 41.7% of the patients. The mean length of hospital stay was 6.3±2.5 days. The mean follow-up period was 24.3±14.5 months. Preoperative symptoms were immediately relieved after surgery in 83.3% of patients and persisted in 16.7% of patients one year after surgery. All patients survived to the end of the two-year follow-up and none had recurrence of DE. CONCLUSION: Early diagnosis and surgical plication of the diaphragm for symptomatic congenital or acquired diaphragmatic eventration offers a good clinical outcome with no recurrence.