Acute type A dissection, coarctation of aorta, and levoatriocardinal vein-A rare combination.

Concomitant presence of acute type A dissection, coarctation of aorta and levoatriocardinal vein has not been described. We here present a case of aortic anuerysm complicated by type A dissection with coarctation of aorta and levoatriocardinal vein.

Midterm outcome of off-pump CABG for severe LV dysfunction-Does LV size and function predict their midterm outcome?

BACKGROUND: The superiority of surgical revascularization in ischemic cardiomyopathy is established beyond doubt, and off-pump CABG (OP-CABG) is a safe way of revascularization in this high-risk subset. Data on the effect of postoperative ventricular function and size on their midterm outcome is scarce. MATERIALS AND METHODS: A retrospective study was done on 211 consecutive patients with severe LV dysfunction who underwent OP-CABG from January 2017 to December 2018. Data were collected from the institutional database. Their operative and midterm outcomes were statistically analyzed. RESULTS: The mean age of the cohort was 58.4 ± 8.3 years. An average number of grafts was 3.1 ± 0.8 (cumulative intended number of grafts-3). Operative mortality was 10.9%. Preoperative NYHA class (p < .0001; OR, 19.72) and postoperative IABP insertion (p < .008; OR, 88.75) were independent predictors of operative mortality. The mean follow-up period was 3.14 ± 0.07 years, was 97.4% complete with cardiac mortality of 5.8%. Postoperative LVEF (p = .002; OR, 0.868) and LV dimensions (systole & diastole) (p = .013, OR = 1.182 and p = .036, OR = 1.184, respectively) were independent predictors of midterm mortality. Midterm major adverse cardiovascular event-free survival of operative survivors was 89%. There was no correlation between postoperative LV dimension and NYHA status(p > .05). Myocardial viability was not associated with early (p = .17) or midterm mortality (p = .676). CONCLUSION: OP-CABG can achieve complete revascularization in patients with severe LV dysfunction with good midterm outcomes, albeit with high early operative mortality. Postoperative change in LV dimension and EF are predictors of midterm mortality.

Re-exploration after off-pump coronary artery bypass grafting: Incidence, risk factors, and impact of timing.

OBJECTIVE: Re-exploration after cardiac surgery still remains a troublesome complication. There is still a scarcity of data about the effect of re-exploration after off-pump coronary artery bypass grafting (OPCABG). We here represent our experience on re-exploration following OPCABG. METHOD: A total of 5990 OPCABG were performed at our center, out of these patients, 132 (2.2%) were re-explored in the operation room and were included in this study. The medical records of these patients were retrospectively reviewed. RESULTS: The most common cause of re-exploration was bleeding (83.3%) and the most common site of bleeding was from graft/anastomosis (53.8%). The mean time to re-exploration was 9.75 ± 8.65 hours. The thirty-day mortality was 1.41%. On univariate and multiple regression analysis, emergency surgery, preoperative low platelet count, and the number of grafts were found to be independent risk factors for re-exploration. On multiple regression, emergency surgery, Euroscore II, low platelet count, low ejection fraction, re-exploration, time to re-exploration, blood products used, and high postoperative serum creatinine and bilirubin were found to be independent factors (P < .001) for mortality. On receiver-operating characteristic analysis, the optimum cutoff for time to re-exploration was 14 hours with a sensitivity of 81.3%, specificity of 80%, and area under the curve of 0.798. Patients who re-explored late (>14 hours) had significantly high mortality (30.55% vs 7.3%) and morbidity. CONCLUSION: Delaying re-exploration is associated with a three fold increase in mortality and morbidity. So, a strategy of minimizing the incidence of re-exploration, like the use of minimally invasive surgery and early re-exploration with the judicial use of products, should be used to improve outcomes after re-exploration following OPCABG.

Effect of Red Blood Cell Storage Duration on Outcome After Paediatric Cardiac Surgery: A Prospective Observational Study.

BACKGROUND: Retrospective reviews have found the use of stored packed red blood cells (PRBCs) in priming to be associated with increased risk of postoperative complications. The purpose of study was to prospectively investigate the influence of duration of storage of PRBCs used in priming the cardiopulmonary bypass (CPB) circuit on the metabolic profile of the patients, and postoperative outcome after paediatric cardiac surgery. METHODS: Between January 2015 and December 2015, 198 consecutive children operated for cardiac surgery using CPB and received blood for priming the circuit were included. Patients were divided into two groups based on the duration of storage of the blood, newer PRBCs group who received blood stored for ≤14days and the older PRBCs group who received blood stored for >14 days. RESULTS: Mean duration of blood storage used for priming in newer PRBCs blood group (n=103) was 8.4±3.7days while it was 21.9±4.5days in older PRBCs group (n=95). Metabolic parameters of the PRBCs improved to physiological limits in both the groups after initiation of CPB. Postoperative hepatic, pulmonary, haematological complications, sepsis and multi-organ failure were more in the old PRBCs group. However, the difference was not significant. Similarly, there was no significant difference in incidence of prolonged mechanical ventilation, intensive care unit stay and hospital stay and mortality between the two groups. CONCLUSIONS: Metabolic parameters of the stored blood become normal after initiation of CPB irrespective of duration of storage. In paediatric patients without significant co-morbidity, undergoing cardiac surgery, transfusion of washed stored blood up to 28days in CPB priming is safe especially if lesser amount of transfusion is required.

