On pump harvesting of Left Internal Mammary Artery (LIMA) in unstable patients undergoing coronary artery bypass grafting (CABG) is a safe operative strategy: A pilot study.

OBJECTIVE: To evaluate the clinical safety of left internal mammary artery (LIMA) harvesting in hemodynamically unstable patients after establishing cardiopulmonary bypass (CPB) in isolated coronary artery bypass graft (CABG) surgery. METHODS: The prospective observational study was conducted at Chaudhry Pervaiz Elahi Institute of Cardiology, Multan, Pakistan, from December 2016 to August 2018. All patients undergoing isolated CABG surgery in which LIMA conduit was harvested after establishing cardiopulmonary bypass because of hemodynamic instability at induction of anaesthesia or during surgery were included in the study. Preoperative, operative and postoperative characteristics of the patients were recorded. Data was analyzed using SPSS 19. RESULTS: In Forty nine patients including 39 male and 10 female, early CPB had to be established because of hemodynamic instability and afterwards LIMA was harvested. Out of 49, 30 patients presented with CCS class III angina. 37 (75.5%) patients were scheduled on elective coronary surgery waiting list. There were 39 (79.59%) patients who weaned off bypass on mild inotropic support and 4 (8.16%) patients needed IABP support. All patients had multi-vessel coronary artery disease. Mean number of grafts were 3.428±0.577, CPB time was 110.59±25.594 and hospital stay was 5.367±1.424. CONCLUSIONS: The study showed that LIMA can be safely harvested in unstable patients after establishing extracorporeal circulation and by using this operative strategy in patients who need urgent or emergent surgical coronary revascularization LIMA can be safely used as a conduit.

Upper gastrointestinal tract symptoms are predictors of postoperative large pericardial effusion in cardiac surgery.

In this prospective observational study we evaluated the clinical symptoms in patients who presented with early or late significant pericardial effusion after cardiac surgery and underwent its open drainage in our institution. It was a series of 35 patients where the clinical symptoms and lab investigations were recorded. There were 21 male and 14 female (3:2). Majority of patients presented with postoperative large pericardial effusion within 2 -3 weeks of cardiac surgery. Eighteen (51.4%) patients presented with predominantly nonspecific upper gastrointestinal tract (GIT) symptoms like nausea, vomiting, loss of appetite and epigastric discomfort, 29 (82.85%) patients with postoperative large pericardial effusion had undergone mechanical valve replacement surgery. Majority of patients were on anticoagulation therapy and had prolonged INR. This study showed that non- specific upper gastrointestinal tract (GIT) symptoms like nausea, vomiting, loss of appetite are very frequent in patients with post-operative pericardial effusion. If a patient presents with these non-specific GI symptoms along with raised INR and low haemoglobin in postoperative follow up, significant pericardial effusion should be excluded.

Myocardial Protection with multiport antegrade cold blood cardioplegia and continuous controlled warm shot through vein grafts during proximal ends anastomosis in conventional coronary artery bypass graft.

OBJECTIVE: To evaluate the benefits of simultaneous aortic root and vein graft cold blood cardioplegia and continuous controlled warm blood perfusion through vein grafts during proximal aortocoronary anastomosis in conventional coronary artery bypass graft surgery in patients with multi-vessel coronary artery disease. METHODS: The prospective randomised study was conducted at Chaudary Pervaiz Elahi Institute of Cardiology, Multan, Pakistan, from April 2013 to June 2014, and comprised patients of isolated conventional coronary artery bypass graft surgery. The patients were randomised into 2 groups; Group I had patients in whom multiperfusion set was used for cardioplegia and continuous warm blood perfusion through vein grafts during proximal ends anastomosis, and Group II had patients in whom routine aortic root antegrade cardioplegia was used with no warm blood perfusion during proximal anastomosis of vein grafts. Data was analysed using SPSS 20. RESULTS: There were 434 patients in the study, with Group 1 having 215(49.5%) being the study group, and Group II having 219(50.5%)being the Control group. The groups showed no significant difference in the number of grafts, and aortic cross-clamp time (p>0.05 each). Total bypass time was significantly prolonged in the Control Group (p=0.001). Incidence of intra-operative arrhythmias, peri-operative myocardial infarction, need for inotropic support and intra-aortic balloon counter-pulsation and operative mortality were significantly higher in the Control group (p<0.05 each). CONCLUSIONS: Simultaneous aortic root and vein graft cold blood cardioplegia and continuous controlled warm blood perfusion was beneficial for myocardial protection and early patient outcome.

Clinical outcomes of intermittent antegrade warm versus cold blood cardioplegia.

