Radial Artery Harvesting With Skin Bridge Technique Among Patients Undergoing Coronary Artery Bypass Grafting: An Approach For Developing Countries.

The risk of wound dehiscence and sternal infections remains high after coronary artery bypass grafting, especially in patients with diabetes. Radial artery is a potential alternative which has shown good post-operative outcomes with least complications. Open and endoscopic techniques for harvesting have been used till now. We propose an interrupted or bridging technique, for harvesting the radial artery. This report describes 25 patients undergoing CABG, using radial artery graft, harvested via skin bridge technique, at South City Hospital, Karachi. It has a better cosmetic outcome, reduced postoperative pain, shortened hospital stay and increased level of satisfaction. The interrupted technique offers less invasive cost-effective approach compared to open and endoscopic techniques for radial artery harvesting.

Mesenchymal Stem Cell Therapy in Ischaemic Heart Failure: Hope or Hype?

Ischaemic heart diseases (IHDs) are the leading contributor to mortality worldwide and more than 60% occur in low-to-middle-income countries (LMICs) and 40% of these are specified as premature. Despite notable improvements in treatment options, premature deaths due to IHDs including ischaemic heart failure (IHF) continue to rise in the South Asian population due to prevalent conventional and inherent cardiovascular risk profiles. Stem cell (SCs) therapy has emerged as a potential frontier in regenerative therapy for acute and chronic illnesses. Among various available sources of SCs, the safety and efficacy of mesenchymal stem cells (MSCs) for non-functional cardiomyocytes have been established, but robust evidence necessitates to endorse these preliminary investigations. Little work has been conducted in resource constraints countries and needs immediate attention of all the stakeholders to explore non-conventional cost-effective and sustainable interventions for long term management of IHDs including IHF. This review article provides an overview of basic technical aspects of SCs therapy and a way forward to inspire the scientific community and health authorities to setup priorities via collaborative public and private partnership toward the formulation and execution of sustainable strategies for IHDs to explore the new contextual destination in the field of SCs therapy.

Dysregulation of metalloproteins in ischemic heart disease patients with systolic dysfunction.

Ischemic heart disease (IHD) is the leading cause of mortality worldwide. Metalloproteins have been linked to human health and diseases. The molecular functions of metalloproteins in IHD is not well understood and require further exploration. The objective of this study was to find out the role of metalloproteins in the pericardial fluid of IHD patients having normal (EF > 45) and impaired (EF < 45) left ventricular ejection fraction (LVEF). IHD patients were grouped into two categories: LVEF<45 (n = 12) and LVEF >45 (n = 33). Pooled samples of pericardial fluid were fractionated by using ZOOM-isoelectric focusing (IEF) followed by further processing using one-dimensional gel electrophoresis (1D SDS-PAGE) and filter-aided sample preparation (FASP). Tryptic peptides of each fraction and differential bands were then analyzed by nano-LC-ESI-MS/MS. Protein identification was performed through a Mascot search engine using NCBI-Prot and SwissProt databases. A total of 1082 proteins including 154 metalloproteins were identified. In the differential bands, 60 metalloproteins were identified, while 115 metalloproteins were identified in all ZOOM-IEF fractions. Twelve differentially expressed metalloproteins were selected in the intense bands according to their molecular weight (MW) and isoelectric point (pI). The 12 differentially expressed metalloprotein includes ceruloplasmin, Prothrombin, Vitamin K-dependent protein, Fibulin-1, Ribosomal protein S6 kinase alpha-6, nidogen, partial, Serum albumin, Hemopexin, C-reactive protein, Serum amyloid P-component, and Intelectin-1 protein which were all up-regulated while serotransferrin is the only metalloprotein that was down-regulated in impaired (LVEF<45) group. Among the metalloproteins, Zn-binding proteins are 36.5 % followed by Ca-binging 32.2 %, and Fe-binging 12.2 %. KEGG, pathway analysis revealed the association of ceruloplasmin and serotransferrin with the ferroptosis pathway. In conclusion, 154 metalloproteins were identified of them the Zn-binding protein followed by Ca-binding and Fe-binding proteins were the most abundant metalloproteins. The two metalloproteins, the Cu-binding protein ceruloplasmin, and Fe-binding protein serotransferrin are involved in the ferroptosis pathway, an iron-dependent form of regulated cell death that has been linked to cardiac pathology, especially in IHD patients having impaired systolic (LVEF<45) dysfunction. However, further research is required to validate these findings.

Paradigm shift in the surgical training: The era of innovation, simulation and beyond.

