Effect Of Internal Mammary Artery Harvesting With And Without Pleurotomy On Respiratory Complications In Patients Undergoing Coronary Artery Bypass Grafting.

BACKGROUND: Respiratory problems are one of the major issues faced by cardiovascular surgeons, which increase morbidity and mortality among patients undergoing coronary artery bypass grafting (CABG). It is possible to harvest the left internal mammary artery (LIMA) without opening the left pleura; however this cannot be reliably achieved in all cases due to intimate anatomical relationship. This study was designed to evaluate the effect of internal mammary artery harvesting with and without pleurotomy on respiratory complications in patients undergoing coronary artery bypass grafting. METHODS: In this observational study 90 patients who underwent coronary artery bypass surgery were included by review of records. Patients were stratified into two groups according to surgical procedures, i.e., Internal Mammary artery harvesting with pleurotomy; (WP Group) (n=45) and with extra pleural harvesting technique; (EP Group) (n=45). Inclusion criteria were elective coronary artery bypass grafting, age over 18 years, willingness to be randomly assigned, provision of informed consent. Exclusion criteria were chronic obstructive pulmonary disease (COPD) or skeletal abnormalities that caused pulmonary restriction. Only the first 30 days postoperative outcome was studied. Data was analysed using SPSS version 21. RESULTS: The demographic characteristics in terms of age and gender were comparable in study groups. The preoperative clinical presentation and medical history were also found similar. The hospital stay was significantly longer in WP Group than EP Group patients (7.2 vs 6.1 days, p<0.005). Moreover, post-operative morbidity was more prevalent in WP group 10 (22.2%) than EP Group 3 (66%) (p<0.03). In WP Group more respiratory complications were observed; 2 (4.4%) patients had dry cough and atelectasis, 1 (2.2%) patient experienced pleural effusion, 3 (6.6%) had bronchospasm while 1 (2.2%) patient each had sternal dehiscence and bleeding, however, these did not differ significantly among study groups. CONCLUSIONS: Respiratory complications were more frequent in patients undergoing Internal Mammary artery harvesting with pleurotomy compared to those managed extra pleural harvesting.

Stroke after coronary artery bypass surgery with and without cardiopulmonary bypass.

BACKGROUND: Stroke is a devastating complication of coronary artery bypass grafting (CABG). This study was carried out with the aim that the development of off pump coronary artery surgery decreases the incidence/adverse outcome due to extra corporeal circulation. METHODS: The data utilized in this study was extracted from a randomized controlled trial that was conducted from January 2006 to March 2007 at Punjab Institute of Cardiology. One hundred patients were included in 'on pump' group-A, and 100 patients in 'off pump' group-B. RESULTS: The mean age of the patients in group-A was 53.51 ± 9.96 years and in group-B it was 51.59 ± 10.30 years. Renal failure occurred in 21% patients of group-A as compared to 10% of group-B while Acute Myocardial Infarction occurred in significantly higher number of patients in group-B (11%) as compared to group-A (2%). Off pump was associated with significant decrease in rate of stroke 1.5% as compared to on pump 3.5%. similarly there was decreased in the risk of deaths after stroke 0% as compared to on pump 1.5% mortality after stroke. In group A 6 (3.5%) patients developed stroke where as in group-B 2 (1.5%) patients developed stroke out of these 6 patients there were 2 mortalities after stroke in group-A while in group-B there was no mortality after stroke within 30 days postoperatively. CONCLUSION: Off pump CABG is associated with significantly decreased rate of stroke in comparison with the on-pump CABG.

Chronic anemia complicated by cardiac failure, pulmonary hypertension, and pericardial effusion: a case report.

