Natural Coronary Bypass: A Rare Case of Aortocoronary Fistula in a Patient with Three-Vessel Disease.

Coronary arterial fistula (CAF) is an abnormal connection between one or both coronary arteries and a cardiac/extra-cardiac chamber or another vessel. Aortocoronary fistula is a rare type of CAF, which involves an anomalous connection between coronary arteries and any segment of aorta. The following case report describes the case of an adult male patient who presented with the complaint of typical chest pain. Coronary angiography was done and the diagnosis of severe three-vessel disease with an associated aortocoronary fistula was made. Coronary artery bypass grafting (CABG) was planned and performed, and the patient was discharged after a week postoperatively.

Thyroid and Heart: Severe Three Vessel Coronary Artery Disease in a Middle-Aged Female with Hypothyroidism.

Hypothyroidism is a common medical condition. The low metabolic state in hypothyroidism leads to significant cardiovascular and hemodynamic changes. Hypothyroidism is associated with heart failure, diastolic hypertension, atherosclerosis, coronary artery disease (CAD), and decreased insulin sensitivity. Similarly, the administration of levothyroxine worsens the cardiovascular disease by establishing a supply-demand mismatch. Here, we present a case of a 45-year-old woman with hypothyroidism who presented to us with exertional chest pain and later got diagnosed with severe three-vessel disease. Coronary artery bypass grafting (CABG) surgery was planned after the establishment of euthyroid state.

Association of Internal Mammary Artery Flow with Different Comorbidities and Post-Coronary Artery Bypass Graft Complications.

Objective The internal mammary artery (IMA) is commonly used arterial graft for coronary artery bypass surgery (CABG). The IMA has a better patency and survival. This study considers different comorbidities and conditions where IMA flow may be low. Therefore, the main objective is to determine the flow of IMA in different diseases, its relation to gender, age, and in different blood groups in order to prevent possible complications. Methods A prospective study was conducted at the Cardiac Surgery Unit, Civil Hospital Karachi from January 2013 to December 2015. The data of 158 patients who underwent primary, isolated, and CABG surgery was collected. Free flow of IMA was measured immediately after harvesting for 30 seconds within a syringe, and its relationship with different diseases and conditions was examined. Data was collected using a structured questionnaire from the patients' medical record files and it was later analyzed and entered into the Statistical Package for Social Sciences (SPSS) software, V17 (IBM SPSS Statistics, Armonk, NY). Results The mean flow was 11.6 ± 9.6 ml. There was no difference in flow related to gender, diabetes, smoking, renal disease, and chronic obstructive pulmonary disease (COPD). There was significantly higher flow in the age group of 50 to 60 years (p = 0.002), hypertensive patients (p = 0.016), patients with liver disease (p = 0.001), BMI > 30 (p = 0.041), and the blood group AB+ (p = 0.02). The atrial fibrillation and readmissions were higher in patients who had low flow. Low flow IMA, which was used on left anterior descending (LAD) artery stenosis patients, showed a significantly higher need of pharmacological and mechanical support. Conclusion IMA should be used carefully in patients where its flow is low; conditions must be analyzed where flow may be low to avoid complications. Further studies are warranted.

Internal mammary artery flow in different racial groups of Pakistan.

