Midterm outcome of off-pump CABG for severe LV dysfunction-Does LV size and function predict their midterm outcome?

BACKGROUND: The superiority of surgical revascularization in ischemic cardiomyopathy is established beyond doubt, and off-pump CABG (OP-CABG) is a safe way of revascularization in this high-risk subset. Data on the effect of postoperative ventricular function and size on their midterm outcome is scarce. MATERIALS AND METHODS: A retrospective study was done on 211 consecutive patients with severe LV dysfunction who underwent OP-CABG from January 2017 to December 2018. Data were collected from the institutional database. Their operative and midterm outcomes were statistically analyzed. RESULTS: The mean age of the cohort was 58.4 ± 8.3 years. An average number of grafts was 3.1 ± 0.8 (cumulative intended number of grafts-3). Operative mortality was 10.9%. Preoperative NYHA class (p < .0001; OR, 19.72) and postoperative IABP insertion (p < .008; OR, 88.75) were independent predictors of operative mortality. The mean follow-up period was 3.14 ± 0.07 years, was 97.4% complete with cardiac mortality of 5.8%. Postoperative LVEF (p = .002; OR, 0.868) and LV dimensions (systole & diastole) (p = .013, OR = 1.182 and p = .036, OR = 1.184, respectively) were independent predictors of midterm mortality. Midterm major adverse cardiovascular event-free survival of operative survivors was 89%. There was no correlation between postoperative LV dimension and NYHA status(p > .05). Myocardial viability was not associated with early (p = .17) or midterm mortality (p = .676). CONCLUSION: OP-CABG can achieve complete revascularization in patients with severe LV dysfunction with good midterm outcomes, albeit with high early operative mortality. Postoperative change in LV dimension and EF are predictors of midterm mortality.

Surgical repair of multiple congenital left ventricular aneurysms with rupture into left atrium.

Congenital left ventricular aneurysm (CLVA) associated with multiple aneurysms with rupture into the left atrium (LA) is rare. We report a 17-year-old male with two CLVAs, one of which ruptured into the LA, and discuss the surgical management and review the literature of this rare disease.

Operative management of intracardiac myxomas: A single center experience.

BACKGROUND: Cardiac myxomas are the most common benign intracardiac tumors. We studied the clinical presentation of cardiac myxomas, their morbidity, mortality and recurrence rate following surgery at our institution over a period of four years. METHODS: During August 2008 to November 2012, a total of 12023 cardiac surgeries were performed. Amongst these, 50 patients (12 males, 38 females) underwent complete removal of primary or recurrent intracardiac myxomas. Complete tumor excision with a cuff of interatrial septum followed copious saline irrigation of the cardiac chambers was performed in each case. RESULTS: Forty six patients survived the surgery of which 43 are being followed up at regular intervals for development of recurrence. Myxomas constituted 0.41% of the total cardiac surgeries at our institute. Most of them were noted in the fourth decade. The commonest location was left atrium (74%) followed by right atrium (22%). Only one patient had a myxoma in the right ventricle. Forty six patients (92%) survived the surgery. CONCLUSION: Cardiac myxoma excision account for a very small percentage of cardiac procedures. Immediate surgical treatment is indicated in all patients. Cardiac myxomas can be excised with a low rate of mortality and morbidity.

Permacath: wrong pathway leading to a correct destination.

Permacath insertion using ultrasound has drastically reduced complications than those associated with blind puncture. We hereby report a case of entry of the permacath into the right femoral vein after through and through puncture of the right femoral artery. Use of real-time ultrasound, early clinical suspicion, timely diagnosis, and emergency surgery can avoid grave complications.

Is Deep Hypothermic Cardiac Arrest Mandatory in Aortic Arch Surgeries?

Cannulation strategies in aortic arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the way out, but it does come with its set of demerits. Here we demonstrate a case with aortic arch dissection dealt with dual cannulation strategy in axillary and femoral artery without need for DHCA and ensuring complete neuroprotection of brain and spinal cord without hinderance of time factor. Inception of new ideas like this may decrease the need for DHCA and hence its drawbacks, thus decreasing the morbidity and mortality associated.

Dual ruptured sinus of Valsalva aneurysms.

Ruptured sinus of Valsalva (RSOV) aneurysm is a rare anomaly accounting for around 0.14-3.5% in patients undergoing open cardiac surgeries. We report a rare case of an 18-year-old male with dual RSOV aneurysms who was managed successfully by patch closure via the transaortic approach and which to our knowledge has never been reported ("PubMed" and "Google Scholar" as the search engine with dual, ruptured, sinus of Valsalva aneurysm as the MeSH words). Dual RSOV aneurysm in a single patient is an extremely rare condition which can lead to early cardiogenic shock and should be managed surgically at the earliest.

