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.

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.

Postoperative arrhythmias after coronary artery bypass grafting: a comparison between 'off pump' and 'on pump' CABG.

BACKGROUND: Coronary artery bypass without cardiopulmonary bypass (CPB) has gained popularity recently with the development of devices that allow for improved exposure and standardization in off pump coronary artery bypass surgery. Off pump coronary artery bypass surgery reduces some of the morbidities traditionally attributed to CPB. The primary goal of off pump coronary artery bypass surgery is to provide an equally comprehensive operational result as the conventional operation. The purpose of the study was to compare intra operative and postoperative arrhythmias in off pump coronary artery bypass (OPCAB) verses conventional CABG. METHODS: This study was a sub-group as part of a randomised control trial and 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: Thirty-three patients in group-A and 22 in group-B developed arrhythmias. Twenty-six patients developed atrial fibrillation in group-A and 16 patients in group-B. Mortality due to arrhythmias was 5, three were in on pump group, and 2 were in off pump group. CONCLUSION: There is non-significant tendency towards less frequency of postoperative arrhythmias in the off pump patients as compared to on pump coronary artery bypass surgery patients.

Echocardiographic profile of rheumatic heart disease at a tertiary cardiac centre.

BACKGROUND: Rheumatic Heart Disease (RHD) continues to be a major public health problem in developing countries like Pakistan. Objective of this cross sectional-analytical study was to analyze the severity of valvular lesions on echocardiography in patients pre-diagnosed with RHD. METHODS: The transthoracic echocardiographic records of RHD patients from 2004 to 2008 were retrospectively reviewed for type and degree of valvular involvement according to AHA/ACC guidelines. RESULTS: A total of 13,414 patients [7,219 Males (53.8%), 6,195 Females (46.2%)] ranging from 11 to 90 years with a mean age of 42.33 +/- 18.976 were studied. On echocardiography, 7,500 (56%) had mitral regurgitation (8.8% severe MR), 6,449 (48.2%) had tricuspid regurgitation (7.1% severe TR) and 5,550 (41.4%) had aortic regurgitation (4.8% severe AR). MS was detected in 2,729 (20.3%) patients (15.3% severe MS), AS in 102 (0.8%) and TS in 31 (0.2%) patients. Mixed mitral valve disease was seen in 3,185 (23.7%), mixed aortic valve disease in 222 (1.7%) and mixed tricuspid valve disease in 47 (0.4%) patients. All three valves were involved in 2,826 (21.06%) patients, combination of mitral and aortic valves in 3,103 (23.13%), mitral and tricuspid in 3,784 (28.2%), and mitral only in 3,701 (27.59%) patients. There was some mitral valve abnormality in all patients. CONCLUSION: Mitral valve was most commonly affected, while regurgitant lesions were more common than stenotic lesions, and most severe in younger patients. All valvular lesions had almost an equal distribution among the sexes, except aortic regurgitation, which was more common in females. Therefore, echocardiography should be done routinely for patients with RHD, focusing on younger population, to facilitate diagnosis and definitive treatment before complications set in.

Early vascular complications of intraaortic balloon counterpulsation in patients undergoing open heart surgery.

BACKGROUND AND OBJECTIVES: The use of IABP is helpful for haemodynamic stability of patients with low cardiac output and compromised left ventricular function in patients who undergo coronary artery bypass grafting. This procedure is also associated with some vascular complications due to the insertion of IABP. The objective of this research was to study the vascular complications in patients with IABP counterpulsation. We observed the clinical outcome of these patients with special reference to post IABP complications in our research. METHODS: One hundred and six consecutive patients were included in this study from August 2005 to February 2007. Mean age of patients was 58.08 +/- 1.814 years. Seventy nine patients (74.5%) were male and 29 (25.5%) were females. Out of these 106 patients, 101 were operated for CABG, one for angina due to aortic stenosis, two patients had ischemic mitral regurgitation and one patient had post infarct VSD. In 102 (96.2%) patients IABP was inserted percutaneously, one patient received transthoracic and in three patients IABP was inserted with open technique. Thirteen (12.3%) patients received IABP with sheath and 93 (87.7%) received IABP without sheath. RESULTS: Ten patients (9.4%) out of 106 developed vascular complications due to insertion of IABP. Seven patients (6.6%) had the major complications and 3 (2.8%) patients developed minor vascular complications. Mortality due to vascular complications in 106 patients was 8.49% with p < 0.005. CONCLUSION: IABP has remarkable beneficial effects in patients with haemodynamic instability due to myocardial ischemia and low cardiac output syndrome. At the same time IABP is related to significant morbidity and mortality related to vascular complications due to its insertion which include limb ischemia, limb loss and even mortality.