BACKGROUND: Worldwide, iron deficiency anaemia (IDA) is the most common cause of anaemia. Iron deficiency alone has an association with heart failure and pulmonary hypertension. Chronic iron deficiency anemia triggers various physiologic adjustments, leading to hyperdynamic circulation and enhanced hypoxic pulmonary vasoconstriction. Those mechanisms may result in the development of high output cardiac failure and pulmonary hypertension; however, pericardial effusion remains a rare association. CASE PRESENTATION: A 44-year-old Nepalese man presented with fatigability and swollen ankles. Except for a hemorrhoidectomy 4 years ago, he had no comorbidities. Labs confirmed severe iron deficiency anemia (hemoglobin 1.8 grams per deciliter) likely secondary to hemorrhoids. An echocardiogram revealed high output cardiac failure, pericardial effusion, and severe pulmonary hypertension. He responded well to the correction of anemia and diuretics with the resolution of vascular complications. CONCLUSION: We report a unique presentation of chronic severe iron deficiency anemia complicated by heart failure, pulmonary hypertension, and pericardial effusion. We believe it to be the first-ever such case reported in the literature. These cardiovascular complications seem to result from internal homeostatic mechanisms against the chronic tissue hypoxemia observed in severe anemia. Furthermore, iron deficiency alone has an association with heart failure and pulmonary hypertension. After excluding other potential causes, we confirmed iron deficiency anaemia as the cause of those complications. The correction of anemia led to an excellent recovery without any sequelae. Our case report highlights the fact that management of such a case should be focused on underlying etiology rather than the complications.

Patterns and Outcomes of Obesity Using Body Mass Index in Patients Hospitalized with Acute Cardiovascular Disorders: A Retrospective Analysis of 7284 Patients in a Middle Eastern Country.

BACKGROUND: We aimed to study the presentation and in-hospital outcomes of obese patients hospitalized for cardiovascular diseases (CVDs) in a Middle Eastern country. METHODS: This retrospective study included patients admitted to the Heart Hospital between 2015 and 2020. Patients were divided according to their body mass index (BMI): Group I (BMI 18.5-24.9), Group II (BMI 25-29.9), and Group III (BMI ≥ 30), by applying one-way ANOVAs and chi-square tests. The obese group (BMI ≥ 30) was graded and compared (Grade I (BMI 30-34.9), Grade II (BMI 35-39.9), and Grade III (BMI ≥ 40)). RESULTS: There were 7284 patients admitted with CVDs (Group I (29%), Group II (37%), and Group III (34%)). The mean age was higher in Group III than Groups I and II (p < 0.001). Male sex was predominant in all groups except for morbid obesity (Grade III), in which females predominated. Diabetes mellitus (DM), hypertension, and dyslipidemia were more common in Group III. Chest pain was more common in Group II, while shortness of breath was more evident in Group III (p < 0.001). Group II had more ST-elevation myocardial infarction (STEMI), followed by Group I (p < 0.001). Atrial fibrillation (AF) was observed more frequently in Group III (p < 0.001). Congestive heart failure (CHF) was common in Group III (19%) (p < 0.001). In the subanalysis, (Grade I (62%), Grade II (22.5%), and Grade III (15.5%)), Grade I had more STEMI, whereas AF and CHF were higher in Grade III (p < 0.001). Percutaneous Coronary Intervention was performed less frequently in Grade III (p < 0.001). In-hospital mortality was higher in Grade III (17.1%), followed by Grades II (11.2%) and I (9.3%) (p < 0.001). CONCLUSIONS: In this study, one third of the hospitalized CVS patients were obese. AF and CHF with preserved EF were the most common cardiovascular presentations in obese patients. In patients with CVDs, obesity was associated with higher rates of comorbidities and in-hospital mortality. However, obesity measured by BMI alone was not an independent predictor of mortality in obese cardiac patients.

Outcome of double vs. single valve replacement for rheumatic heart disease.

