Stapler versus polyamide sutures for skin closure for sternal wounds in coronary artery bypass graft surgery - our experience.

INTRODUCTION: Patients undergoing coronary artery bypass graft surgery constitute a large population of patients with anatomically similar incisions created under similar circumstances. AIM: Our study aimed at analysing and comparing rates of surgical site infections (SSIs) at the sternotomy sites based on the material used for skin closure of the sternal wound with special emphasis on presence of risk factors such as diabetes (glycated haemoglobin (HbA1c) > 9) and obesity (body mass index (BMI) > 30 kg/m2) in the 2 respective groups. MATERIAL AND METHODS: This is a retrospective observational study. A total of 864 patients were included in the study. The patients were grouped into 2 groups depending on the sternal wound closure strategy used. One group consisted of patients in whom polyamide sutures were used for skin closure, while the other group comprised patients in whom skin staples were used for skin closure. Incidence of sternal wound SSIs in both groups was noted. Co-morbid conditions such as diabetes mellitus (with HbA1c > 9) and obesity (BMI > 30 kg/m2) were noted and analysed as contributory factors for SSIs. RESULTS: Group A comprised 432 patients out of whom 42 (9.72%) had sternal wound SSIs. Group B comprised the other 432 patients of whom only 20 (4.62%) developed sternal wound SSIs. Co-morbid conditions were analysed in each group. Group A showed SSI in 22/64 (34.3%) diabetic patients, 6/28 (21.8%) obese patients and 16/22 (72.72%) with diabetes and obesity. Group B showed SSIs in 6/56 (10.715) diabetics, 4/26 (6.01%) obese and 4/24 (16.67%) with diabetes and obesity. CONCLUSIONS: By pairing staples and sutures, we observed a significantly lower incidence of total wound complications with suture than with staple closure.

Our experience of total pericardiectomy for constrictive pericarditis: a comprehensive analysis over a period of 5 years.

INTRODUCTION: Constrictive pericarditis (CP) usually presents as a result of chronic fibrous pericardial thickening and calcification of the pericardium which causes reduced cardiac output. Despite the lack of prospective studies comparing the different therapeutic strategies, surgical pericardiectomy is a valuable treatment under most circumstances. AIM: We analyzed our records to highlight the predictors of morbidity and mortality of pericardiectomy and also short-term surgical outcome of the same procedure in a single center. MATERIAL AND METHODS: We carried out a comprehensive retrospective analysis of the records of patients who underwent surgery for CP at our institute between 2013 and 2018. 30 patients underwent isolated pericardiectomy. All patients underwent median sternotomy and total pericardiectomy without the use of cardiopulmonary bypass. Pre-operative, intra-operative and post-operative characteristics were noted. RESULTS: Fifteen patients had a history of pulmonary tuberculosis. The majority of the patients presented with NYHA grade III or IV. 60% of the patients were male. The preoperative mean central venous pressure was 24 ±9 mm Hg and decreased to 9 ±5 mm Hg after surgery. The 30-day mortality was 6.66% (2/30). Morbidity was mainly due to low-cardiac output syndrome (n = 4). A total of 26 patients had significant improvement in their NYHA status. CONCLUSIONS: Although pericardiectomy for CP remains associated with some operative mortality, the short-term outcome is favorable, and surgical treatment is able to improve the functional class in the majority of survivors.

Effect of octopus tissue stabilizer on cardiac output during off-pump coronary artery bypass graft surgery.