OBJECTIVE: To find out any differences in free flow of internal mammary artery among different ethnic groups. METHODS: This observational, cross-sectional study was conducted at the Civil Hospital, Karachi, from January 2013 to December 2015, and comprised patients who underwent coronary artery bypass grafting. The participants were divided into 5 groups, i.e. Sindhi, Muslim migrants from India, Punjabi, Pathan and Balochi patients. Free flow of internal mammary artery was measured immediately after harvesting within a syringe, and its flow was measured in 30 seconds. SPSS 18 was used for data analysis. RESULTS: Of the 158 patients, 44(27.8%) were Sindhi, 33(20.9%) Punjabi, 8(5%) Baloch, 21(13.3%) Pathan and 52(32.9%) were migrants. The overall mean age was 52±8 years and the mean flow was 11.6±9.6ml per 30 seconds. The flow was 9.3±6 ml, 10±8ml, 13±11ml, 17±14ml and 15±13 ml in 30 seconds among migrants, Sindhi, Punjabi, Pathan and Baloch patients, respectively, with significant higher flow in Pathan patients compared to Sindhi and migrant patients (p<0.05). A flow of less than 5ml/30 sec was mostly found in migrants or Sindhi subjects 30/40(75%), and flow more than 30ml/ 30 seconds was found mostly in Baloch or Pathan patients 4/8(50%). Low flow internal mammary artery, which was used on left anterior descending artery, showed significantly higher need of inotropic support as compared to high flow internal mammary artery (p=0.004), more low cardiac output syndrome (p=0.022) and more use of intra-aortic balloon pump (p=0.028). CONCLUSIONS: Internal mammary artery flow was higher in Pathan and Baloch patients and low in migrants and Sindhis.

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.

Assessment of Blood Glucose and Electrolytes during Cardiopulmonary Bypass in Diabetic and Non-Diabetic Patients of Pakistan.

INTRODUCTION: Perioperative hyperglycemia has been shown to be related to higher levels of morbidity and mortality in patients on cardiopulmonary bypass (CPB) undergoing coronary artery bypass grafting (CABG), both diabetic and non-diabetic. Blood electrolytes, like sodium, potassium, calcium, and chloride play a very important role in the normal functioning of the body and can lead to a variety of clinical disorders if they become deficient. A minimal number of studies have been conducted on the simultaneous perioperative changes in both blood glucose and electrolyte levels during CPB in Pakistan. Therefore, our aim is to record and compare the changes in blood glucose and electrolyte levels during CPB in diabetic and non-diabetic patients. MATERIALS & METHODS: This was a prospective, observational study conducted on 200 patients who underwent CABG with CPB, from October 2014 to March 2015. The patients were recruited from the Cardiac Surgery Ward, Civil Hospital Karachi after they complied with the inclusion criteria. Repeated-measures analysis of variance (ANOVA) was used to compare the trend of the changes perioperatively for the two groups. RESULTS: There was no significant difference in changes in blood glucose between the two groups (P = 0.62). The only significant difference detected between the two groups was for PaCO2 (P = 0.001). Besides, further analysis revealed insignificant group differences for the trend changes in other blood electrolytes (P > 0.05). CONCLUSION: Our findings highlighted that there is no significant difference in blood electrolytes changes and the increase in blood glucose levels between diabetic and non-diabetic patients.

Predictors of Mortality in Patients Undergoing Mitral Valve Replacement.

OBJECTIVE: Although mitral valve replacement is frequently performed in patients of all age groups, there are few studies available which determine the causes of operative mortality in mitral valve replacement especially in our region. Therefore, the objective of this study was to identify factors that are significantly associated with operative mortality in mitral valve replacement. METHODS: From August 2012 to March 2013, 80 consecutive patients undergoing mitral valve replacement in a single tertiary hospital were included. Patients with a history of previous coronary artery bypass graft surgery or congenital heart problems were excluded from the sample. The included patients were observed for a period of 30 days. Pre and post-operative variables were used to identify significant predictors of mortality. RESULTS: The overall hospital mortality (30 days) was 15%. High post-perative creatinine (P =0.05), high ASO titre (P=0.03), young age (P=0.011), low cardiac output (P=0.0001), small mitral valve size (P=0.002) and new onset of atrial fibrillation (P=0.007) were the significant independent predictors of operative morality. CONCLUSION: Mitral valve replacement can be performed in third world countries with limited resources with low mortality. However, optimal selection of mitral valve size can help to improve operative mortality.

Knowledge, Awareness and Self-Care Practices of Hypertension Among Cardiac Hypertensive Patients.

