Double cobra head technique of distal coronary anastomosis.

In 1967, Dr. René Favaloro introduced the use of reversed greater saphenous vein graft for coronary artery bypass grafting, since then a lot of efforts were made to improve the venous graft patency rate. We introduce a novel double cobra head technique of distal coronary anastomosis for better distal runoff. We expect our technique will help in difficult situations such as limited conduit availability and target vessel with bifurcation lesions. Refining our surgical techniques is essential to keep ourselves well equipped to compete with the rapidly evolving stent culture.

Weight gain potential-a neglected entity during valve replacement.

INTRODUCTION: During valve replacement, appropriate valve size will be chosen based on many factors, neglecting the potential of the patient for gaining weight. We aimed at evaluating the weight gain potential and its effect on hemodynamics in post mitral valve replacement (MVR) patients. MATERIAL AND METHODS: In 118 post-MVR patients, demographic and echocardiographic data at the time of discharge and follow-up were obtained and analyzed. Primary aim of study is to analyze the hemodynamics of patients based on weight gain/loss. Secondary aim is to evaluate the same in patient-prosthesis mismatch (PPM) subgroup and to evaluate the study population for the potential to gain/loss weight. RESULTS: Among 118 patients, 87 patients (73.7%) gained weight. In 87 weight gained patients, left atrial (LA) size (p = 0.011) and pulmonary artery systolic (PA) pressure (p = 0.028) at follow-up were significantly elevated than the discharge values. Among 53 PPM patients (incidence, 44.9%), 34 patients gained weight and their PA pressure was found to be elevated at follow-up (p = 0.021) whereas weight lost group does not show any significant difference (p = 0.972). Frequency of weight gain was more among patients who weighed < 50 kg preoperatively (28 out of 30) (p = 0.013) and 20 to 30 years age group patients (p = 0.043). No sex predilection was noted (p = 0.149). CONCLUSION: In post-MVR patients, weight gain has definitive influence over hemodynamics. In PPM subgroup, weight gained patients had significantly increased PA systolic pressure at follow-up. Young, < 50 kg weighed, and PPM patients should be advised to maintain their weight post MVR for better hemodynamics.

Porcine versus bovine bioprosthetic valves in mitral position: does choice really matter?

BACKGROUND: Bioprosthetic valves are increasingly used for surgical mitral valve replacement (MVR). The long-term outcomes of bovine (BoMVR) vs porcine (PoMVR) remain an enigma regarding the durability. This study aims to examine the outcomes of BoMVR vs PoMVR. METHODS: A retrospective analysis of all bioprosthetic MVRs, with concomitant procedures, at a single tertiary referral institution from January 2005 to December 2008 was conducted. Procedures were classified as BoMVR or PoMVR. The age group was from 40 to 70 years. RESULTS: We identified 154 BoMVR patients and 120 PoMVR patients after matching the two groups with respect to age, sex, valve size and concomitant procedures. Kaplan-Meier survival analysis model was used for corresponding statistical analysis. Freedom from reoperation (all cause), freedom from non-structural valve deterioration, freedom from structural valve deterioration, freedom from heart failure and freedom from infective endocarditis were 96.4 ± 0.08, 97.1 ± 0.07, 96.4 ± 0.08%, 98.2 ± 0.07, and 98.6 ± 0.06% in PoMVR, respectively, and 92.6 ± 0.09, 91.6 ± 0.08, 90.6 ± 0.09, 94 ± 0.08, and 92.8 ± 0.08% in BoMVR groups, respectively, at the end of 10-year follow-up (mean follow up of 6.2 ± 2.3 years). Overall, 20 (12.9%) patients were lost to follow-up in the BoMVR and 15(12.5%) patients in the PoMVR groups for a global follow-up of 87.1%. CONCLUSIONS: For patients undergoing MVR with a bioprosthetic valve, the choice of PoMVR vs BoMVR favours more in favour of PoMVR as evidenced by the outcome results. Probably long-term follow-up with more patients might throw further light on the debatable topic.

Improving hemodynamics - Prolonged intra-aortic balloon pump usage in posterior ventricular septal rupture with right ventricle dysfunction.

The associated mortality and morbidity of posterior ventricular septal rupture (VSR) is quite high increasing to almost 80% due to severe right ventricle dysfunction and pulmonary artery hypertension. Herein, we present a case of posterior VSR due to inferior wall myocardial infarction who underwent surgery. Premature removal of intra-aortic balloon pump (IABP) led to hemodynamic deterioration and he was salvaged with prolonged and prompt re-institution of IABP. This case also highlights the importance of IABP in right ventricle failure.

Role of surgical ventricular restoration post surgical treatment of heart failure (STICH) trial.

OBJECTIVE: To compare the outcomes of isolated coronary artery bypass grafting (CABG) versus surgical ventricular restoration (SVR) with or without CABG for patients with ischemic cardiomyopathy (ICM). METHODS: Retrospectively, 49 patients with ICM and severe LV dysfunction (LVEF < 35%) who underwent SVR with or without CABG from January 2009 to December 2016 at a single institution was compared with 49 patients who underwent isolated CABG. The two groups were matched for preoperative clinical and echocardiographic parameters including left ventricular end-diastolic diameter (LVIDd), left ventricular end-systolic diameter (LVIDs), left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), and left ventricular end-systolic volume (LVESV). Primary outcomes analyzed included early mortality, late mortality, and major adverse cardiac or cerebrovascular events (MACCE). Secondary outcomes analyzed included echocardiographic parameters of left ventricular volume and function-indexed left ventricular end-diastolic volume (LVEDVi), indexed left ventricular end-systolic volume (LVESVi), and LVEF. Cox and survival analysis was performed. RESULTS: Early and late mortality in SVR vs. CABG groups were 4 (8.1%) and 6 (12.2%) vs. 1 (2%) and 5 (10.2%) respectively. Mean improvement in LVEF was 3.39 ± 7.51 compared to 4.97 ± 5.45 between the two groups at 3-month follow-up. Mean improvement in LVEF was 5.1 ± 8.3 in the SVR group vs 5.9 ± 7.1 in the CABG group at the last follow-up. There was no statistically significant improvement between the two groups in terms of LVEF at 3 months or the last follow-up. There were statistically significant differences between LVEDVi and LVESVi between the two groups at 3 months and the last follow-up. The 5-year rates of survival were 85 ± 6 and 82 ± 9% for SVR and CABG groups respectively. The 5-year rates of freedom from MACCE were 75 ± 7 and 60 ± 11% for SVR and CABG groups respectively. CONCLUSION: Compared with isolated CABG, SVR plus CABG results in equivalent late mortality and better left ventricular reverse remodeling (as evidenced by LV volume reduction) and better freedom from MACCE at 5-year follow-up.

Papillary fibroelastoma of tricuspid valve presenting as pulmonary embolism.

A 65-year-old gentleman was admitted with recurrent dyspnea. Two-dimensional and transesophageal echocardiography revealed a highly mobile echogenic mass attached to the tricuspid valve. A (99m)Tc lung perfusion scan was suggestive of pulmonary embolism. The patient underwent surgical resection of the mass. Histopathological examination revealed a papillary fibroelastoma.