OBJECTIVE: To compare the follow-up results of double valve replacement (DVR) i.e. mitral valve replacement (MVR) and aortic valve replacement (AVR) vs. isolated MVR or AVR for rheumatic heart disease. STUDY DESIGN: An interventional qausi-experimental study. PLACE AND DURATION OF STUDY: Department of Cardiac Surgery, Punjab Institute of Cardiology, Lahore, from September 1994 till December 2007. METHODOLOGY: Prospective follow-up of 493 patients with mechanical heart valves was carried out using clinical assessment, international normalized ratio and echocardiography. Patients were divided into three groups: group I having MVR, group II having AVR and group III having DVR. Survival, time and causes of mortality, and frequency of valve thrombosis, haemorrhage and cerebrovascular haemorrhage was noted in the three groups and described as proportions. Actuarial survival was analyzed by Kaplan-Meier method. RESULTS: There were 493 with 287 (58.3%) in group I, 87 (17.6%) in group II and 119 (24.1%) in group III. Total follow-up was 2429.2 patient (pt)-years. Of 77 (15.6%) deaths, 19 (3.8%) were in-hospital and 58 (11.8%) were late. In-hospital mortality was highest 4 (4.6%) in group II followed by 5 (4.2%) group III and 10 (3.5%) group I. Late deaths were 39 (13.4%) in group I, 9 (10.2%) in group II and 10 (8.3%) in group III. The total actuarial survival was 84.4% with survival of 83%, 85.1%, 87.4% in groups I, II and III respectively. On follow-up valve thrombosis occurred in 12 (0.49%/pt-years) patients; 9 (0.67%/pt-years) group I, 1 (0.22%/pt-years) in group II and 2 (0.31%/pt-years) in group III. Severe haemorrhage occurred in 19 (0.78%/pt-years); 14 in (1.04%/pt-years) in group I, 3 (0.66%/pt-years) group II and 2 (0.31%/pt-years) in group III. Cerebrovascular accidents occurred in 34 (1.3%/pt-years); 26 (1.95%/pt-years) in group I and 4 in groups II (0.89%/pt-years) and III (0.62%/pt-years) each. CONCLUSION: In patients with rheumatic heart disease having combined mitral and aortic valve disease DVR should be performed whenever indicated as it has similar in-hospital mortality and better late survival as compared to isolated aortic or mitral valve replacement.

Carotid disease in diabetic patients undergoing coronary artery bypass grafting.

OBJECTIVE: To compare the severity of carotid artery disease in diabetic and non-diabetic patients undergoing coronary artery bypass grafting. METHODS: From January to June 2008, 379 patients undergoing elective coronary artery bypass surgery were preoperatively evaluated for the presence of carotid stenoses by duplex scanning. Patients were divided into two groups, Group I, 156 (41.2%) diabetic patients and Group II, 223 (58.8%) non-diabetic patients. RESULTS: There were 314 (82.8%) males and 65 (17.2%) females with a mean age of 57.2 +/- 9.1 years. In diabetic group there were 125 (80.1%) males and 31 (19.9%) females with a mean age of 56.3 +/- 8.9 years. Left main stem stenosis was present in 59 (37.8%) diabetics and 45 (20.2%) non-diabetics (p<0.0001). Diffuse disease in left anterior descending (LAD) artery was observed in more diabetic patients 72 (46.2%) as compared to non-diabetics 83 (37.2%) (p<0.295). Single tight stenosis in LAD was observed in more non-diabetics. Significant carotid artery stenosis was observed in 50 (13.2%) patients. Carotid artery stenosis was observed in 30 (19.2%) diabetics as compared to 20 (9%) non-diabetics (p<0.004). Analysis of percentage stenosis of carotid artery disease in the study population revealed that >70% stenosis was present in 20 (5.3%) with 13 (8.3%) diabetics and 7 (3.1%) non-diabetics (p<0.025). Stenosis of 50-70% was observed in 30 (7.9%) of which 17 (10.9%) were diabetics and 13 (5.8%) were non-diabetics. CONCLUSION: Presence of diabetes mellitus is associated with diffuse coronary artery disease and significant carotid artery disease in patients undergoing coronary artery bypass grafting.

The Effect of Ivabradine on Hospitalization of Heart Failure Patients: A Retrospective Cohort Study.

