OPCABG for Moderate CIMR in Elderly Patients: a Superior Option?

OBJECTIVE: To compare the early and late outcomes of off-pump coronary artery bypass grafting and coronary artery bypass graft + mitral valve repair in elderly patients with moderate chronic ischemic mitral regurgitation. METHODS: One hundred and fifty elderly (age > 70 years) patients with moderate chronic ischemic mitral regurgitation who underwent off-pump coronary artery bypass grafting (n=95) or coronary artery bypass graft + mitral valve repair (n=55) between January 2007 and December 2014 were studied. They were subdivided according to presence or absence of high operative risk. Peri-operative variables and early operative outcomes were retrospectively studied. Survival, mitral regurgitation grade, and functional outcomes were prospectively analysed. RESULTS: Both groups were comparable in terms of age (P=0.23), sex (P=0.74), left ventricle ejection fraction (P=0.6) and preoperative functional class (P=0.52). The mean number of grafts for off-pump coronary artery bypass grafting group was 3.14 and coronary artery bypass graft + mitral valve repair was 3.21. Off-pump coronary artery bypass grafting group had statistically significant better early operative outcomes i.e perioperative blood transfusions, intraaortic balloon pump usage, arrhythmias, renal dysfunction, liver dysfunction, sepsis, mean hours of ventilation, intensive care unit stay and operative mortality. On a prospective follow up of 5±2.33 years (1-9 years), coronary artery bypass graft + mitral valve repair in low operative risk subgroup had better improvements in mitral regurgitation grade than off-pump coronary artery bypass grafting. Both groups had similar improvements in functional class and cumulative survival was also comparable (63.2% vs. 54.5%). CONCLUSION: Off-pump coronary artery bypass grafting is a safer alternative to coronary artery bypass graft + mitral valve repair with better early operative outcomes and comparable late survival and functional outcomes in elderly patients with moderate chronic ischemic mitral regurgitation, especially those with higher operative risk.

OPCABG for moderate cimr in elderly patients: a superior option?

Abstract Objective: To compare the early and late outcomes of off-pump coronary artery bypass grafting and coronary artery bypass graft + mitral valve repair in elderly patients with moderate chronic ischemic mitral regurgitation. Methods: One hundred and fifty elderly (age > 70 years) patients with moderate chronic ischemic mitral regurgitation who underwent off-pump coronary artery bypass grafting (n=95) or coronary artery bypass graft + mitral valve repair (n=55) between January 2007 and December 2014 were studied. They were subdivided according to presence or absence of high operative risk. Peri-operative variables and early operative outcomes were retrospectively studied. Survival, mitral regurgitation grade, and functional outcomes were prospectively analysed. Results: Both groups were comparable in terms of age (P=0.23), sex (P=0.74), left ventricle ejection fraction (P=0.6) and preoperative functional class (P=0.52). The mean number of grafts for off-pump coronary artery bypass grafting group was 3.14 and coronary artery bypass graft + mitral valve repair was 3.21. Off-pump coronary artery bypass grafting group had statistically significant better early operative outcomes i.e perioperative blood transfusions, intraaortic balloon pump usage, arrhythmias, renal dysfunction, liver dysfunction, sepsis, mean hours of ventilation, intensive care unit stay and operative mortality. On a prospective follow up of 5±2.33 years (1-9 years), coronary artery bypass graft + mitral valve repair in low operative risk subgroup had better improvements in mitral regurgitation grade than off-pump coronary artery bypass grafting. Both groups had similar improvements in functional class and cumulative survival was also comparable (63.2% vs. 54.5%). Conclusion: Off-pump coronary artery bypass grafting is a safer alternative to coronary artery bypass graft + mitral valve repair with better early operative outcomes and comparable late survival and functional outcomes in elderly patients with moderate chronic ischemic mitral regurgitation, especially those with higher operative risk.

Techniques, Timing & Prognosis of Post Infarct Ventricular Septal Repair: a Re-look at Old Dogmas.

OBJECTIVE:: The study aimed to identify the factors affecting the prognosis of post myocardial infarction (MI) ventricular septal rupture (VSR) and to develop a protocol for its management. METHODS:: This was a single center, retrospective-prospective study (2009-2014), involving 55 patients with post MI VSR. The strengths of association between risk factors and prognosis were assessed using multivariate logistic regression analysis. The UNM Post MI VSR management and prognosis scoring systems (UPMS & UPPS) were developed. RESULTS:: Thirty-day mortality was 52.5% (35% in the last 3 years). Twenty-eight (70%) patients underwent concomitant coronary artery bypass grafting. Residual ventricular septal defect was found in 3 (7.5%) patients. The multivariate analysis showed low mean blood pressure with intra-aortic balloon pump (OR 11.43, P=0.001), higher EuroSCORE II (OR 7.47, P=0.006), higher Killip class (OR 27.95, P=0.00), and shorter intervals between MI and VSR (OR 7.90, P=0.005) as well as VSR and Surgery (OR 5.76, P=0.016) to be strong predictors of mortality. Concomitant coronary artery bypass grafting (P=0.17) and location (P=0.25) of VSR did not affect the outcome. Mean follow-up was 635.8±472.5 days and 17 out of 19 discharged patients were in NYHA class I-II. CONCLUSION:: The UNM Post-MI VSR Scoring Systems (UPMS & UPPS) help in management and prognosis, respectively. They divide patients into 3 groups: 1) Immediate Surgery - Patients with scores of <25 require immediate surgery, preferably with extracorporeal membrane oxygenation support, and have poor prognosis; 2) Those with scores of 25-75 should be managed with "Optimal Delay" and they have intermediate outcomes; 3) Patients with scores of >75 can undergo Elective Repair and they are likely to have good outcomes.