Left handedness in cardiac surgery-boon or bane?

Left-handed individuals consist of around 11% of the population and true ambidextrous consists of only 2-3% of the total population. Almost a similar ratio is seen in medical profession also. Difficulties are obvious for left-handed cardiac surgeons in the operating room due to regular right-handed instruments, laterality, and positioning of the patients. In this article, we discuss about the problems and the potential solutions for left-handed cardiac surgeons.

Prognosis of aortic valve disease following mitral valve surgery.

INTRODUCTION: Little is known about the course of aortic valve disease in patients undergoing mitral valve surgery for rheumatic mitral valve disease. In addition, there are no guidelines regarding the appropriate treatment of mild aortic valve disease while replacing the mitral valve. AIM: To evaluate the long-term outcome of aortic valve disease and the need for aortic valve surgery in patients with rheumatic mitral valve disease who underwent mitral valve surgery. MATERIAL AND METHODS: Twenty patients (6 male, 14 female; mean age: 23.4 years, range: 14-41) were followed after mitral valve surgery for a mean period of 14 years. All patients had rheumatic heart disease. Aortic valve function was assessed preoperatively by transthoracic echocardiography and during follow-up. RESULTS: At the time of mitral valve surgery, 11 (55%) patients had aortic valve disease with aortic regurgitation. Nine (45%) patients had no evidence of aortic valve disease. At second surgery, all patients had aortic valve disease (either pure regurgitation or with stenosis). Most had mild disease at the time of mitral valve surgery. Aortic valve replacement was needed after a mean period of 14.1 years (range: 3-26 years). CONCLUSIONS: In patients with rheumatic heart disease, a noticeable number of patients have mild aortic valve disease at the time of mitral valve surgery. Only a few progress to severe disease, and aortic valve replacement is rarely needed after a long follow-up period.

Is Deep Hypothermic Cardiac Arrest Mandatory in Aortic Arch Surgeries?

ABSTRACT Cannulation strategies in aortic arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the way out, but it does come with its set of demerits. Here we demonstrate a case with aortic arch dissection dealt with dual cannulation strategy in axillary and femoral artery without need for DHCA and ensuring complete neuroprotection of brain and spinal cord without hinderance of time factor. Inception of new ideas like this may decrease the need for DHCA and hence its drawbacks, thus decreasing the morbidity and mortality associated.

Surgical overview of cardiac echinococcosis: a rare entity.

OBJECTIVES: The purpose of this study was to describe our experience with the presentation and management of cardiac echinococcosis and the outcomes. METHODS: We performed a retrospective study from January 2012 to September 2017 in 10 patients operated on for cardiac echinococcosis. There were 6 men and 4 women; the age range was 17-55 years (mean age, 35.9 ± 12.04 years). Among the 10 patients, 3 had multiple cysts and of the 7 patients with a solitary cyst, 5 cysts were in the left ventricle, 1 was in the right ventricle and 1 was in the interventricular septum. All patients were evaluated with electrocardiography, transthoracic echocardiography, computed tomography/magnetic resonance imaging of the thorax, ultrasound examinations of the abdominal organs, haemagglutination tests and histopathological examination of the cyst. RESULTS: Nine operations were performed using cardiopulmonary bypass. One patient with a pericardial cyst was operated on with a beating heart with cystectomy and partial pericardiectomy. Preoperatively, all patients received albendazole for 2 weeks except for 1 patient who had an emergency operation. Albendazole was continued postoperatively in all patients for 12 weeks. There were no postoperative complications. No recurrences have been observed so far. CONCLUSIONS: Cardiac echinococcosis is an infrequently encountered entity, but with clinical suspicion and early diagnosis it can be successfully managed with good outcomes.

Ascending aortic aneurysm and diaphragmatic hernia in a case of Marfan syndrome.

Marfan syndrome commonly affects the skeletal, ocular, and cardiovascular systems. Involvement of the gastrointestinal system is known but uncommon. Intervention depends upon the system involved and the severity of symptoms. Special awareness is required for the diagnosis and management of gastrointestinal involvement in these patients. We report a rare case of simultaneous surgical repair of an ascending aortic aneurysm and a type IV hiatal hernia in a 35-year-old man with Marfan syndrome.

Invasive pericardial hydatid cyst: Excision of multiple huge cysts.

Cardiac hydatid cyst is rare even in endemic countries, and poses a therapeutic challenge due to varying presentation and unpredictable pre-, peri-, and postoperative complications. We herein present a case of multiple, multifocal, huge pericardial hydatid cyst, with invasion into the left ventricle and main pulmonary artery in a young male patient, presented with atypical chest pain.