BACKGROUND: Ivabradine is recommended in heart failure (HF) patients to reduce cardiovascular death and hospitalization due to worsening of HF symptoms. AIMS AND OBJECTIVES: To study the effect of Ivabradine in addition to guideline-directed medical therapy (GDMT) in a group of HF patients with HR more than 70 bpm, HF with reduced ejection fraction (HFrEF) left ventricular ejection fraction (LVEF ≤ 40%), and New York Heart Association class II-IV. METHODS: The study was conducted at Heart Hospital, Hamad Medical Corporation, Qatar. HF patients with age > 18 years, LVEF ≤40%, on GDMT, and HR of ≥70 bpm were included. The study population was divided into two groups: ivabradine group and non-ivabradine group. The primary outcomes were risk, number and length of hospitalizations due to worsening HF, and cardiovascular mortality. The secondary outcome was all-cause mortality. Baseline characteristics were collected at enrollment. Study outcomes were compared in the two groups by applying Chi-square and Fisher's exact tests. Logistic regression model was applied to assess both hospitalizations and cardiovascular mortality. RESULTS: A total of 111 patients were studied, 37 (33.94%) ivabradine group and 74 (66.67%) non-ivabradine group. Risk of hospitalization was lower in Ivabradine group compared to non-Ivabradine group (odds ratio: 0.43, 95% confidence interval [CI]: 0.16-1.015, P = 0.094). Average length of hospitalization in ivabradine and non-ivabradine groups was 12.54 and 8.91 days, respectively (incidence rate ratio [IRR]: 1.63, 95% CI: 0.79-3.38, P = 0.187). Compared to non-ivabradine, ivabradine patients had lower number of hospitalizations (IRR: 1.13, 95% CI: 0.61-2.11, P = 0.694). Death rate in both ivabradine and non-ivabradine groups was 3. CONCLUSIONS: Ivabradine along with GDMT reduces the risk of hospitalization due to worsening HF symptoms. Ivabradine had no significant effect on cardiovascular mortality and all-cause mortality. HFrEF non-Arabs patients have lower risk, number and length of hospitalization, and mortality compared to Arabs.

Right atrial mass in a patient with COVID-19 pneumonia: A case report.

Lipomatous hypertrophy of the interatrial septum can have an atypical appearance by transthoracic echocardiography. The authors emphasize on the importance of the multimodality imaging approach to reach the appropriate diagnosis in such cases.

Biatrial myxoma and atrial septal defect.

Myxomas are rarely associated with congenital cardiac anomalies. We report a case of a young female presenting with symptoms of atrial myxoma but having co-existing ASD visualized on 64 slice multidetector computed tomography (MDCT) prior to cardiac surgery. Patient had a successful resection of biatrial myxoma and ASD repair. This case is unique as the myxoma originated from the inferior margin of the ASD straddling the inferior limbus. Over the years due to the left to right shunt at the ASD, the myxoma was initially prolapsing and oscillating between the two atria. As it grew larger it obliterated the ASD and got stuck in the right atrium (RA) and continued to grow giving false impression of a right atrial mass. Multi detector computed tomography is an alternative diagnostic modality to the gold standard transesophageal echocardiograph for detection of an ASD in the presence of atrial myxoma. Biatrial myxoma with associated atrial septal defect has optimal postoperative results.

Cardiovascular Manifestations of COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is the cause of COVID-19, was first reported in Wuhan, China. SARS-CoV-2 especially involves alveolar epithelial cells, which results in respiratory symptoms more severe in patients with cardiovascular disease (CVD) probably linked with increased secretion of angiotensin-converting enzyme 2 in these patients compared with healthy individuals. Cardiac manifestations may contribute to overall mortality and even be the primary cause of death in many of these patients. A higher prevalence of hypertension (HTN) followed by diabetes mellitus and CVD was observed in COVID-19 patients. A higher case-fatality rate was seen among patients with pre-existing comorbid conditions, such as diabetes, chronic respiratory disease, HTN, and cancer, compared to a lesser rate in the entire population. Cardiovascular (CV) manifestations of COVID-19 encompass a wide spectrum, including myocardial injury, infarction, myocarditis-simulating ST-segment elevation myocardial infarction, nonischemic cardiomyopathy, coronary vasospasm, pericarditis, or stress (takotsubo) cardiomyopathy. This review is intended to summarize our current understanding of the CV manifestations of COVID-19 and also to study the relationship between SARS-CoV-2 and CVDs and discuss possible mechanisms of action behind SARS-CoV-2 infection-induced damage to the CV system.