INTRODUCTION: Significant hemodynamic derangements can occur during off-pump coronary artery bypass graft (OPCAB) surgery resulting from the displacement of the beating heart, which may necessitate conversion to on-pump surgery. AIM: We proposed to evaluate the alterations in hemodynamic parameters in patients during the course of anastomosis in OPCAB surgery using the Octopus tissue stabilizer. MATERIAL AND METHODS: In 100 consecutive patients undergoing OPCAB surgery, hemodynamic variables including cardiac output (CO), heart rate (HR), mean arterial pressure (MAP) and central venous pressure (CVP) were recorded at baseline, during each coronary artery anastomosis at 2 min, 10 min and after release of the Octopus tissue stabilizer. RESULTS: CO decreased significantly after target stabilization and during all coronary anastomoses (5.42 ±1.1 l/min at baseline, 4.26 ±1.02 l/min at 2 min and 3.92 ±0.98 l/min at 10 min; p < 0.001), with the greatest decrease noted during obtuse marginal (OM) branch of left circumflex artery anastomosis (3.67 ±0.86 l/min at 2 min and 3.38 ±0.78 l/min at 10 min). Inotropic drugs were required to maintain mean arterial pressure (MAP) > 60 mm Hg in 43 patients, which was most frequently noted during OM anastomosis (p < 0.001). The incidence of bradycardia requiring inotropes was noted to be the highest during left anterior descending (LAD) artery anastomosis (p = 0.002). CONCLUSIONS: During OPCAB surgery using the Octopus for coronary target stabilization, CO decreased the most during OM anastomosis requiring inotropes, while bradycardia was most frequent during LAD anastomosis. Careful monitoring and management of hemodynamic variables are therefore of utmost importance to avoid conversion to on-pump surgery.

Left sided PAPVC with intact IAS-Surgically managed with vertical vein anastomosis to LA appendage: A rare case report.

INTRODUCTION: Partial anomalous pulmonary venous connection (PAPVC) is a rare entity. Only 10% of these are left sided. An intact atrial septum is further uncommon. PRESENTATION OF CASE: We present a case of left sided PAPVC with no atrial septal defect (ASD), who presented with effort intolerance and an unremarkable physical examination. Computed tomography pulmonary angiography (CTPA) confirmed the primary diagnosis as suggested by an initial 2-D echocardiography, and aided in better understanding of the anatomy. CONCLUSION: Patient underwent successful surgery through a simple & reproducible technique of anastomosis of vertical vein to left atrial appendage. Patient recovered uneventfully and was discharged on day 10.

Use of nitroglycerin and verapamil solution by organ bath technique in preparation of left internal thoracic artery for coronary artery bypass surgery.

BACKGROUND: The aim of this prospective study was to compare the effect of application of nitroglycerin and verapamil solution (GV) by organ bath technique with other methods of applications and solutions on the free blood flow of LITA. The technique was not described for in situ graft before. METHOD: The patients were randomly assigned to four groups: group I (n_32, GV solution by organ bath technique), group II (n_30, papaverine solution by organ bath technique), group III (n_29, topical GV solution) or group IV (n_29, topical papaverine solution). In each patient, pedicled LITA was harvested; thereafter applied with the randomized different methods and solutions. The free flow from the distal end of the divided LITA was measured for 15s under controlled hemodynamic conditions after harvesting (Flow 1). The flow of LITA was measured again just prior to anastomosing the conduit (Flow 2). RESULT: The mean blood flow in LITA was 56.2±5.0ml/min before application of solutions. After application, the mean blood flow in group I:102.3±7.0ml/min, in group II: 92.7±3.4ml/min, and in group III: 88.6±2.2ml/min and in group IV: 81.4±2.1. Proportional increases in blood flow observed in group I (82.6%)>group II (65.1%)>group III (57.6)>group IV (44.8%) (p<0.05). CONCLUSIONS: GV solution by organ bath technique is effective and superior in comparison to use of papaverine using organ bath technique or topical spray of GV or papaverine solution.

Relationship between High Red Cell Distribution Width and Systemic Inflammatory Response Syndrome after Extracorporeal Circulation.