Clonidine and ketamine for stable hemodynamics in off-pump coronary artery bypass.

BACKGROUND: The current era of fast-track extubation and faster recovery after cardiac surgery requires agents that provide perioperative sedation, suppress sympathetic response, reduce opioid requirement, and maintain hemodynamic stability. METHODS: In a prospective randomized double-blind study, 75 off-pump coronary artery bypass patients were divided into 3 groups of 25 each: group A had clonidine 1 µg·kg(-1), group B had clonidine 1 µg·kg(-1) and ketamine 1 mg·kg(-1), and group C had a saline placebo. Perioperative changes in heart rate, systolic and diastolic blood pressure, sedation score, pain score, and requirement of analgesics, beta blockers, fentanyl, propofol, and inotropes were recorded, as well time to extubation, intensive care unit stay, and 30-day mortality. RESULTS: The combination of clonidine and ketamine led to stable hemodynamics and reduced beta-blocker dosage. The sedation score was highest in groups A and B up to 24 h postoperatively. The pain score was lowest in group B in the first 24 h, and the total dose of analgesics was highest in group C. Clonidine and ketamine or clonidine alone reduced extubation time, but intensive care unit stay was unchanged CONCLUSIONS: Combined low-dose clonidine and ketamine produced perioperative sedation and effective suppression of sympathetic response with stable hemodynamics. Intraoperative beta-blocker use was reduced without increasing inotrope requirement. This combination prolonged the analgesic effect of opioids, reducing postoperative pain score and analgesic requirement. Low-dose clonidine alone produced sedation but did not completely block sympathetic response. Intensive care unit stay and patient outcome were not affected by clonidine or ketamine.

Safe and easy method with little modification in technique is useful for successful internal jugular vein cannulation on the same side even after intra-arterial puncture without using ultrasound guidance in adult cardiac patients.

BACKGROUND: The modification in technique is useful for successful right-sided internal jugular vein (IJV) cannulation on the same side even after intra-arterial puncture without using ultrasound guidance in adult patients. MATERIALS AND METHODS: This study was carried out in total 160 adult patient from American Society of Anesthesiologists Grade II to III patients male (n = 95) and female (n = 65) who underwent cardiac surgery where cannulation was done on right sided by triple lumen catheter (7 French) using Seldinger technique. RESULTS: Majority of patients were cannulated successfully by Seldinger technique with single or double attempt except for five patients in which arterial puncture occurred. All five patients were cannulated successfully on the same side with this modified technique without any significant major complications. They were managed by application of blocker at the end of arterial needle puncture without removing it. In our routine practice, we were used to removing this needle and applying compression for few minutes to prevent hematoma formation after an arterial puncture. In this study, cannula was used as a marker or guideline for the relocation of IJV on the same side and recannulation was performed by changing the direction of needle on same side lateral to the previous one and without going towards the same direction to prevent the arterial puncture again. CONCLUSION: Most simple and useful modified technique for institutes where the complications are most common with trainee doctors and in hospitals where there is no advanced facility like ultrasound-guided cannulation available. By this modification, it will be time saving, very comfortable, and user-friendly technique with high success rate.

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery in Adulthood: Challenges and Outcomes.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is an extremely rare, potentially fatal, congenital anomaly with a high mortality rate in the first year of life. It occurs rarely in adulthood and may appear with malignant ventricular a rrhythmia or sudden death. We report a case of a 49-year-old woman with ALCAPA who presented with dyspnea on exertion. Management was coronary artery bypass grafting to the left anterior descending artery and obtuse marginal arteries, closure of the left main coronary artery ostium, and reestablishment of the dual coronary artery system.

Recurrent Left Atrial Myxoma in a Young Patient: A Rare Entity.

Recurrence of atrial myxoma arising from the site other than inter-atrial septum is quite rare, which is more common in familial than sporadic cases. We here in present a case of 15-year-old young female who presented with recurrence of left atrial (LA) myxoma from unusual site - posterior LA wall after 3 years without any constitutional symptoms, which is the hallmark of recurrence. Complete removal of underlying atrial septum with atrial wall for recurrence prevention is the dictum in primary operation for tumour removal.

Redo Mitral Valve Replacement for Prosthetic Valve Thrombosis: Single Center Experience.