OBJECTIVE: To compare clinical outcome in patients undergoing conventional coronary artery bypass graft surgery who received intermittent antegrade warm blood cardioplegia or intermittent antegrade cold blood cardioplegia for myocardial protection. METHODS: The observational, prospective non-randomised analytical comparative study was conducted at the Punjab Institute of Cardiology, Lahore, and Chaudhry Pervaiz Elahi Institute of Cardiology, Multan, from September 2012 to October 2013, and comprised patients undergoing coronary artery bypass graft surgery. They were divided into two groups, with Group I having those who received intermittent antegrade warm blood cardioplegia, and Group II having those who received intermittent antegrade cold blood cardioplegia. SPSS 16 was used for statistical analysis. RESULTS: Of the 215 patients, 94(44%) were in Group I, and 121(56%) in Group II. Total surgical time in Group II was 119.26±22.24 minutes compared to 105.73±31.34 in Group I (p >0.0001). Spontaneous resumption of sinus rhythm and peri-operative myocardial infarction was statistically insignificant (p>0.05). There were 21(17.4%) patients in Group II to whom peri-operative myocardial infarction occurred compared to 9(9.6%) in Group I (p=0.10). CONCLUSIONS: Intermittent antegrade warm blood cardioplegia showed better myocardial protection in early postoperative period compared to intermittent antegrade cold blood cardioplegia.

Early outcome of Coronary Artery Bypass Graft Surgery in patients with significant Left Main Stem stenosis at a tertiary cardiac care center.

OBJECTIVE: Primary objective of this study was to evaluate the impact of significant left main stem (LMS) stenosis on the early outcome of coronary artery bypass graft (CABG) surgery. METHODS: A Retrospective non-randomized analytical study was conducted in Cardiac surgery department, Chaudhary Pervaiz Elahi Institute of Cardiology (CPEIC) Multan, Pakistan. The data of patients who underwent isolated CABG at our institution from February 2008 to March 2014 were analyzed. Two thousand six hundred two (2602) patients of isolated CABG were divided into 2 groups according to the LMS disease. Group I (n=2088): without significant LMS disease and Group II (n=514): with LMS disease. Data was analyzed using SPSS V16. The groups were compared using Student's t-test for numeric variables. Chi-square test and Fishers Exact test were used for categorical variables. P-value ≤ 0.05 was considered as significant difference. RESULTS: Out of two thousand six hundred two, 2088 patients were in Non.LMS group (Control Group) and five hundred fourteen were in LMS Group (Study Group). Patients with LMS disease were older. In both groups there was no statistically significant difference regarding gender distribution, risk factors of IHD, pre-operative renal function and preoperative CKMB levels. Significant number 50 (9.7%) of patients were unstable in LMS group and they needed urgent surgery (p-value <0.0001). Need and duration for inotropic support and intra-aortic balloon counter-pulsation support were significantly high in LMS group (p-value <0.0001, 0.002, 0.003 respectively). Similarly Mechanical ventilation time and hospital stay were higher in LMS group. Incidence of pulmonary complications and operative mortality were significantly higher in LMS group (p-value 0.005 and 0.001 respectively). Mortality of CABG patients with significant left main coronary stenosis was 13 out of five hundred fourteen (2.5%) as compared to just 17 out of two thousand eighty eight (0.8%) in control group. CONCLUSION: This study showed that significant LMS disease is an independent risk factor for early cardiopulmonary morbidity and mortality after CABG surgery.

Is there any benefit of preoperative oral trimetazidine in coronary artery bypass graft?

OBJECTIVE: To evaluate the impact of preoperative oral trimetazidine on myocardial protection in coronary bypass surgery. METHODS: We conducted a prospective double blind randomized study in the Department of Cardiac Surgery, Chaudhry Pervaiz Elahi (CPE) Institute of Cardiology, Multan, Pakistan. One hundred and seventy (170) patients of isolated CABG were included in the study. All operations were done by conventional technique of CABG using cardiopulmonary bypass, moderate systemic hypothermia and cold antegrade blood cardioplegia. The patients were randomized into 2 groups i.e. Group 1 (n = 85), who received and Group 2 (n = 85), who did not receive Trimetazidine. Trimetazidine (20 mg) was given orally, at 10:00 pm the night before operation and also at 7.00 am on the day of surgery. The CPK and CK-MB levels were determined before operation, immediately after shifting to the ICU, 12 hours and 36 hours after the operation. The comparison of CPK and CK-MB levels was carried out using analysis of variance with repeated measures. The peri-operative clinical and laboratory data were compared using Student's t-test for numeric variables and Chi-square test for categoric varaibles. The difference was considered statistically significant if the p-value was < 0.05. RESULTS: The pre-operative variables i.e. age, gender, Canadian Cardiovascular Society (CCS) class, ejection fraction, diabetes, history of smoking, haemoglobin level, serum creatinine etc had no differences in both group. Both groups showed no significant difference in Cardiopulmonary Bypass time (BPT), Aortic cross Clamp Time (CxT), prevalence of intra-operative arrhythmia and need for inotropic support. The analysis did not show any within group or between groups differences in the CPK and CKMB levels. CONCLUSION: This study showed that oral Trimetazidine given before coronary bypass grafting did not provide any benefit in myocardial protection.