Non-ST Segment Elevation Myocardial Infarction in a Patient with COVID-19.

Coronavirus disease 2019 (COVID-19) is associated with a wide spectrum of cardiovascular (CV) manifestations. Primary cardiac manifestations of COVID-19 disease include acute coronary syndrome (ACS), myocarditis, and arrhythmias. Secondary cardiac involvement is usually due to a systemic inflammatory syndrome and can manifest as acute myocardial injury/biomarker elevation and/or heart failure (congestive heart failure). Elevated cardiac biomarkers indicate an unfavorable prognosis. Health-care systems of the world are rapidly learning more about the manifestations of COVID-19 on the CV system, as well as the strategies for the management of infected patients with CV disease. There is still a paucity of literature on the management of non-ST-segment elevation ACSs in the current literature. Herein, we report the case of a 53-year-old male patient, who presented with severe COVID-19 pneumonia deteriorating into adult respiratory distress syndrome requiring mechanical ventilation. The patient had a history of coronary artery disease. During the course of treatment, he developed sudden cardiac arrest with diffuse ST-segment depression, which was treated by percutaneous coronary intervention to the left anterior descending artery. The patient had a favorable outcome with excellent recovery from the disease.

Predictors of positive thallium 201 single photon emission computed tomography in patients of end stage renal disease.

OBJECTIVES: To study coronary artery disease (CAD) risk factors predicting positive thallium-201 single photon emission computed tomography (SPECT) indicating underlying CAD among patients of end stage renal disease. PLACE AND DESIGN: This cross-sectional (analytical) study was done at Department of Cardiology, Punjab Institute of Cardiology, from April 2004 to Dec 2007. METHODS: One hundred consecutive patients with ESRD undergoing thallium SPECT as a routine screening test before renal transplant were studied. Dipyridamole thallium SPECT was performed in patients who were unable to exercise. RESULTS: Thallium SPECT was positive in 47 (47%) cases. There were significant differences in age, underlying diabetic nephropathy and total cholesterol levels among patients positive and negative on thallium SPECT. Among the risk factors age and underlying diabetic nephropathy were significantly associated (p < 0.05) with a positive thallium SPECT in patients with ESRD. CONCLUSION: Positive thallium SPECT indicating underlying CAD was observed in a significant number of patients with ESRD awaiting renal transplant. Presence of advanced age and underlying diabetic nephropathy predict a positive thallium SPECT in this population.

Three pregnancies with mechanical heart valve and no follow-up in 10 years.

Anticoagulation and proper INR (International Normalized Ratio) monitoring is essential for patients having mechanical heart valves; it is vital in these patients in order to prevent lethal complications such as valve thrombosis and systemic embolism. In pregnancy, it becomes even more important as pregnancy itself is a hypercoagulable state. This report describes a female patient having undergone mitral valve replacement with a Starr Edward metallic prosthesis. She came back to the operating surgeon after 10 years of valve replacement with a history of three uneventful healthy deliveries and no follow-up and INR monitoring during this period.

Non-cardiac surgery in patients with prosthetic heart valves: a 12 years experience.