OBJECTIVE: Cardiac surgical operations involving extracorporeal circulation may develop severe inflammatory response. This severe inflammatory response syndrome (SIRS) is usually associated with poor outcome with no predictive marker. Red cell distribution width (RDW) is a routine hematological marker with a role in inflammation. We aim to determine the relationship between RDW and SIRS through our study. METHODS: A total of 1250 patients who underwent cardiac surgery with extracorporeal circulation were retrospectively analyzed out of which 26 fell into the SIRS criteria and 26 consecutive control patients were taken. RDW, preoperative clinical data, operative time and postoperative data were compared between SIRS and control groups. RESULTS: The demographic profile of the patients was similar. RDW was significantly higher in the SIRS versus control group (15.5±2.0 vs. 13.03±1.90), respectively with P value <0.0001. There was significant mortality in the SIRS group, 20 (76.92%) as compared to 2 (7.6%) in control group with a P value of <0.005. Multiple logistic regression analysis revealed that there was significant association with high RDW and development of SIRS after extracorporeal circulation (OR for RDW levels exceeding 13.5%; 95% CI 1.0-1.2; P<0.05). CONCLUSION: Increased RDW was significantly associated with increased risk of SIRS after extracorporeal circulation. Thus, RDW can act as a useful tool to predict SIRS in patients undergoing cardiac surgery with extracorporeal circulation. Hence, more aggressive measures can be taken in patients with high RDW to prevent postoperative morbidity and mortality.

Relationship between high red cell distribution width and systemic inflammatory response syndrome after extracorporeal circulation

Abstract Objective: Cardiac surgical operations involving extracorporeal circulation may develop severe inflammatory response. This severe inflammatory response syndrome (SIRS) is usually associated with poor outcome with no predictive marker. Red cell distribution width (RDW) is a routine hematological marker with a role in inflammation. We aim to determine the relationship between RDW and SIRS through our study. Methods: A total of 1250 patients who underwent cardiac surgery with extracorporeal circulation were retrospectively analyzed out of which 26 fell into the SIRS criteria and 26 consecutive control patients were taken. RDW, preoperative clinical data, operative time and postoperative data were compared between SIRS and control groups. Results: The demographic profile of the patients was similar. RDW was significantly higher in the SIRS versus control group (15.5±2.0 vs. 13.03±1.90), respectively with P value <0.0001. There was significant mortality in the SIRS group, 20 (76.92%) as compared to 2 (7.6%) in control group with a P value of <0.005. Multiple logistic regression analysis revealed that there was significant association with high RDW and development of SIRS after extracorporeal circulation (OR for RDW levels exceeding 13.5%; 95% CI 1.0-1.2; P<0.05). Conclusion: Increased RDW was significantly associated with increased risk of SIRS after extracorporeal circulation. Thus, RDW can act as a useful tool to predict SIRS in patients undergoing cardiac surgery with extracorporeal circulation. Hence, more aggressive measures can be taken in patients with high RDW to prevent postoperative morbidity and mortality.

Effect of prosthesis patient mismatch in mitral position on pulmonary hypertension.

OBJECTIVES: Pulmonary arterial hypertension (PAH) is associated with poor outcome after mitral valve replacement (MVR). We proposed to evaluate the effect of valve prosthesis patient mismatch (PPM) on pulmonary arterial (PA) pressure following MVR. METHODS: Five hundred patients who have undergone MVR were studied retrospectively. Postoperative PA systolic pressure (PASP) measured 6 months postoperatively by Doppler echocardiography was compared with preoperative values. PASP ≥ 40 mmHg was defined as PAH. Mitral valve effective orifice area was calculated by the continuity equation and indexed for body surface area. PPM was defined as indexed effective orifice area ≤ 1.2 cm2/m2. A multivariate model was constructed to ascertain the independent determinants of systolic PA pressure. Also, a propensity score model was constructed to overcome the baseline differences between the PPM and no PPM groups. RESULTS: The incidence of PPM in this study was 37.2%. The average postoperative PASPs were 30.49 and 42.35 mmHg in the no PPM and PPM groups, respectively; (P < 0.001). Regression of PAH in the PPM and no PPM groups was 76.26% and 20.64%, respectively; (P < 0.001). The indexed effective orifice area correlated well with postoperative PASP (r = 0.71). The overall survival and freedom from cardiac death at 10 years were 79.8% and 85.3%; and at 20 years were 66.5% and 74.3%, respectively. Both, overall survival and the freedom from cardiac death were higher in the no PPM group than in the PPM group; (P < 0.001). Propensity score matching analysis yielded 112 pairs of the PPM and no PPM cohorts, which revealed higher overall survival and freedom from cardiac death in the no PPM group; (P = 0.028 and 0.012, respectively). CONCLUSIONS: Mitral PPM is an independent predictor of persistent PAH after MVR along with associated morbidity and reduced survival.