INTRODUCTION: The most prevalent form of hypertension is systolic blood pressure (SBP) and it is considered to be predisposing risk factor for cardiovascular disease. The objective of the study was to assess self-care practices, knowledge and awareness of hypertension, especially related to SBP among cardiac hypertensive patients. METHODOLOGY: A Cross sectional study was conducted on 664 cardiac hypertensive patients, which were selected by non-probability convenience sampling from cardiology outpatient department of three tertiary care hospitals. Face to face interviews were conducted using a pre designed questionnaire. Data was entered and analyzed by SPSS (V17). RESULTS: 81.8%, did not know that hypertension is defined as high blood pressure. 97.1% of the sample population did not know that top measurement of blood pressure was referred to as systolic and only 25.0% correctly recognized normal systolic blood pressure to be less than 140 mmHg. 7.4% of the patients consulted their doctor for hypertension once or twice in a month. Risk factor for high blood pressure most commonly identified by the participants was too much salt intake CONCLUSIONS: The results state that there is an inadequate general knowledge of hypertension among cardiac patients and they do not recognise the significance of elevated SBP levels. There is a need to initiate programs that create community awareness regarding long term complications of uncontrolled hypertension, particularly elevated SBP levels so that there is an improvement in self-care practices of the cardiac patients.

Predictors of Knowledge of Coronary Intervention in a Group of PCI Patients.

OBJECTIVE: This study was performed to assess the knowledge of CAD risk factors and post management of coronary intervention among sample of population who were hospitalized for PCI. METHODOLOGY: A cross-sectional, descriptive survey was conducted in Cardiology ward of a tertiary care hospital from July 2013 to May 2015 on 600 patients. A structured questionnaire was used to interview the patients. In univariate analysis, t-tests were employed to assess association of knowledge of CAD risk factors with gender, education level and monthly household income. RESULTS: The mean score of participants with no education was 4.42 and patients with education of bachelors or higher was 8.59 (p-value: 0.01). Similarly, the mean score for participants with monthly household income less than 5000 was 3.32 and participants with income higher than 50,000 had a score of 8.31 (p-value: 0.01). Furthermore, only 28% (N=168) claimed aerobic exercise as a key part of angioplasty recovery. CONCLUSIONS: Our results indicate the lack of good level of knowledge of risk factors for CAD and post management of coronary intervention among PCI patients of Pakistan. There is urgent need for targeted educational programs on national basis to reduce mortality associated with CAD in Pakistani population.

Post angioplasty coronary artery bypass grafting in patient with myasthenia gravis.

A 62 years old patient developed myasthenia gravis 2 years after his percutaneous coronary intervention. He was advised thymectomy for myasthenia gravis. During his cardiological evaluation, he was incidentally diagnosed to have 3 vessel disease. Hence, a simultaneous surgical intervention was performed consisting of thymectomy and CABG via standard cardiopulmonary bypass through median sternotomy. Previous medical history of diabetes and corticosteroid therapy made the patient immunocompromised. Therefore, a careful overall therapeutic strategy was devised to prevent mediastinitis. After his thymectomy and coronary artery bypass grafting, he was extubated within 6 hours. Plasmapheresis was done one day before the surgery and on first postoperative day. His medications for myasthenia gravis (pyridostigmine and prednisolone) were not stopped before and after the surgery. Patient was discharged on 6th postoperative day without any complications. On his follow-up 6 weeks postoperatively, his condition was unremarkable.

Predictors of the size of prosthetic aortic valve and in-hospital mortality in aortic valve replacement.

PURPOSE: We hypothesized that gender, age, aortic root dimension, blood group and Left Ventricular End Diastolic and Systolic Diameters may have a significant correlation with the size of mechanical valve used. METHODS: We included 48 patients retrospectively who had been operated at a single tertiary hospital. All patients with aortic stenosis or regurgitation were included in the study. Patients who had undergone previous cardiac surgery or concomitant surgical procedures, such as coronary artery bypass grafting, were excluded from the study. RESULTS: The median size of the valves used in males (23mm) and females (21mm) were significantly different (P = 0.001). Size of the valve used was significantly associated with Left Ventricular End Systolic Diameter (LVESD) (r = 0.327, P = 0.007) and aortic root dimension (r = 0.526, P < 0.001). Moreover, significantly higher values of LVESD were observed in the expired patients (P = 0.023). CONCLUSION: This study shows that aortic root dimension and gender may be important predictors for the size of the prosthetic aortic valve used in aortic valve replacement. Our study also concludes that LVESD has significant relationship with in-hospital mortality. However, more long term clinical trials should be conducted to confirm these relationships.