OBJECTIVE: To study patients with mechanical heart valves undergoing non-cardiac surgery and their anticoagulation management during these procedures. STUDY DESIGN: It was a cohort study. PLACE AND DURATION OF STUDY: The study was conducted at the Department of Cardiac Surgery, Punjab Institute of Cardiology, Lahore and Department of Surgery, Services Institute of Medical Sciences, Lahore, from September 1994 to June 2006. PATIENTS AND METHODS: Patients with mechanical heart valves undergoing non-cardiac surgical operation during this period, were included. Their anticoagulation was monitored and anticoagulation related complications were recorded. RESULTS: In this study, 507 consecutive patients with a mechanical heart valve replacement were followed-up. Forty two (8.28%) patients underwent non-cardiac surgical operations of which 24 (57.1%) were for abdominal and non-abdominal surgeries, 5 (20.8%) were emergency and 19 (79.2%) were planned. There were 18 (42.9%) caesarean sections for pregnancies. Among the 24 procedures, there were 7(29.1%) laparotomies, 7(29.1%) hernia repairs, 2 (8.3%) cholecystectomies, 2 (8.3%) hysterectomies, 1(4.1%) craniotomy, 1(4.1%) spinal surgery for neuroblastoma, 1(4.1%) ankle fracture and 1(4.1%) carbuncle. No untoward valve or anticoagulation related complication was seen during this period. CONCLUSION: Patients with mechanical valve prosthesis on life-long anticoagulation, if managed properly, can undergo any type of non-cardiac surgical operation with minimal risk.

Exercise Tolerance Test: a comparison between true positive and false positive test results.

BACKGROUND: To study the factors which predetermine the coronary artery disease in patients having positive Exercise Tolerance Test (ETT) after comparing the ETT test results and coronary angiographic findings in true positive and false positive groups. METHODS: This Cross-sectional study was conducted at Punjab Institute of Cardiology, Lahore from January 1, 2004 to December 31, 2004. All patients who had ETT done for chest pain diagnosis were studied. Patients were advised coronary angiography if ETT was positive for exercise induced ischaemia. One hundred and forty eight patients had coronary angiography done after positive ETT. Patients were divided into two groups depending upon the angiographic findings, i.e., true positive and false positive. Both groups were compared with each other. RESULTS: Out of 148 patients, 126 (85.1%) patients had true positive ETT and 22 (14.9%) patients had false positive ETT. The mean age of patients in true positive group was 48.96 +/- 9.08 years and 50.9 +/- 7.85 years in false positive group. One hundred and eighteen (93.7%) male patients and 8 (6.3%) female patients had true positive ETT, whereas 14 (63.6%) males and 8 (36.4%) females had false positive ETT (p < 0.0001). There was no statistically significant difference in the two groups in comparison of age and other conventional risk factors like diabetes mellitus, hypertension, smoking, family history and dyslipidemia. Abnormal resting ECG had a statistically significant diffErence between the groups (p < 0.04), likewise is hypertensive haemodynamic response during ETT (p < 0.003). The symptom limited ETT as compared to no symptoms during ETT also conferred a statistically significant difference between the groups (p < 0.0001). Strongly positive ETT was also associated with true positive ETT (p < 0.002). Amongst the vessels involved the most common was the LAD 113 (89.7%), followed by LCX 80 (63.5%) and the RCA 72 (57.1%). Most of the patients 51 (40.5%) had three vessel disease as compared to SVD 34 (27%). CONCLUSION: It can be concluded that amongst the patients who have positive ETT, females with abnormal resting ECG, who achieve target heart rate and have a hypertensive haemodynamic response with no symptoms are likely to have a false positive test result. Conversely male patients with normal resting ECG who do not achieve target heart rate, have a normotensive haemodynamic response and a strongly positive, symptom limited ETT are likely to have a true positive treadmill test result.

Significance of perfusion defects on dipyridamole thallium cardiac SPECT in patients with left bundle branch block.