Acute cardio-embolic stroke in a preschooler-a surgical dilemma.

Myxomas are the most common primary intra-cardiac tumors in adults. Myxoma occurring in a preschooler is very rare, and cardiac surgery in acute stroke is a challenging decision. We present a rare case of acute cardio-embolic stroke in a 3-year-old child due to left atrial myxoma which was successfully treated.

Repairing the rheumatic mitral valve in the young: The horizon revisited.

Objective: Most of the rheumatic mitral valve repair literature focuses on older patients with burnt out disease. We present our midterm results of rheumatic mitral valve repair in young patients. Methods: In this retrospective-prospective study, 106 consecutive children (<18 years) underwent mitral valve repair for rheumatic etiology (2013-2017). Patients were evaluated at regular intervals. Results: The mean age of the cohort was 13.1 ± 3.2 years; 30 (29.6%) patients had recent rheumatic activity (<8 weeks); 80 (78.4%) had mitral regurgitation; 8 (7.8%) had mitral stenosis; 14 (13.7%) had mixed lesions; 11 underwent emergency surgery for intractable heart failure; and 34 (33.3%) patients underwent autologous pericardial augmentation. All patients underwent annuloplasty (ring, band, or other); 40 (39.2%) required chordal procedures. Operative mortality was 1%. Mean follow-up was 25.6 ± 9.5 months and was 100% complete. At last follow-up, mean mitral regurgitation grade was 1.2 ± 0.3, mean mitral valve gradient was 2.96 ± 0.18, and 94.8% of patients were in New York Heart Association class I. Four patients developed recurrent rheumatic carditis (resulting in severe mitral regurgitation), but there were no thromboembolic or hemorrhagic events. Actuarial survival and freedom from reoperation at 2.5 years were 96.2% (number at risk, 38), and 97.1% (number at risk, 38), respectively. Conclusions: Rheumatic valves in children are eminently repairable. The surgeon who ventures to repair a rheumatic mitral valve should consider all lesions of the various components of the mitral valvular apparatus and must have numerous techniques in the armamentarium to effect a successful repair.

Damus-Kaye-Stansel: Valuable Option for Retraining of Left Ventricle in Late Arterial Switch for Transposition of the Great Arteries.

Management of dextro-transposition of the great arteries with intact interventricular septum along with regression of the left ventricle remains a challenge. Atrial switch always raises concerns about the fate of the right ventricle as a systemic ventricle in the long run. A two-stage repair with pulmonary artery banding and a modified Blalock-Taussig shunt or a single-stage arterial switch with mechanical support has a higher mortality and morbidity. This report describes a case of a 3-year-old girl with dextro-transposition of the great arteries with intact interventricular septum that was managed by a Damus-Kaye-Stansel procedure with a right bidirectional cavopulmonary anastomosis in the first stage to train the left ventricle, followed by a definitive operation (arterial switch) in the second stage.

OPCABG for Moderate CIMR in Elderly Patients: a Superior Option?

OBJECTIVE: To compare the early and late outcomes of off-pump coronary artery bypass grafting and coronary artery bypass graft + mitral valve repair in elderly patients with moderate chronic ischemic mitral regurgitation. METHODS: One hundred and fifty elderly (age > 70 years) patients with moderate chronic ischemic mitral regurgitation who underwent off-pump coronary artery bypass grafting (n=95) or coronary artery bypass graft + mitral valve repair (n=55) between January 2007 and December 2014 were studied. They were subdivided according to presence or absence of high operative risk. Peri-operative variables and early operative outcomes were retrospectively studied. Survival, mitral regurgitation grade, and functional outcomes were prospectively analysed. RESULTS: Both groups were comparable in terms of age (P=0.23), sex (P=0.74), left ventricle ejection fraction (P=0.6) and preoperative functional class (P=0.52). The mean number of grafts for off-pump coronary artery bypass grafting group was 3.14 and coronary artery bypass graft + mitral valve repair was 3.21. Off-pump coronary artery bypass grafting group had statistically significant better early operative outcomes i.e perioperative blood transfusions, intraaortic balloon pump usage, arrhythmias, renal dysfunction, liver dysfunction, sepsis, mean hours of ventilation, intensive care unit stay and operative mortality. On a prospective follow up of 5±2.33 years (1-9 years), coronary artery bypass graft + mitral valve repair in low operative risk subgroup had better improvements in mitral regurgitation grade than off-pump coronary artery bypass grafting. Both groups had similar improvements in functional class and cumulative survival was also comparable (63.2% vs. 54.5%). CONCLUSION: Off-pump coronary artery bypass grafting is a safer alternative to coronary artery bypass graft + mitral valve repair with better early operative outcomes and comparable late survival and functional outcomes in elderly patients with moderate chronic ischemic mitral regurgitation, especially those with higher operative risk.