Techniques, timing & prognosis of post infarct ventricular septal repair: a re-look at old dogmas

Abstract Objective: The study aimed to identify the factors affecting the prognosis of post myocardial infarction (MI) ventricular septal rupture (VSR) and to develop a protocol for its management. Methods: This was a single center, retrospective-prospective study (2009-2014), involving 55 patients with post MI VSR. The strengths of association between risk factors and prognosis were assessed using multivariate logistic regression analysis. The UNM Post MI VSR management and prognosis scoring systems (UPMS & UPPS) were developed. Results: Thirty-day mortality was 52.5% (35% in the last 3 years). Twenty-eight (70%) patients underwent concomitant coronary artery bypass grafting. Residual ventricular septal defect was found in 3 (7.5%) patients. The multivariate analysis showed low mean blood pressure with intra-aortic balloon pump (OR 11.43, P=0.001), higher EuroSCORE II (OR 7.47, P=0.006), higher Killip class (OR 27.95, P=0.00), and shorter intervals between MI and VSR (OR 7.90, P=0.005) as well as VSR and Surgery (OR 5.76, P=0.016) to be strong predictors of mortality. Concomitant coronary artery bypass grafting (P=0.17) and location (P=0.25) of VSR did not affect the outcome. Mean follow-up was 635.8±472.5 days and 17 out of 19 discharged patients were in NYHA class I-II. Conclusion: The UNM Post-MI VSR Scoring Systems (UPMS & UPPS) help in management and prognosis, respectively. They divide patients into 3 groups: 1) Immediate Surgery - Patients with scores of <25 require immediate surgery, preferably with extracorporeal membrane oxygenation support, and have poor prognosis; 2) Those with scores of 25-75 should be managed with "Optimal Delay" and they have intermediate outcomes; 3) Patients with scores of >75 can undergo Elective Repair and they are likely to have good outcomes.

Cervical Cannulation for Surgical Repair of Congenital Cardiac Defects in Infants and Small Children.

INTRODUCTION:: The biggest challenge faced in minimally invasive pediatric cardiac surgery is cannulation for cardiopulmonary bypass. Our technique and experience of cervical cannulation in infants and small children for repair of congenital cardiac defects is reported in this study. METHODS:: From January 2013 to June 2015, 37 children (22 males) with mean age of 17.97±8.63 months and weight of 8.06±1.59 kg were operated on for congenital cardiac defects through right lateral thoracotomy. The most common diagnosis was ventricular septal defect (18 patients). In all patients, right common carotid artery, right internal jugular vein and inferior vena cava were cannulated for institution of cardiopulmonary bypass and aorta was cross clamped through right 2nd intercostal space. RESULTS:: There were no deaths or any major complications related to cervical cannulation. Common carotid artery cannulation provided adequate arterial inflow while internal jugular vein with inferior vena cava provided adequate venous return in all patients. No patient required conversion to sternotomy or developed vascular, neurological or wound related complications. Three patients had residual lesions (small leak across ventricular septal defect patch-2, Grade II left atrio-ventricular valve regurgitation-1) and one patient had mild left ventricular dysfunction. At discharge, both common carotid artery and internal jugular vein were patent on color Doppler ultrasonography in all patients. In a mean follow-up period of 11.4±2.85 months, all patients were doing well. No patient had any wound related, neurological or vascular complication. No patient had residual leak across ventricular septal defect patch. CONCLUSION:: Cervical cannulation of common carotid artery and internal jugular vein is a safe, reliable, efficient and quick method for institution of cardiopulmonary bypass in minimally invasive pediatric cardiac surgery.

Cervical cannulation for surgical repair of congenital cardiac defects in infants and small children

Abstract INTRODUCTION: The biggest challenge faced in minimally invasive pediatric cardiac surgery is cannulation for cardiopulmonary bypass. Our technique and experience of cervical cannulation in infants and small children for repair of congenital cardiac defects is reported in this study. METHODS: From January 2013 to June 2015, 37 children (22 males) with mean age of 17.97±8.63 months and weight of 8.06±1.59 kg were operated on for congenital cardiac defects through right lateral thoracotomy. The most common diagnosis was ventricular septal defect (18 patients). In all patients, right common carotid artery, right internal jugular vein and inferior vena cava were cannulated for institution of cardiopulmonary bypass and aorta was cross clamped through right 2nd intercostal space. RESULTS: There were no deaths or any major complications related to cervical cannulation. Common carotid artery cannulation provided adequate arterial inflow while internal jugular vein with inferior vena cava provided adequate venous return in all patients. No patient required conversion to sternotomy or developed vascular, neurological or wound related complications. Three patients had residual lesions (small leak across ventricular septal defect patch-2, Grade II left atrio-ventricular valve regurgitation-1) and one patient had mild left ventricular dysfunction. At discharge, both common carotid artery and internal jugular vein were patent on color Doppler ultrasonography in all patients. In a mean follow-up period of 11.4±2.85 months, all patients were doing well. No patient had any wound related, neurological or vascular complication. No patient had residual leak across ventricular septal defect patch. CONCLUSION: Cervical cannulation of common carotid artery and internal jugular vein is a safe, reliable, efficient and quick method for institution of cardiopulmonary bypass in minimally invasive pediatric cardiac surgery.