Isolated pericardial cystic Echinococcosis: A rare clinical presentation.

Isolated pericardial Hydatid cyst without involvement of other viscera is a rare condition with reported incidence of 0.5-2% of all cases of cystic echinococcosis even in the countries endemic for the disease. Hydatid disease is a major public health concern in the animal raising regions worldwide. Pericardial hydatid disease can be asymptomatic or present with varying symptoms from atypical chest pain, arrhythmias, rupture and tamponade to anaphylaxis. Early diagnosis and surgical treatment is necessary to prevent fatal complications. Here we report a case of symptomatic isolated pericardial hydatid cyst who presented with epigastric pain.

Frequency of Renal Dysfunction and its effects on outcomes after open heart surgery.

OBJECTIVES: In this study we determined the frequency of renal dysfunction and its outcomes in terms of morbidity and mortality in patients who underwent open heart surgery at the Aga Khan University Hospital, Karachi, Pakistan. METHODS: A total of 175 patients aged between 15-80 years having open heart Surgery(OHS) were included. Preoperative and postoperative serum creatinine (SCr) was noted and the glomerular filtration rate (GFR) calculated by Cockcroft-Gault equation. Their hospital course was charted and followed-up for 30-day. RESULTS: The mean age and mean BMI were 58.1±12.6 years and 26.4±4.3 kg/m2 respectively. Females were 18.3%, out of which 51.4% hypertensive, 46.9% diabetics, 45.1% had dyslipidemia, 2.9% had preoperative renal dysfunction and 40% had moderate ejection fraction. On follow up, 30.3% developed postoperative renal dysfunction within 30-days after OHS with mean SCr and GFR as 1.6±0.7 and 56.9±24.5, respectively. In RD group more patients showed positive outcomes i.e. prolonged inotropic requirement (75.5% vs. 18%, p-value <0.005), diuretic infusion usage (47.2% vs. 3.3%, p-value <0.005), dialysis/renal replacement therapy (17% vs. 0%, p-value <0.005), requirement for prolonged ventilation (35.8% vs. 6.6%, p-value <0.005), prolonged ICU and hospital stay (15.4% vs. 1.6%, p-value <0.005 and 41.5% vs. 17.2%, p-value <0.005), sepsis (20.8% vs. 1.6%, p-value <0.005) and death (9.4% vs. 2.5%, p-value 0.05). CONCLUSION: Timely recognition of renal dysfunction, early renal replacement therapy, diuretics or dialysis and proper nutritional and inotropic support to maintain adequate hemostasis shows survival benefits.

Superior septal approach versus left atrial approach for mitral valve replacement: A retrospective cohort study.

OBJECTIVE: To compare the outcomes of superior septal approach and left atrial approach for mitral valve replacement. METHODS: This retrospective cohort study was conducted at the Aga Khan University Hospital, Karachi, and comprised records of patients who had undergone isolated mitral valve replacement from May 2003 to April 2012. Cases were reviewed for the outcomes [primary: loss of normal sinus rhythm; secondary: complications, residual defect and mortality]. Patients with prior history of dysrhythmia, low ejection fraction (<30%), emergency/redo mitral valve replacement and concomitant coronary artery bypass grafting were excluded. SPSS 19 was used for data analysis. RESULTS: Of the 78 patients, 52(66.67%) were of superior septal approach and 26(33.33%) of left atrial approach. Both groups were comparable for baseline variables except cardiopulmonary bypass and cross-clamp times, which were significantly shorter in the superior septal approach group than the left septal approach group (p<0.05). No residual atrial septal defect was found in any approach. Although loss of normal sinus rhythm was observed more frequent in superior septal approach 25(48%) compared to left septal approach 10(38.4%), but the difference was statistically insignificant (p=0.28). Age was the only significant variable affecting loss of normal sinus rhythm after adjusting for approaches. The difference of post-operative complications was also statistically insignificant between superior 9(17.3%) and left septal approach 4(15.38%) (p=1.0)]. CONCLUSIONS: The operative durations were significantly higher in left atrial approach compared to superior septal approach.