A Concomitant Intramyocardial and Pulmonary Hydatid Cyst: A Rare Case Report.

Cardiac hydatid cyst is an uncommon but potentially fatal disease. In cystic Echinococcus humans are an accidental host. Liver and lungs are the most frequently involved organs. Herein a unique case of intramyocardial hydatid cyst of left ventricle along with pulmonary hydatid cyst in a 38-year-old lady is reported. Surgical removal of the cardiac hydatid cyst was done with the aid of cardiopulmonary bypass followed by removal of pulmonary hydatid cyst.

A concomitant intramyocardial and pulmonary hydatid cyst: a rare case report

Abstract Cardiac hydatid cyst is an uncommon but potentially fatal disease. In cystic Echinococcus humans are an accidental host. Liver and lungs are the most frequently involved organs. Herein a unique case of intramyocardial hydatid cyst of left ventricle along with pulmonary hydatid cyst in a 38-year-old lady is reported. Surgical removal of the cardiac hydatid cyst was done with the aid of cardiopulmonary bypass followed by removal of pulmonary hydatid cyst.

Comparison of del Nido cardioplegia and St. Thomas Hospital solution - two types of cardioplegia in adult cardiac surgery.

INTRODUCTION: St. Thomas' cardioplegic solution No. 2 (ST), although most widely used in adult cardiac surgery, needs to be given at short intervals, causing additional myocardial injury. AIM: To determine whether del Nido (DN) cardioplegia, with longer periods of arrest, provides equivalent myocardial protection as compared to ST. MATERIAL AND METHODS: The study population comprised 100 patients who underwent elective coronary artery bypass grafting (CABG) or double valve replacement (DVR) surgery between January 2015 and January 2016. The patients were divided into two groups based on the type of cardioplegia administered during surgery: 1) intermittent ST (ST, n = 50) and 2) DN cardioplegia (DN, n = 50). We compared the aortic cross clamp (CC) and cardiopulmonary bypass (CPB) times, number of intra-operative DC shocks required, and postoperative changes in left ventricular ejection fraction (LVEF) in the two groups. RESULTS: The aortic cross clamp and bypass times were shorter with DN (110.15 ±36.84 vs. 133.56 ±35.66 and 158.60 ±39.92 vs. 179.81 ±42.36 min respectively, p < 0.05). Fewer cardioplegia doses were required in the DN group vs. the ST group (1.38 ±0.59 vs. 4.15 ±1.26; p = 0.001), while a single cardioplegia dose was given to 35 DN patients (70%) vs. 0 ST patients (p < 0.001). Postoperative LVEF was better preserved in the DN group. CONCLUSIONS: The use of DN leads to shorter cross clamp and CPB times, reduces cardioplegia dosage, and provides potentially better myocardial protection in terms of LVEF preservation, with a safety profile comparable to ST cardioplegia.

Extensive ossification of thymoma in a child.

A case of thymoma with extensive ossification in an 8-year-old female child is presented. The presence of extensive ossification in the stroma of the thymoma is an extremely rare feature. To date, there is a single report of ossifying thymoma in children. This report represents the second known case in a child in the worldwide literature.