BACKGROUND: Left Bundle Branch Block (LBBB) is a known cause of false positive results in myocardial perfusion studies. We aimed at investigation of correlation between degree of severity of perfusion defect on cardiac Single Photon Emission Computed Tomography (SPECT) and presence of coronary artery disease on angiography in patients with LBBB. STUDY DESIGN: This was an analytical study and was carried out at Department of Nuclear Cardiology and Department of Cardiac Catheterisation of Punjab Institute of Cardiology, Lahore from January 2007 to April 2007. METHODS: In this study patients having LBBB without known coronary artery disease (CAD) referred for myocardial perfusion studies to the Nuclear Cardiology Department from outpatient, indoor and emergency departments were included. Thallium201 stress/rest Single-Photon Emission Tomography (SPECT) acquisition scanning was performed. The myocardial perfusion pattern was classified as normal, fixed defect and reversible defect. Coronary angiography was used to confirm CAD only in patients with abnormal scan. RESULTS: Thirty consecutive patients having LBBB were studied. All patients underwent myocardial perfusion imaging using dipyridamole pharmacologic stress. Fourteen patients (47%) revealed normal Thallium201 uptake and distribution at the septum. Reversible defects were noted in 13 (43%) patients. Fixed defects were noted in 3 (10%) patients. Among four patients with mild perfusion defects only 1 (25%) had significant coronary artery disease. In patients with moderate perfusion defects, coronary angiogram was positive for significant coronary artery disease in 1 (33%) patient. In six patients having severe perfusion defects significant coronary artery disease was noted in 5 (83%) patients. All patients with fixed defects had significant coronary artery disease. False positive studies were found to be significantly greater in patients with reversible defects particularly with mild to moderate defects. CONCLUSIONS: Patients with left bundle branch block showing moderate to severe reversible perfusion defects on dipyridamole thallium cardiac SPECT have high likelihood of coronary artery disease.

In-hospital outcome of acute myocardial infarction (st segment elevation type) in diabetics and non-diabetics.

OBJECTIVE: To evaluate the in-hospital mortality and complications of acute myocardial infarction in diabetic and non-diabetic patients. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Coronary Care Unit and Cardiology Ward of Nishtar Hospital, Multan from 1st October 2002 till 15th May 2003. PATIENTS AND METHODS: Four hundred and forty-eight (448) consecutive patients who fulfilled the inclusion criteria were studied while they were admitted to the hospital. Patients were divided into two groups of diabetics and non-diabetics depending on the presence of diabetes mellitus. In-hospital mortality and complications were compared between the two groups by Chi-square method. RESULTS: Diabetic patients presented in more advanced Killip class as 32(26.7%) patients presented in Killip class II, 13(10.8%) patients presented in Killip class III and 6(5%) patients presented in Killip class IV. In the non-diabetic group, 68(20.7%), 24(7.3%) and 11(3.4%) patients presented in these Killip classes respectively (p<0.042). The total in-hospital mortality was 17%. Mortality was 28(23.3%) in diabetics and 48(14.6%) in non-diabetics (p<0.03). In-hospital mortality was almost double in diabetics as compared to non-diabetics. Mechanical complications were observed in 42(35%) patients in diabetic group and 80(24.4%) patients in non-diabetic group. Left ventricular failure was the most commonly observed mechanical complication. Electrical complications were observed in 84(70%) diabetic and 162(49.4%) non-diabetic patients (p<0.205). CONCLUSION: In patients with acute myocardial infarction, presence of diabetes mellitus was associated with worse in-hospital outcome leading to increased mortality and complications as compared to non-diabetic patients.

Age-related in-hospital mortality among patients with acute myocardial infarction.

OBJECTIVE: To evaluate the in-hospital mortality of acute myocardial infarction among different age groups. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Coronary Care Unit and Cardiology Ward of Nishtar Hospital, Multan from 1st of September 2002 till 10th of April 2003. SUBJECTS AND METHODS: The subjects were 460 admitted patients of acute myocardial infarction who fulfilled our inclusion criteria. Patients were divided into four age groups. Group-I included patients in 20-40 years, group-II (41-50 years), group-III (51-60 years) and group-IV (>60 years). Mortality was compared between different age groups by Chi-square and linear-regression models. RESULTS: The total in-hospital mortality was 16.7%. It gradually increased from 5.6% in group-I (20-40 years) patients to 21% in group-IV (>60 years) patients. While mortality in groups group-II (41-50 years) and group-III (51-60 years) patients was 16.7% and 18.6% respectively. A marked increase in mortality was noted with increase in age. Group-IV (>60 years) patients presented 2 hours late to the hospital than the group-I (20-40 years) patients. There was no statistical difference in site of infarction in different age groups. Old age (group-IV i.e. >60 years old) was more associated with heart failure (higher Killip class) on presentation. Lesser number of patients in group-IV received thrombolytic therapy than group-I. Only 31.09% patients in group-IV and 62.5% patients in group-I received streptokinase therapy respectively. CONCLUSION: In patients with acute myocardial infarction age was a powerful independent predictor of in-hospital mortality and complications.