Relationship between stress and coronary heart disease.

BACKGROUND: Coronary heart disease is the leading cause of death worldwide and accounts for 13.7% of deaths in countries like Pakistan. Its association with stress has not been well considered in our setup. Patients with coronary artery disease admitted for coronary artery bypass grafting may have a high prevalence of stress that might increase the risk of adverse outcomes. METHODS: 60 patients with coronary artery disease admitted to the Civil Hospital Karachi for coronary artery bypass graft surgery from January 1 to March 31, 2012, were evaluated using a stress evaluation scale. RESULTS: Stress of varying degrees was found to be a significant independent risk factor in patients with coronary heart disease. Analysis of our collected sample of patients with stress showed 60% with high stress (p = 0.025) and 36.7% moderate stress (p = 0.0025). An appreciable relationship was found between stress and patient age, sex, body mass index, blood group, and the incidence of myocardial infarction. CONCLUSION: Our study found evidence of an independent causative association between psychological stress and coronary heart disease, of a similar order to the more conventional coronary heart disease risk factors.

Effect of risk factors like age, gender, hypertension, diabetes, smoking, dyslipidemia on coronary artery disease in Karachiites with angiographical data of local population: Number, site, severity of coronary lesion.

The aim of this study was to determine the effect of major risk factors like age, gender, hypertension, diabetes, smoking, dyslipidemia on coronary artery disease in Karachiites and highlighted the angiographic data of local population like number of vessels involvement, site and severity of coronary lesions. This was a cross sectional analytical prospective study which was carried out at Abbasi Shaheed Hospital Karachi from August 2004 - July 2014. We includedfive hundred (500) consecutive patients (188 female & 312 male) between 26-80 years old, who came for coronary angiography with suspecting ischemic heart disease clinically or otherwise proven by relevant tests like ETT, ECHO, and Thallium stress test. Post PCI and CABG patients were excluded from study. During this study variables like age, gender, hypertension, diabetes, smoking and dyslipidemia were taken into account in relation to coronary artery disease in Karachiites. In addition we also assorted some important findings of coronary angiography like: number of vessels involved, site and severity lesions in our population and compared them with existing literature. Our study revealed that in our local population not only old age and male gender are potential threat for an early coronary artery disease but other variables like hypertension, diabetes, smoking, and dyslipidemia are also playing important role in coronary artery disease. It is also concluded that our population is more prone to multiple vessels involvement with almost involvement of LAD in majority of population.

Needle stick injuries among health care workers of public sector tertiary care hospitals of Karachi.

OBJECTIVE: To estimate the frequency of needle stick injuries (NSI) among health care workers (nurses, student nurses and paramedical staff) in public hospitals of Karachi. STUDY DESIGN: Cross sectional, observational. PLACE AND DURATION OF STUDY: This study was conducted in three public tertiary care hospitals of Karachi, from November 2007 to January 2008. METHODOLOGY: Data was collected by structured interview-based questionnaires in Urdu and English language. Questionnaire was designed to obtain information regarding demography, work experience, hepatitis vaccination status, and occurrence of needle stick injuries with associated factors. Needle stick injury that occurred in the previous month was the defined outcome. Data was entered in Epi Data and analyzed in SPSS version 15. RESULTS: A total of 417 health care workers participated in the study. Mean age of the participants was 24+/-11 years. Estimated proportion of participants with history of at least one time NSI was found in 66%. Around 13% (n=54) had one or more NSI in the previous one month at work and half of them were affected by non-sterile needle. None of them sought medical care. Almost 90% of them were not wearing gloves or taking any other protective measures at the time of injury. CONCLUSION: There can be serious consequences of needle stick injuries in public hospitals as large proportion of injuries involve non-sterile used needles and health care workers do not take appropriate measures of protection.