In hospital outcome of patients undergoing coronary endarterectomy: comparison between off-pump vs on pump CABG.

BACKGROUND: Due to advancement of non-surgical methods of coronary revascularization the patients referred for surgery have extensive and complex coronary anatomy. Patients with diffuse atheromatous coronary artery disease required coronary artery reconstruction or coronary endarterectomy (CE). Coronary endarterectomy on beating heart needs skill and better surgical technique. Coronary endarterectomy along with coronary artery bypass grafting (CABG) done on beating heart is compared with coronary endarterectomy done by using conventional CABG technique. METHODS: Seven hundred and ninety five consecutive patients underwent CABG from January 2006 to March 2007 in a prospective randomized trial at cardiac surgery department, Punjab Institute of Cardiology, Lahore; out of these 115 patients underwent coronary endarterectomy (CE) and were included in this study. RESULTS: Coronary artery bypass grafting was performed in 115 patients. Seventy two (62.6%) were in group A on-pump and 43 (37.39%) were in group B off-pump. Mean age in group A was 55.68 +/- 1.06 and 52.63 +/- 1.40 in group B. Sixty six male and 6 female were included in group A, 40 male and 3 female patients were in group B. In-hospital mortality among patients undergoing CABG was 5.6 % in on-pump group and 2.3 % in off-pump group (p = 0.649), the duration of post-operative mechanical ventilation in on-pump was 6.78 +/- 9.34 hours and 5 +/- 4.0 hours in off-pump group (p = 0.060), 66.7% patients in on-pump and 58.1% patients in off-pump group required blood transfusions, Intra-aortic balloon pump (IABP) was required in 5.6% of the patients in on-pump group. Other factors included, smoking 26.4% in on-pump and 41.9% in off-pump group (p = 0.01), Intensive care unit (ICU) stay was statistically significant 4 +/- 3 in on-pump group and 4 +/- 2 in off-pump group (p = 0.02), and drain in on-pump group was 455 +/- 208 ml and 540 +/- 370 ml in off-pump group (p = 0.01). CONCLUSION: Coronary endarterectomy (CE) has higher post-operative morbidity and mortality but the post-operative outcome after the procedure on either technique is comparable and CE is feasible on off-pump technique as well.

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.

Early left ventricular remodeling after aortic valve replacement.

BACKGROUND: Aortic valve disease is associated with eccentric or concentric left ventricular (LV) hypertrophy and changes in the LV mass. The relationship between LV mass and function and the effect of LV remodeling after aortic valve replacement (AVR), in patients with aortic valve disease needs evaluation, that is largely unknown in our population. The aim of this study was to evaluate the effect of AVR on LV remodeling, in patients with aortic valve disease. METHODS: Fifty patients with aortic valve disease were studied using transthoracic echocardiography to assess LV mass before AVR and compared with early postoperative changes in the LV dimensions and function. LV mass was studied preoperatively and before discharge in 50 consecutive patients undergoing isolated aortic valve replacement. RESULTS: Out of fifty patients, 47 (94%) were male and 03 (6%) were female. Mean age of the patients was 40.42 years. 22 (44%) had isolated aortic stenosis (AS), 16 (32%) patients had isolated aortic regurgitation (AR) and 12 (24%) patients had mixed aortic valve disease (MAVD). 02 (4%) patients died. LV mass regression was studied in all the patients. In group A, with aortic stenosis, LV regressed to 69.88 gm (mean) with maximum of 156.88 gms and minimum of 0.00 gms (SD 43.67 gms, p value = 0.001). In group B, with aortic regurgitation, LV mass regressed to 203.96 gms (mean) with maximum 453.79 gms and minimum of 45.65 gms (SD 95.33, p value = < 0.001). In group C, with mixed aortic valve disease, postoperatively LV mass regressed to 122.94 gms (mean) with minimum 9.57 and maximum of 224.75 gms (SD 69.53, p value = 0.524). CONCLUSION: There was significant early LV mass regression after aortic valve replacement in patients with pre existing aortic valve disease. However, it was noticed that LV mass regressed in all patients except no significant changes in LV wall thickness (hypertrophy).