Isolated pericardial and intracardiac hydatidosis: presentation as congestive cardiac failure and fatal pulmonary embolism.

Localization of hydatid cysts in the heart is a rare phenomenon, with an incidence of 0.5-2%. In almost half these cases, the heart is the sole organ to be involved. We report a case of massive pericardial hydatidosis in a female patient who presented with features of congestive cardiac failure. Cysts in the endocardium of right side of the heart resulted in fatal pulmonary embolism.

Aortic pseudo-aneurysm: cause of life-threatening hemoptysis in a 13-month-old child.

Aortic aneurysms and pseudo-aneurysms are a rare occurrence in the pediatric age group. True aneurysms are usually related to infection or to inherited disorders while pseudo-aneurysms occur following trauma or infection. We present a case of a pseudo-aneurysm of the descending thoracic aorta in a 13-month-old child, who presented with life-threatening massive hemoptysis. Though no clear-cut etiologic factor was identified on clinical examination and investigations, presence of neutrophilic infiltration in the wall suggested an infective nature.

Rhabdomyoma of the right atrium: report of a case.

Rhabdomyomas are the most common primary cardiac tumors in childhood, and are considered to be congenital lesions. They are uncommon in adolescents and adults due to their tendency for spontaneous regression. Majority of them are located in the ventricular chambers, and are also associated with tuberous sclerosis. The indications for surgery include hemodynamic compromise and intractable arrhythmias. We describe a right atrial rhabdomyoma in a previously healthy 16-year-old girl who presented with palpitation and dizziness of recent onset. Postoperative evaluation had not revealed stigmata of tuberous sclerosis.

Efficacy of three different ablative procedures to treat atrial fibrillation in patients with valvular heart disease: a randomised trial.

OBJECTIVES: Various modifications have been proposed to the original Cox's Maze procedure due to concerns about the long bypass and cross clamp times. The efficacy of these procedures has been studied and reported. We conducted a randomised prospective study to compare three procedures, differing in extent, of ablation in patients in atrial fibrillation who were undergoing surgery for rheumatic valvular heart disease. These procedures utilised radiofrequency in the bipolar mode. The extent of ablation was (1) biatrial (replication of the Cox Maze) (2) left atrial portion of the Cox Maze and (3) pulmonary vein isolation along with a control group (the No Maze group). Conversion rate to sinus rhythm was studied over a mid-term follow-up period. METHODS: A total of 160 patients were studied with 40 patients in each group. Antiarrhythmic drugs were not used in the three months preceding surgery and for seven days postoperatively. The patients underwent surgery for their valve disease along with the ablative procedure as per randomisation using radiofrequency microbipolar coagulation and cryoablation. They were followed up and were evaluated for symptomatic improvement, rhythm with ECG documentation and 2D echocardiography. RESULTS: Follow-up was available for 133 patients. Mid-term results showed that sinus rhythm was restored in 62.5% patients of Biatrial Maze group and 57.5% in the Left Atrial Maze. In the Pulmonary Vein Isolation Maze group, 67.5% patients converted to NSR whereas in the No Maze group only 20% patients were in sinus rhythm (p value for all the groups was 0.001 when compared to the No Maze group). The incidence of other arrhythmias was not significant and there were no other major complications. All the patients in sinus rhythm at follow-up were in NYHA functional class I-II and showed good effort tolerance. CONCLUSIONS: Results achieved with the three ablative procedures are comparable. Therefore lesser procedures viz. Left Atrial Maze and the Pulmonary Vein Isolation Maze procedures must be studied further with the additional use of antiarrhythmic drugs.

Persistent left SVC with absent right SVC: a rare anomaly.

A persistent left superior vena cava is an anomaly found in association with many congenital heart disorders. However its presence along with absence of the right superior vena cava is a very rare congenital anomaly. This anomaly has implications in various interventional procedures and in cardiac surgery. We present here a case with absence of the right SVC and a persistent left SVC found in association with an ostium secundum atrial septal defect.