Coronary artery bypass surgery in old age group: is age itself a barrier?

OBJECTIVE: To analyse the data retrospectively and identify risk factors that may adversely affect mortality in patients aged seventy years and older with coronary artery bypass graft (CABG). METHODS: From Jan 2003 to Oct 2007, 63 consecutive patients of 70 years or older underwent primary isolated CABG on cardiopulmonary bypass (CPB) in Department of Surgery, Liaquat National Hospital. Forty one (65%) were male. The mean age was 72.7 +/- 3 years (range 70 to 81 years). Preoperatively 83% were in New York Heart Association (NYHA) class III or IV. Left main stem (LMS) lesion (> 70%) was present in 20 (32%). Renal impairment (RI) with creatinine more then 2 mg/dl was present in 9 (14%) patients. History of prior stroke was present in 7 (11%). Emergency surgery (within 48 hours after Myocardial Infarct (MI)) was performed in 33 (52%) patients. RESULTS: The overall hospital mortality (30 days) was 9.5%. The mean Parsonet score was 23 +/- 3, and 10 +/- 3 in those who died or survived respectively. Mean intensive care unit stay was 2.3 +/- 0.7 days, mean ward stay was 6 +/- 3 days. Preoperative LMS lesion or MI less then 48 hours, poor left ventriculal function, prolonged CPB time and post operative stroke were the significant independent predictors of operative morality. CONCLUSION: CABG can be performed in a selected elderly population. Careful attention to risk factors associated with high mortality can be helpful in improving post-operative morality. Age in itself may not be responsible for high morality.

Effect of aspirin on postoperative bleeding in coronary artery bypass grafting.

PURPOSE: It is not uncommon for aspirin therapy to be withheld before coronary artery bypass grafting (CABG) because it is thought to increase the risk of postoperative bleeding. Many studies have shown that continued aspirin therapy reduces postoperative myocardial infarction and increases survival. The purpose of this study is to analyze the effect of preoperative aspirin on postoperative bleeding in patients undergoing CABG. MATERIAL AND METHODS: Patients (n=30) undergoing CABG were divided into two groups, group 1 (n=15) who received aspirin till the day of surgery, and group 2 in whom aspirin was stopped 5 days before surgery. Postoperative bleeding up to 76 h (approximately 3 days) was noted in both groups. RESULTS: Preoperative, intraoperative, and postoperative variables were equal in both groups. Postoperative bleeding in the 2nd hour was significantly lower in group 1 compared to group 2 (p=0.004). Bleeding 28-76 h postoperatively was also significantly lower in the first group (p=0.043). CONCLUSION: Our study suggests that contrary to the commonly held beliefs in our setup, the use of aspirin till the date of surgery does not increase the risk of postoperative bleeding after CABG. In contrast, our data show reductions in the bleeding incidence of those in whom aspirin was not withheld prior to surgery. Therefore we strongly recommend its continued use of aspirin until the date of surgery.

Analyzing the outcome of early versus prolonged extubation following cardiac surgery.

OBJECTIVES: This study considered the factors associated with prolonged ventilation and the effects of reduced extubation times on patient recovery, intensive care unit stay, and overall hospital stay. MATERIALS AND METHODS: A retrospective study was performed, including 86 consecutive patients who underwent cardiac surgery from August 2006 to January 2007. The patients were divided into two groups following intensive care unit admission: Group A, duration of intubation <4 h (n=34); Group B, duration of intubation >4 h (n=52). RESULTS: Two deaths occurred in 86 patients, and overall hospital mortality was 2.32%. Patients in Group A were younger (33.2+/-12 versus 45.8+/-13 years; p=0.001) and had better preoperative left ventricular ejection fraction (LVEF) (62.4+/-9.8 versus 44.6+/-9.4; p=0.003) than those in Group B. Moreover, Group A patients had a shorter intensive care unit length of stay (1.7+/-0.5 versus 2.2+/-0.8 days; p=0.006) and were discharged earlier than Group B patients (2.7+/-2.4 versus 4.01+/-3.96; p=0.014). CONCLUSIONS: Early extubation offers a substantial advantage in terms of accelerated recovery, shorter intensive care unit, and hospital stay, suggesting that efforts to reduce extubation times are cost-effective.