Intramural Anomalous Right Coronary Artery From the Main Pulmonary Artery.

Anomalous origin of the right coronary artery from the main pulmonary artery (anomalous right coronary artery from pulmonary artery; ARCAPA) is a rare congenital anomaly. Here, we present an unusual case of anomalous right coronary artery from the main pulmonary artery with proximal intramural course.

Dumb-bell in the heart: rare case of biatrial myxoma with mitral regurgitation.

Cardiac myxomas are rare intracardiac tumors, and the majority are benign myxomas involving the left atrium. We report a case of the very rare occurrence of biatrial myxoma associated with mitral regurgitation, which was successfully treated.

Hyperbilirubinemia after cardiac surgery: An observational study.

BACKGROUND: We aimed to assess the incidence and perioperative risk factors for hyperbilirubinemia after cardiac surgery, and determine its influence on early operative outcome. METHODS: This prospective observational study was conducted on 476 patients who underwent cardiac surgical procedures from January 2014 to March 2014. Postoperative hyperbilirubinemia was defined as serum total bilirubin >2.0 mg dL(-1). RESULTS: The overall incidence of postoperative hyperbilirubinemia was 25% (119 patients). Patients undergoing valve repair or replacement had the highest incidence of hyperbilirubinemia (36.2%), followed by coronary artery bypass grafting with concomitant valve surgery (34.1%), congenital heart surgery (23.1%), and coronary artery bypass alone (12.7%). Postoperative hyperbilirubinemia was associated with increased duration of inotropic support (p = 0.0001), mechanical ventilation (p = 0.0001), intensive care unit stay (p = 0.001), hospital stay (p = 0.006), and mortality (p = 0.014). The perioperative factors associated with postoperative hyperbilirubinemia were increased preoperative bilirubin level (p < 0.0001), preoperative prothrombin time (p < 0.0001), cardiopulmonary bypass time (p = 0.028), aortic crossclamp time (p = 0.004), and blood transfusion units (p = 0.0001). CONCLUSIONS: Postoperative hyperbilirubinemia is common in patients undergoing cardiopulmonary bypass and is associated with high hospital mortality. The factors associated with its occurrence are increased preoperative bilirubin level, preoperative prothrombin time, cardiopulmonary bypass time, aortic crossclamp time, and blood transfusion units. Persistent hyperbilirubinemia is associated with a worse outcome than early transient hyperbilirubinemia.

OPCABG for moderate cimr in elderly patients: a superior option?

Abstract Objective: To compare the early and late outcomes of off-pump coronary artery bypass grafting and coronary artery bypass graft + mitral valve repair in elderly patients with moderate chronic ischemic mitral regurgitation. Methods: One hundred and fifty elderly (age > 70 years) patients with moderate chronic ischemic mitral regurgitation who underwent off-pump coronary artery bypass grafting (n=95) or coronary artery bypass graft + mitral valve repair (n=55) between January 2007 and December 2014 were studied. They were subdivided according to presence or absence of high operative risk. Peri-operative variables and early operative outcomes were retrospectively studied. Survival, mitral regurgitation grade, and functional outcomes were prospectively analysed. Results: Both groups were comparable in terms of age (P=0.23), sex (P=0.74), left ventricle ejection fraction (P=0.6) and preoperative functional class (P=0.52). The mean number of grafts for off-pump coronary artery bypass grafting group was 3.14 and coronary artery bypass graft + mitral valve repair was 3.21. Off-pump coronary artery bypass grafting group had statistically significant better early operative outcomes i.e perioperative blood transfusions, intraaortic balloon pump usage, arrhythmias, renal dysfunction, liver dysfunction, sepsis, mean hours of ventilation, intensive care unit stay and operative mortality. On a prospective follow up of 5±2.33 years (1-9 years), coronary artery bypass graft + mitral valve repair in low operative risk subgroup had better improvements in mitral regurgitation grade than off-pump coronary artery bypass grafting. Both groups had similar improvements in functional class and cumulative survival was also comparable (63.2% vs. 54.5%). Conclusion: Off-pump coronary artery bypass grafting is a safer alternative to coronary artery bypass graft + mitral valve repair with better early operative outcomes and comparable late survival and functional outcomes in elderly patients with moderate chronic ischemic mitral regurgitation, especially those with higher operative risk.