Clinical Outcome of Rheumatic Mitral Valve Repair and Replacement Surgery in Indonesia; A Comparison with Non-Rheumatic Aetiology.

Introduction: Mitral valve repair (MVr) has been shown to achieve better outcomes than mitral valve replacement (MVR) in degenerative aetiology. However, that cannot be applied in rheumatic mitral valve disease. Therefore, this study aims to evaluate early and late clinical outcomes and mid-term survival in RHD compared to the non-RHD group and whether mitral valve repair is a better surgical approach in RHD patients. Methods: Patients who underwent mitral valve surgery with or without coronary artery bypass grafting were included in this study. All patients were divided into the RHD and non-RHD group by the type of mitral surgery performed. Early and late outcomes were evaluated, and mid-term cumulative survival was reported. Results: A total of 1382 patients post MV surgeries were included. The 30-day mortality was significantly higher in the RHD group compared to the non-RHD group (8.7% vs. 4.4%, p = 0.003). There was no difference in 30-day mortality between repair and replacement in each respective group. During follow-up (12-54 months), all-cause mortality between RHD and non-RHD groups (16.7% vs. 16.2%) was not different. In the RHD group, the survival of MVr was 85.6% (95% CI 82.0%-88.5%), and MVR was 78.3% (95% CI 75.8%-80.6%), p-value log rank 0.26 However, in the non-RHD group, patients who underwent MVr had better survival than MVR, with cumulative survival of 81.7% (95% CI 72.3%-88.2%) vs. 71.1% (95% CI 56.3%-81.7%) p-value log rank 0.007. Conclusion: Early mortality rate in rheumatic mitral valve surgery was higher than in non-rheumatic valve surgery. Although in rheumatic MV disease MV repair did not show a significant survival advantage over MV replacement, a trend towards more favourable survival in the repair group was observed.

Giant lipoma in superior vena cava: A case report and literature review.

INTRODUCTION: Intravascular lipomas are rare occurrences, especially in major vessels. This tumour is composed of adipocytes in a fibrous capsule that has a slow growth rate and usually shows no symptoms. There were only eight reports in the literature regarding intravascular lipoma located in the superior vena cava. CASE PRESENTATION: A 54-year-old man had episodes of supraventricular tachycardia and atrial flutter for over a year. Preoperative radiological findings showed a giant mass that arose from the superior vena cava to the right atrium and a biopsy catheter showed that there were no signs of malignancy. The patient then underwent surgery through median sternotomy and the mass was extirpated on the highest part of the stalk that could be reached. The patient was stable and remained to show no symptoms or evidence of residual mass or stalk in 2 years follow-up. CONCLUSION: The surgical approach in excising lipoma in SVC should be considered wisely with the support of adequate preoperative diagnosis. Since lipoma is a very slow-growing tumour, extensive manipulation that could increase surgical technique difficulty or postoperative morbidity and mortality is not necessary.

Association between Right Ventricle-Pulmonary Artery Coupling with In-Hospital Outcome after Triple Valve Surgery in Rheumatic Heart Disease.

Context: Triple valve surgery (TVS) is a relatively higher in-hospital mortality rate than any isolated valve surgery. In advanced-stage valvular heart disease, maladaptation may occur, creating RV-PA uncoupling. Aims To evaluate whether RV-PA coupling is associated with the in-hospital outcome of patients after TVS. Settings and Design: From the medical records, clinical and echocardiography data were collected and compared between the survived and patients with in-hospital mortality groups. Methods and Material: Patients with the rheumatic multivalvular disease who underwent triple valve surgery were included in the study. Statistical and analysis used Uni and bivariate analysis assessed any association between the RV-PA coupling using TAPSE/PASP and other clinical variables with the in-hospital mortality post TVS. Result: From 269 patients, the in-hospital mortality rate was 10 %. The median value of TAPSE/PASP ratio in all group is 0.41 (0.02-5.79). Impaired RV-PA coupling which value < 0.36 occurs in 38.3 % population. By multivariate analysis, independent predictors of in-hospital mortality were TAPSE/PASP < 0.36 (OR 3.46, 95 % CI 1.21 - 9.89; P 0.02), age (OR 1.04, 95 % CI 1.003-1.094; P 0.035), CPB duration, (OR 1.01, 95 % CI 1.003-1.017; P 0.005). Conclusion: RV-PA uncoupling assessed by TAPSE / PASP ratio < 0.36 is associated with the in-hospital mortality in patients post triple valve surgery. Other factors associated with the outcome were older age and longer CPB machine duration.

A 48-Year-Old Man at Low Risk for SARS-CoV-2 Infection Who Underwent Planned Elective Triple-Vessel Coronary Artery Bypass Graft Surgery at a National Heart Center in Indonesia Followed by a Fatal Case of COVID-19.

BACKGROUND This is of the first fatal case of coronavirus disease 2019 (COVID-19) pneumonia at a National Heart Center in Indonesia following planned elective triple-vessel coronary artery bypass graft (CABG) who was considered to be at low risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection when admitted for surgery. CASE REPORT A 48-year-old man was diagnosed with coronary artery disease (CAD) in 3 vessels (3VD) with an ejection fraction (EF) of 61% and chronic kidney disease (CKD) with routine hemodialysis. The patient was scheduled for a coronary artery bypass graft (CABG) surgery. He underwent surgery after COVID-19 screening using a checklist provided by the hospital. The patient's condition worsened on the 3rd postoperative day in the ward, and he was transferred back to the Intensive Care Unit (ICU), reintubated, and tested for COVID-19 with a real time-polymerase chain reaction (PCR) test. Because of the COVID-19 pandemic, we excluded the other possible pneumonia causes (e.g., influenza). An RT-PCR test performed after surgery revealed that the patient was positive for COVID-19. COVID-19 tracing was performed for all health care providers and relatives; all results were negative except for 1 family member. The patient was treated for 4 days in the isolation ICU but died due to complications of the infection. CONCLUSIONS This report shows the importance of testing patients for SARS-CoV-2 infection before hospital admission for elective surgery and during the hospital stay, and the importance of developing rapid and accurate testing methods that can be used in countries and centers with limited health resources.

Effectivity of dexamethasone in patients undergoing off-pump coronary artery bypass surgery.

BACKGROUND: Based on our previous pilot study, systemic inflammatory response syndrome is more common in off-pump compared to on-pump coronary artery bypass. Therefore, we conducted a clinical trial of dexamethasone in patients undergoing off-pump coronary artery bypass. METHODS: Sixty consecutive patients undergoing off-pump coronary artery bypass were enrolled from August 2018 to January 2019 and randomized to a dexamethasone or placebo group of 30 each. Clinical outcomes were analyzed. RESULTS: There was a lower incidence of major adverse cardiac events in the dexamethasone group compared to the placebo group (17% versus 43%, p = 0.024). Clinical outcomes in the dexamethasone group were better than those in the placebo group, in terms of duration of mechanical ventilation (p = 0.029), intensive care unit stay (p = 0.028), hospital stay (p = 0.04), and vasoactive-inotropic score (p = 0.045). There were significant differences in inflammatory markers between the two groups: interleukin-6 (p = 0.0001), procalcitonin (p = 0.0001), and C-reactive protein (p = 0.0001) were lower in the dexamethasone group. There was a significant association between the incidence of major adverse cardiac events and both interleukin-6 (p = 0.005) and procalcitonin (p = 0.007). CONCLUSION: Preoperative dexamethasone in patients undergoing off-pump coronary artery bypass is effective in improving clinical outcomes and controlling the postoperative inflammatory reaction.