Penetrating cardiac injury by a metallic fragment.

An adult male had a penetrating injury of the chest resulting in cardiac tamponade. The injury resulted as a consequence of a detached iron piece from an iron bar in a steel mill. Emergency sternotomy and percardiotomy revealed blood in the pericardial cavity and full thickness penetration of the right ventricle. The defect was repaired following the removal of the iron fragment. Postoperative recovery was uneventful.

Outcome of patients after coronary artery bypass grafting in cardiogenic shock.

PURPOSE: Coronary artery bypass graft (CABG) surgery in patients with cardiogenic shock (CS) is a rare and very high-risk procedure carrying high mortality. In this study we reviewed hospital outcomes and 1-year survivals in these high-risk patients. MATERIALS AND METHODS: During a 4-year period (May 2001 to April 2005), 412 patients were operated on for CABG by a single surgeon, and 13 (3.1%) of them were in CS at the time of procedure. RESULTS: The 30-day mortality of patients who underwent CABG during CS was 16%, and mean age was 57+/-10 years. A total of 77% were male, 77% were hypertensive, 38% were diabetic, and 31% had renal impairment. Myocardial infarction (MI) affected 62% within 48 h of surgery. Moderate to poor left ventricular function was found in 92%. Twenty-three percent had a preoperative intra-aortic balloon pump. Postinfract ventricular septal defect was present in 16%, and catheter-related problems were present in 23% of patients. After 1 year, all patients (11) were alive, and 85% of them were in New York Heart Association (NYHA) classes I to II. CONCLUSION: CABG in CS produces significant 1-year survival benefits and improvements in functional class. Therefore, early surgical intervention is suggested where percutaneous coronary intervention is not possible or contraindicated for anatomical reasons.

The role of long-term antibiotics in the prevention of infection in postoperative cardiac surgeries.

OBJECTIVE: To compare the effect of long-term (7 days) versus short-term (2 days) postoperative antibiotics in preventing postoperative infective complications in patients who have undergone open-heart surgeries. DESIGN: Interventional, randomized controlled trial (RCT). PLACE AND DURATION OF STUDY: Department of Cardiac Surgery, Dow University of Health Sciences, from February 2006 to July 2006. PATIENTS AND METHODS: Cardiac patients (n=42), operated for valvular disease (36%), coronary artery bypass grafting (50%), or septal repair (14%), were included in our study. Patients were prospectively randomized into two groups. Group A (n=21) patients received oral antibiotics for 7 days, whereas group B (n=21) patients were given the same for 2 days postoperative. Pre-operative and intra-operative variables were equal in both groups. Total leukocyte count and temperature were monitored daily until the patients were discharged. The chest and leg wounds were inspected daily for any signs of infection. Sputum and urine cultures were sent for selected patients in case of respiratory tract infection or urinary tract infection, respectively. Each patient was followed until the next routine visit in outpatient department. RESULTS: In group A, 3 patients (14%), developed infection postoperatively, whereas in group B, 13 patients (62%) (p =0.001) had to be started on oral or intravenous antibiotics as a result of developing either wound infection, a positive sputum culture, a positive urine culture or a localized infection elsewhere. Mean ward stay in group A was 4.8 +/- 4.5 days and in group B 6.5 +/- 4.1 days (p =0.011). CONCLUSION: In this series, there was a significantly higher frequency of infection and longer hospital stay in patients who received antibiotics for 2 days postoperatively as compared to those who received antibiotics for 7 days.