Existence of renal dysfunction in diabetics undergoing coronary artery bypass.

INTRODUCTION: The effect of diabetes mellitus on morbidity and mortality in patients undergoing coronary artery bypass grafting has remained uncertain, and conflicting conclusions have been reported in clinical trials. Evidence suggests that coronary artery bypass in patients with diabetes mellitus carries a higher risk of stroke, renal failure, perioperative complications, and sternal wound infection. This study evaluated the frequency of acute renal dysfunction after coronary artery bypass in diabetic patients, and the associated risk factors. METHOD: This cross-sectional observational study included 135 patients with diabetes (111 males and 24 females with a mean age 51 years and a body mass index of 27.44 kg m(-2)), who underwent elective coronary artery bypass from March 2015 to October 2015. Data were collected prospectively in 2 tertiary care centers. Renal dysfunction was assessed by serum creatinine levels preoperatively and at 24 and 48 h postoperatively. RESULTS: Fifteen percent of patients were found to have postoperative renal dysfunction. Univariate analysis revealed that patients with increased serum creatinine preoperatively were at greater risk of developing renal dysfunction after coronary artery bypass (p = 0.00). On multivariable binary logistic regression analysis, preoperative serum creatinine level was the only independent predictor of postoperative renal dysfunction; age, body mass index, dyslipidemia, hypertension, cardiopulmonary bypass time, and aortic crossclamp time showed no significant association. CONCLUSION: Diabetic patients with increased serum creatinine preoperatively are at greater risk of kidney damage postoperatively; therefore, these patients should be monitored and treated critically in the perioperative period.

Atresia of the Descending Aorta in a Young Woman Requiring Bypass Graft.

Congenital aortic atresia is a malformation accounting for 4 - 6% of all congenital heart diseases in children. Left ventricular outflow obstruction due to atresia is common at the aortic valve but rarely has atresia been identified in the descending aorta. We report the case of a 25-year woman who was evaluated for headache and uncontrolled hypertension. CTscan chest showed a short atretic segment in the descending aorta at the isthmus, distal to the takeoff of the subclavian artery. She underwent surgery; a 22 mm Dacron graft was taken and jump graft was placed between the arch of the aorta and the descending aorta, using partial occlusion clamps. Patient tolerated the procedure well and was discharged on ACE Inhibitors and beta blockers, which were then weaned off over a period of one year. She remained stable and had no further complaints.

Resection of Posterior Mediastinal Tumors by Video Assisted Thoracic Surgery.

This case report illustrates successful Video Assisted Thoracic Surgery (VATS) performed on a 45-year-old woman and 52-year-old man presenting with a mass in left and right paravertebral space on the CT scan respectively. VATS has many benefits over traditional open operation (thoracotomy), resulting in less pain and shorten recovery time. However, VATS has higher equipment cost but when an experienced surgeon performs the surgery, better outcomes are achieved. VATS is not common in Pakistan's surgical setup as it is an expensive method of eradicating mediastinal pathologies and not every patient undergoes VATS. The primary objective of presenting these cases is to promote the use of VATS specifically for removal of posterior mediastinal tumors and improve the surgical outcomes.

Successful tricuspid valvectomy in a septic patient with tricuspid valve endocarditis.

Endocarditis is characterized by vegetations, which is a mass of platelets, fibrin, micro-colonies of micro-organisms, and inflammatory cells, in the endocardium. Over the past three decades, the incidence of right-sided endocarditis has risen dramatically in Pakistan. We report a 36-year woman with a history of repeated intravenous analgesic injections for low back pain, presenting with high grade fever, sepsis and a white cell count of 44,000 with 90% neutrophils. Echocardiography showed large mobile vegetations on Tricuspid Valve (TV). Tricuspid Valve Endocarditis (TVE) is generally responsive to medical treatment; however, about 25% of TVE patients require surgical intervention. Long-term survival of a patient is possible without a prosthetic TV replacement, particularly if the pulmonary artery pressure is normal.