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.

Aniticoagulation in patients following prosthetic heart valve replacement.

PURPOSE: To identify optimum international normalized ratio (INR) levels and required warfarin doses and anticoagulation-related complications in patients following mechanical prosthetic valve replacement. MATERIALS AND METHODS: Five hundred and seven patients were prospectively followed up for 10 years (2008.5 patient-years). Anticoagulation-related complications were classified into hemorrhage and thromboembolism. RESULTS: Two hundred and ninety-two (57.6%) were males and 215 (42.4%) were females with a mean age of 29.5 +/- 11.32 years. A total of 268 (52.9%) patients had mitral, 96 (18.9%) had aortic and mitral, and 76 (15%) had aortic valve replacement (AVR). Valves implanted totaled 345 (68%) ball and cage, 126 (24.9%) bileaflet, and 36 (7.1%) single disc. There were 10,669 total visits, with mean INR 2.6 +/- 0.59 and mean warfarin 5.17 +/- 1.6 mg. Sixty-four (3.2% per patient-years) events occurred during follow-up, of which 23 (1.13% per patient-years) events were due to thromboembolism and 41 (2.04% per patient-years) to bleeding. Atrial fibrillation occurred in 12 (52.4%) patients having thromboembolic events and in 24 (58.5%) suffering from bleeding complications. Among thromboembolic events, valve thrombosis occurred in 9 patients (0.44% per patient-years) and cerebrovascular accidents (CVAs) in 14 (0.69% per patient-years). Atrial fibrillation was present in 7 (77.8%) patients in the valve thrombosis group and in 5 (35.7%) in the CVA group. Of 41 bleeding events, 8 (0.39% per patient-years) were minor episodes, 20 (0.99% per patient-years) were major episodes, and severe hemorrhage occurred in 5 (0.34% per patient-years). Intracranial hemorrhage leading to CVA was seen in 8 patients (0.34% per patient-years). There were 22 (1.1% per patient-years) fatal hemorrhages and 15 (0.74% per patient-years) fatal thromboembolic events. In-hospital mortality was 25 (4.9%), and 62 (12.2%) were late deaths; of these, 37 (7.3%) were anticoagulation related. CONCLUSIONS: Anticoagulation for mechanical heart valve replacement can be managed with INR levels of 2-2.5 with acceptable hemorrhagic and thromboembolic events.

Surgery for chronic total occlusion of the left main stem: a 10-year experience.

Chronic total occlusion of the left main stem coronary artery is rare. This retrospective study was conducted to evaluate outcomes of coronary artery bypass grafting between June 1998 and June 2008 in patients with chronic left main stem total occlusion. There were 17 (0.025%) cases detected in 67,082 coronary angiograms. The 14 men and 3 women had a mean age of 55.32 +/- 9.2 years. Risk factors included diabetes in 8, hypertension in 6, and smoking in 6. Of 54 grafts applied, 15 were arterial and 39 were venous; 14 patients had 3-vessel disease, and 3 had 4-vessel disease. Three patients required intraaortic balloon counterpulsation perioperatively. The mean intensive care unit stay was 2.1 +/- 1.2 days, and hospital stay was 7.1 +/- 1.5 days. Postoperatively, one patient suffered myocardial infarction, another had a transient ischemic attack with spontaneous recovery, and 2 developed atrial fibrillation. There was no operative or hospital death. Surgical revascularization is considered appropriate treatment for chronic total occlusion of the left main stem.

A surgical report of Bland White Garland syndrome.

We report a 22-year-old mother of 2 who presented to us with exertional chest pain for 3 years. On coronary angiography she was diagnosed to be suffering from Bland White Garland syndrome (BWGS). She had a giant and grossly tortuous right coronary artery (RCA) forming collaterals with the left coronary artery (LCA), which was draining into the pulmonary artery (PA). Surprisingly, she had no evidence of mitral regurgitation on echocardiography, and she had a preserved left ventricular systolic function. She underwent Takeuchi's repair with uneventful recovery. Postoperative CT angiography revealed adequate reimplantation of the left main coronary artery to the aorta with patent tunnel. On a 6-month follow-up, she is asymptomatic and has an optimal flow through the tunnel to the LCA.