Clinical outcome of double valve repalcement with or without small aortic prosthesis.

OBJECTIVE: To determine the effect of aortic prosthesis size on clinical outcome of patients undergoing double cardiac valve replacement (DVR). STUDY DESIGN: A quasi-experimental study. PLACE AND DURATION OF STUDY: Cardiac Surgery Department, Punjab Institute of Cardiology, Lahore, Pakistan, from February 1996 to December 2008. METHODOLOGY: One hundred and forty patients undergoing double cardiac valve replacement were divided into 2 groups. Group I, 75 (53.6%) receiving aortic prosthesis size of ² 21 mm. Group II, 65 (46.4%) having aortic prosthesis of > 21 mm size. All patients were prospectively followed-up for 12 years in order to study mortality and valve related complications. RESULTS: There were 94 males (67.1%) and 46 females (32.9%) with a mean age of 25.5 ± 10 years. In Group I, 21 patients (28%) had aortic valve replacement (AVR) with 19 mm valve size and 54 patients (72%) had 21 mm size valves implanted. In Group II, 39 patients (60%) had AVR with 23 mm size valves implanted followed by 16 (24.6%) who received 25 mm size valves. Posterior mitral leaflet was preserved in 15 patients (20%) in Group I and 14 (21.5%) in Group II. Mortality was seen in 13 patients (9.3%); of these 5 (3.6%) were in Group I and 8 (5.7%) were in Group II. Nine patients (6.4%) had incomplete follow-up (In Group I, 2 patients died in ICU, 2 died within 30 days of admission and one was a late death. In Group II, 1 patient died in ICU, 1 within 30 days of admission and 6 within 1 year of operation). CONCLUSION: Double valve replacement with implantation of small aortic prosthesis has similar overall mortality as compared to patients having larger sized aortic valves.

Functional tricuspid regurgitation in rheumatic heart disease: surgical options.

OBJECTIVES: In this study, we compare the follow-up results of two types of tricuspid valve repair and review the results of no repair in moderately severe tricuspid regurgitation (TR) along with mitral valve replacement or mitral and aortic valve replacement. PATIENTS AND METHODS: This prospective follow-up study, carried out on 106 consecutive patients, was conducted at the Department of Cardiac Surgery, Punjab Institute of Cardiology, Lahore, from September 1994 through August 2008. The patients were divided into three groups: suture bicuspidization, 36 (34%); modified De Vega's repair, 47 (44.3%); and no repair, 23 (21.7%). Freedom from moderate 2+ TR was compared among these groups by the Kaplan-Meier method. RESULTS: In the suture bicuspidization group, freedom from TR2+ was 97.2%, 77.8%, and 39.6% at 30 days and 7 and 14 years after surgery, respectively. In the modified De Vega group, it was 100% at the end of 7 years. In the no-repair group, it was 91.3%, 91.3%, and 61.6% at 30 days and 7 and 14 years after surgery, respectively. Overall in-hospital mortality was 3 (2.8%), with 4 late deaths after discharge. Preoperative right ventricular dysfunction, preoperative TR severity, preoperative mitral regurgitation, preoperative ejection fraction, and remnant TR following surgery were significant independent predictors of TR recurrence. CONCLUSION: Repair by suture bicuspidization fails to prevent further annular dilatation and has no comparable results. Modified De Vega's repair is safe with superior results compared to other groups at the end of 7 years. Patients without significant annular dilatation in the no-repair group improved during follow-up once their left-sided valve lesion was corrected.