This is an era of transformation of surgical education and training. Modern methods of training are being introduced at a rapid pace and are being adopted in surgical practice not only to improve the outcomes and patient satisfaction, but also to provide an opportunity to develop a new well-structured training curriculum by integrating both traditional and modern approaches to teach and learn surgical skills. Various surgical simulators are in use as training aids and are constantly undergoing further refinement and development. To achieve a smooth transition in surgical training to modern methods, a structured programme has to be developed and validated to bridge the gaps in terms of safety, efficiency and ethics during the training process.

Comparing Outcomes in Patients Undergoing Coronary Artery Bypass Grafting With and Without Using the Internal Mammary Artery in a Tertiary Care Hospital.

Purpose The left internal mammary artery in coronary artery bypass grafting (CABG) is considered to be an important intraoperative quality indicator with excellent long-term results. The purpose of this study is to compare the early outcomes of CABG with and without the left internal mammary artery (LIMA) in the South Asian population and to look for the utilization of LIMA as per the recommendations of the Society of Thoracic Surgeons in a developing country. Materials and methods A retrospective review was carried out for all patients who underwent CABG from 2010 to 2015. Patients were divided into two groups on the basis of whether LIMA was used (Group I) or not used (Group II) as a conduit. Both groups were further subdivided into elective and urgent. Preoperative, intraoperative, and postoperative variables were recorded and compared. Results After exclusion, a total of 2619 patients underwent isolated CABG surgery during the required duration. The LIMA was used in 94% of the patients (n=2472) while 147 patients underwent CABG without LIMA. The use of LIMA was associated with significantly lower mortality (2% LIMA vs 8.8% no LIMA), as well as a decrease in major comorbidity, stroke, and prolonged ventilation. In the subgroup analysis, LIMA usage in elective and urgent cases was associated with significantly lower mortality (elective 1.6% LIMA vs 7.4% No LIMA) (urgent 4.8% LIMA vs 15.7 % no LIMA)) and major morbidity. Conclusion The outcomes of CABG procedures without LIMA were not encouraging. Our results support compliance with standard adult cardiac surgery quality-of-care guidelines.

Direct true lumen versus conventional cannulation for acute type-A aortic dissection.

Acute type-A aortic dissection is a surgical emergency and has a high rate of short-term mortality. Aortic dissection is highly under-reported in Pakistan. With the technological developments in its management, arterial cannulation technique of direct true lumen cannulation has emerged with improved outcomes. We aimed to compare the mortality and morbidity outcomes between direct true lumen and conventional cannulation techniques for arterial access in patients with acute type- A aortic dissection under a single-centre retrospective review from 2007 to 2017. Mean age of the participants was 43.3±11.6 vs 45±12.4 years with males being dominant in both groups. Frequency of overall morbidity was high in conventional cannulation group (Group-B), though it did not attain statistical significance, (p>0.999). Mortality rate was also high in Group-B (10% vs 30%), (p=0.582). Direct true lumen cannulation is an equally reliable option for establishing cardiopulmonary bypass due to reduced mortality and morbidity and may be given preference when dissection is extending into femoral and innominate arteries.

Understanding of metals dysregulation in patients with systolic and diastolic dysfunction in ischemic heart disease.

Ischemic heart disease (IHD) is the leading cause of death and chronic disability in the world. IHD affects both the systolic and diastolic function of the heart which progressively leads to heart failure; a structural and functional impairment of filling or ejection of blood from the heart. In this study, the progression of systolic and diastolic dysfunction characterized according to their echocardiographic parameters including left ventricular ejection fraction (EF), grades of diastolic dysfunction and ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E/e'), were correlated with differential regulation of various metals in patients sera samples (n = 62) using inductive coupled plasma-mass spectrometry (ICP-MS). Chromium, nickel and selenium were found significant (p < 0.05) in patients having EF < 45% compared with EF > 45%. In patients with systolic dysfunction (EF < 45%), the level of selenium was decreased while the level of chromium and nickel was increased compared to patients with EF > 45%. Selenium level was also decreased significantly (p < 0.05) in grade 1A and 2 patients that are considered as higher grades of diastole dysfunction in comparison to grade 0-1. Overall, selenium deficiency was identified in both systolic and diastolic dysfunctions of IHD patients corresponding to the progression of disease that could be related to many metabolic and translational pathways specifically which involve selenoproteins.

Iatrogenic trauma following percutaneous and minimally invasive surgical interventions.