INTRODUCTION: Prosthetic Valve Thrombosis (PVT) remains a significant cause of morbidity and mortality after valve replacement. Although surgical treatment is usually preferred as life-saving in cases of obstructive PVT, optimal treatment is yet to be decided. AIM: To evaluate risk factors and outcome of the patients undergoing redo mitral valve surgery for acute PVT. MATERIALS AND METHODS: Between January 2012 and February 2015, 65 patients underwent redo surgery for obstructive PVT of mitral valve in Department of Cardiothoracic Surgery, UN Mehta Institute of Cardiology & Research Centre. Patients having acute PVT of aortic valve or combined aortic and mitral valve were excluded. Pre-operative, intra-operative and post-operative factors affecting the outcome as well as follow-up data were measured. RESULTS: There were total 65 patients, 17 males and 48 females. Most common presenting symptom was dyspnea (100%), followed by palpitation (57.88%) and fatigue (29.45%). Total mortality was 29.2% (19/65). Mortality rate was significantly higher (16/35, 46%) in patients with direct surgery (Group-2) as compared to those with failed thrombolysis (3/30, 10%) (Group-1). Mortality was also significantly higher in patients presented with New York Heart Association (NYHA) III/IV class as compared to those presented with NYHA I/II class (p=0.02). All survived patients are NYHA Class I-II in follow-up with mean follow-up period was 24 ± 9 months. CONCLUSION: PVT still remains a challenging problem in a post-operative patient with a high mortality independent of treatment modality. Though life-saving, the surgical management of this condition still carries a high risk in haemodynamically unstable and in NYHA class III/IV patients.

Ring annuloplasty for ischemic mitral regurgitation: a single center experience.

BACKGROUND: Ischemic mitral regurgitation associated with coronary artery disease presents a management challenge to cardiac surgeons. We report our early and midterm results of chronic ischemic mitral regurgitation treated with concomitant mitral ring annuloplasty and coronary artery bypass grafting. METHODS: We performed a retrospective review of the medical records of patients who underwent coronary artery bypass grafting at our institute from January 2009 to December 2011. Data were collected in 50 patients with chronic ischemic mitral regurgitation who had mitral ring annuloplasty along with coronary artery bypass grafting. Preoperative data, echocardiographic findings, operative procedure, outcome, and perioperative hemodynamics were analyzed. Early and intermediate follow-up data were also collected and analyzed. RESULTS: There were 3 (6%) early and 9 (18%) late deaths. Of the survivors, 38 (76%) had a significant reduction in left ventricular end-diastolic and end-systolic dimensions and improvement in New York Heart Association functional class. CONCLUSION: Despite a risk of residual regurgitation, mitral ring annuloplasty combined with coronary artery bypass appears to be a good treatment option in selected patients with chronic ischemic mitral regurgitation.

Effect of preoperative oral sildenafil on severe pulmonary artery hypertension in patients undergoing mitral valve replacement.

AIM: Long standing mitral valve disease is usually associated with severe pulmonary hypertension. Perioperative pulmonary hypertension is a risk factor for right ventricular (RV) failure and a cause for morbidity and mortality in patients undergoing mitral valve replacement. Phosphodiesterase 5 inhibitor-sildenafil citrate is widely used to treat primary pulmonary hypertension. There is a lack of evidence of effects of oral sildenafil on secondary pulmonary hypertension due to mitral valve disease. The study aims to assess the effectiveness of preoperative oral sildenafil on severe pulmonary hypertension and incidence of RV failure in patients undergoing mitral valve replacement surgery. MATERIALS AND METHODS: A total of 40 patients scheduled for mitral valve replacement with severe pulmonary hypertension (RV systolic pressure (RVSP) ≥60 mmHg) on preoperative transthoracic echo were randomly treated with oral sildenafil 25 mg (N = 20) or placebo (N = 20) eight hourly for 24 h before surgery. Hemodynamic variables were measured 20 min after insertion of pulmonary artery catheter (PAC) under anesthesia (T1), 20 min at weaning from cardiopulmonary bypass (CPB) (T2) and after 1,2, and 6 h (T3, T4, T5, respectively) during the postoperative period. RESULTS: Systolic and mean pulmonary artery pressure (MPAP) and pulmonary vascular resistance index (PVRI) were significantly lower (P < 0.0001) in sildenafil group at all times. Ventilation time and postoperative recovery room stay were significantly lower (P < 0.001) in sildenafil group. CONCLUSION: Sildenafil produces significant pulmonary vasodilatory effect as compared with placebo in mitral valve replacement patients with severe pulmonary hypertension. It also reduces ventilation time and intensive care unit (ICU) stay time as compared with placebo. It is concluded that sildenafil is effective in reducing pulmonary hypertension when administered preoperatively in patients with severe pulmonary hypertension undergoing mitral valve replacement surgery.