Technological progress has changed the landscape of surgical practice. Minimally invasive surgery (MIS) and percutaneous interventions (PC) are constantly replacing open procedures. This reduces hospital stay and allows quicker recovery. The application of MIS should follow the good medical practice dictum by Hippocrates i.e. "First do no harm". To remain abreast with new procedures, the medical personnel are required to update and enhance their knowledge and skill. To ensure safety, the innovations are rigorously tested and tried. The learning curve of MIS is shortened by simulator training and proctorship. Credentialing processes are in place to enhance safe delivery of care. Despite of all these measures MIS and PCI are associated with adverse effects. The purpose of this article is to overview the iatrogenic trauma associated with MIS and PCI in major surgical subspecialties.

Pericardial fluid proteomic label-free quantification of differentially expressed proteins in ischemic heart disease patients with systolic dysfunction by nano-LC-ESI-MS/MS analysis.

Left ventricular systolic dysfunction (LVSD) is common in patients with pre-existing ischemic heart disease (IHD) and myocardial infarction. An untargeted proteomic approach is used to improve the understanding of the molecular mechanisms associated with LVSD and to find out potential proteomic signatures in pericardial fluid. The pericardial fluid of IHD (n = 45) patients was grouped into two categories according to the left ventricular ejection fraction, LVEF ≥45 (n = 33) and LVEF <45 (n = 12), and analyzed by using nano-liquid chromatography-mass spectrometry (nano-LC-MS/MS) technique. The nano-LC-MS/MS analysis resulted in the identification of 709 pericardial fluid (PF) proteins in both normal and impaired systolic functional groups (LVEF ≥45 vs. LVEF <45). Sixteen proteins were found to be differentially expressed (p < 0.05, fold change >2) including 12 down-regulated and 4 up-regulated in the impaired systolic functional group (LVEF <45) compared to the normal group (LVEF ≥45). Among the differentially expressed proteins the inflammatory marker albumin, atherosclerosis marker apolipoprotein A-IV and hedgehog-interacting protein marker of angiogenesis were predominantly associated with the impaired LVEF <45 group. KEGG pathway analysis revealed that the hedgehog (Hh) signalling pathway is up-regulated in LVSD reflecting the underlying molecular and pathophysiological processes.

Ionomic profiling of pericardial fluid in ischemic heart disease.

Metals are essential cofactors that play a crucial role in heart function at the cell and tissue level. Information regarding the role of metals in the pericardial fluid and its ionome in ischemic heart disease (IHD) is limited. We aimed to determine the association of elements in pericardial fluid and serum samples of IHD patients and their correlation with systolic and diastolic function. IHD patients have been studied with systolic and diastolic dysfunction categorized on the basis of echocardiographic parameters. We measured concentrations of sixteen elements in the pericardial fluid and serum of 46 patients obtained during open heart surgery with IHD by ICP-MS. The levels of chromium and nickel in pericardial fluid were significantly higher as compared with serum samples of IHD patients (p < 0.05). The chromium, nickel and manganese levels in pericardial fluid were lower in patients with ejection fraction (EF) < 45% as compared to EF > 45% (p < 0.05). There was no significant difference in pericardial concentrations of elements in diastolic dysfunction grade 0-1 with 2 in IHD patients. We also found that decreased concentration of these elements in pericardial fluid is associated with decreased systolic function. These results suggest that pericardial fluid concentrations of these metals may reflect the extent of ischemic heart disease. These findings are hypothesis generating with regards to a role in the pathogenesis of the disorder.

Rare aneurysm of anterior mitral valve leaflet-a case report.

BACKGROUND: Mitral valve aneurysm (MVA) is a saccular outpouching of the mitral leaflet which expands on systole and collapses during diastole. The case of MVA was first described in 1729 by Morand. It is one of the rare entities with a reported incidence of only 0.2-0.29% and no such case reported in Pakistan before. CASE PRESENTATION: A 51 year old female presented with dyspnea and chest pain for 3 months. Upon investigating, trans-esophageal echocardiography (TEE) revealed thickened anterior mitral valve leaflet with rolled up margins, forming an aneurysm, with severe mitral regurgitation. Subsequently, the valve was evaluated intra-operatively for repair but eventually had to be excised and then successfully replaced with a bioprosthetic valve. CONCLUSIONS: TEE is an excellent technique to confirm the diagnosis of a mitral valve leaflet aneurysm, and depending upon the severity of the defect, valve repair can be attempted but replacement becomes the most suitable treatment modality, once repair is deemed impossible. We hereby report a rare case, where timely diagnosis, appropriate surgical intervention and regular post-operative follow up helped in achieving good prognosis of this rare entity.

Untargeted metabolomic analysis of coronary artery disease patients with diastolic dysfunction show disturbed oxidative pathway.

INTRODUCTION: Left ventricular diastolic dysfunction (LVDD) is common in patients with coronary artery disease (CAD) with prevalence estimates of 34% and constitutes a predictor of all-cause mortality. Although diastolic dysfunction is induced by myocardial ischemia and has been shown to alter the clinical course, the role of coronary artery disease in the diastolic dysfunction and its progression into heart failure has not been completely elucidated. OBJECTIVE: The present study was conducted to identify possible metabolites in coronary artery disease patients that are differentially regulated in patients with diastolic dysfunction. METHODS: The serum of CAD (n = 75) patients and young healthy volunteers (n = 43) were analysed by using gas chromatography mass spectrometry (GC-MS) technique. Pre-processing of data results in 1547 features; among them 1064 features were annotated using NIST library. RESULTS AND CONCLUSION: Fifteen metabolites were found to be statistically different between cases and control. Variation in metabolites were identified and correlated with several clinically important echocardiography parameters i.e. LVDD grades, ejection fraction (EF) and E/e' values. The results suggested that metabolic products of fatty acid oxidation and glucose oxidation pathways such as oleic acid, stearic acid, palmitic acid, linoleic acid, galactose, pyruvic and lactic acids are predominantly up regulated in patients with coronary artery disease and severity of diastolic dysfunction appears to be linked to increase in fatty acid oxidation and inflammation. The metabolic fingerprints of these patients give us an insight into the pathophysiological mechanism of diastolic dysfunction in coronary artery disease patients although it did not identify validated novel markers.

Is Grown Up Congenital Heart (GUCH) disease different in a developing country?

In the current era grown up congenital heart disease (GUCH) patients undergoing surgical interventions are increasing. Most of the interventions in the developed countries are either complex or redo-operations in patients who had previously undergone repair, palliation or correction. However, in the developing countries most of the interventions are primary and corrective. This descriptive retrospective study comprised GUCH patients who underwent surgical intervention for congenital heart disease (CHD) at Aga Khan University Hospital, Karachi, from January 2006 to December 2015. A total of 195 patients had been treated surgically with a mean age of 31.0±13.5 years. Majority of the patients underwent surgical interventions for closure of atrial 109(55.3%) and ventricular 51(26.2%) septal defect. The most common complications were prolonged ventilation 16(8.1%). Overall mortality was 4(2.1%). GUCH in our practice is for primary procedure with simple diagnosis that should have been treated before reaching adulthood as is done in the developed countries.

Coronary artery bypass grafting in South Asian patients: Impact of gender.

BACKGROUND: Outcomes following Coronary artery bypass grafting (GABG) vary between genders, with females having a higher postoperative mortality than males. Most of the studies are on Caucasian or mixed population and it is postulated that Asian population and in particular women have higher morbidity and mortality. In this study we have compared outcomes of elective CABG in men and women of South Asian origin in terms of morbidity and mortality. METHODS: From January 2006 to December 2012, 1970 patients underwent isolated elective CABG at the Aga Khan University Hospital, Pakistan were selected. The prospectively collected data was analyzed retrospectively including univariate and multivariate analysis to find the association of morbidity and mortality. RESULTS: Among the study patients 1664 (85%) were male and 306 (15%) female. Hypertension and diabetes were the most common comorbid conditions seen preoperatively in female patients. Atrial fibrillation and sepsis were the most common postop complications seen in females. In hospital mortality was 3.9% in female underwent CABG as against 0.6% in male. Multivariate analysis showed older age, renal failure, dyslipidemia and prolonged cross clamp time as predictors of postoperative morbidity. Multivariate analysis showed female gender, age and renal failure as predictors of in hospital mortality. CONCLUSIONS: Female gender is an independent risk factor for postoperative mortality following CABG however, female gender is not found to be independent risk factor for morbidity. The trend of higher mortality in female patients was comparable to most studies done on Caucasian patients.

Anemia in a middle aged female with aortitis: a case report.

BACKGROUND: Idiopathic aortitis is among the most common causes of non-infectious aortitis, which rarely presents with anemia. CASE PRESENTATION: Here we report a case of a 49-year-old muhajir female who presented with shortness of breath and easy fatigability for the past 6 months. Physical examination revealed pallor and a diastolic murmur in the aortic region. Echocardiography showed thickened and calcified aortic and mitral valves, severe aortic regurgitation and dilatation of ascending aorta. She was advised aortic valve replacement and was referred to a haematologist due to concomitant anemia. Complete blood counts revealed haemoglobin: 7.7 gm/dl, mean corpuscular volume (MCV): 78 fl, mean corpuscular haemoglobin (MCH):23 pg, total white cell count: 9.0 × 10(9)/L and platelet count: 227 × 10(9)/L. Erythrocyte sedimentation rate (ESR) was 100 mm/hr. There was suspicion of myelodysplastic syndrome, but could not be confirmed as the patient refused bone marrow and cytogenetic studies. She was given erythropoietin, folic acid and ferrous sulphate. Following relatively prolonged therapy, her haemoglobin level increased to approximately 9.0 gm/dL. She was transfused with packed red cells and underwent aortic valve and ascending aorta replacement. The ascending aorta was dilated and aortic wall markedly thick and irregular. Histopathology of the resected aorta revealed granulomatous aortitis. She was prescribed prednisolone, which resulted in further incremental rise of haemoglobin to 13.1 gm/dL. One month later, she developed complaints of blurred vision in the right eye and was diagnosed with central retinal vein occlusion. She was treated with antiplatelet agents and her vision improved. After 3 months, she was asymptomatic and her haemoglobin level rose to 11.2 gm/dL without hematinic therapy or blood transfusion. She was begun on anticoagulant therapy and remains clinically stable. CONCLUSION: We report a case of idiopathic aortitis with presumed diagnosis of anemia of chronic disease exhibiting a transient response towards steroid therapy post-valvuloplasty.

Intraoperative air embolism originating from a pulmonary vein.

Air embolism entering the systemic arterial system originating from the pulmonary circuit itself is an extremely rare occurrence. We report the case of an 18-year-old female undergoing correction of an atrial septal defect, who had an air embolism that is believed to have originated from the right superior pulmonary vein. Although the exact mechanism of air entry remains a matter of speculation, several plausible hypotheses are proposed and discussed. Injury to a pulmonary vein may lead to air entry with migration to the left atrium and ultimately to systemic embolism.

Tuberculous ascending aortic pseudoaneurysm.

Pseudoaneurysms of the ascending aorta due to infective organisms are a rare but challenging entity with a risk of high morbidity and mortality. Previous cardiac surgery is an attributing factor, but they can present without previous surgical interventions. Various micro-organisms are responsible for this pathology. Tuberculous pseudoaneurysms of the ascending aorta are extremely rare. We report a case of a 25-year old man who presented to us with shortness of breath and recurrent haemoptysis. After preoperative evaluation including clinical and radiological assessment and echocardiography, he underwent successful repair of a pseudoaneurysm of the ascending aorta by excision and replacement of the diseased aorta with a Dacron tube graft using cardiopulmonary bypass. Postoperatively, he was started on antituberculous chemotherapy based on histological findings.

Pericardial fluid and serum biomarkers equally predict ventricular dysfunction.

BACKGROUND: serum level of amino-terminal pro-B-type natriuretic peptide, a cardiac hormone produced by the heart, is elevated in patients with left ventricular dysfunction. The purpose of this study was to compare the abilities of serum and pericardial fluid levels of amino-terminal pro-B-type natriuretic peptide to detect the left ventricular systolic dysfunction determined by echocardiography. METHODS: 50 patients undergoing coronary artery bypass grafting were included in this study. Left ventricular systolic function was assessed using echocardiography before coronary artery bypass grafting. The samples of serum and pericardial fluid were collected during surgery, and amino-terminal pro-B-type natriuretic peptide levels were assessed by an electrochemiluminescence immunoassay. The log value of amino-terminal pro-B-type natriuretic peptide concentrations was calculated. RESULTS: the pericardial fluid levels of log amino-terminal pro-B-type natriuretic peptide were significantly elevated compared to the serum levels in patients with impaired left ventricular systolic function. Both serum and pericardial fluid levels of log amino-terminal pro-B-type natriuretic peptide correlated significantly with left ventricular ejection fraction and end-diastolic and end-systolic volume indices. Furthermore, a paired comparison of receiver operating characteristic curves showed a similar performance of amino-terminal pro-B-type natriuretic peptide levels both in serum and pericardial fluid to discriminate left ventricular systolic dysfunction. CONCLUSION: serum amino-terminal pro-B-type natriuretic peptide levels have comparable diagnostic value for left ventricular systolic dysfunction with its pericardial fluid levels in patients undergoing CABG.