Effect of peri-operative intra-aortic balloon pump in patients undergoing coronary artery bypass grafting on outcomes in a resource limited setting.

INTRODUCTION: Intra-aortic balloon pump (IABP) insertion for diminished myocardial function is standard of care in cardiac surgery. Previous studies have suggested a possible benefit to IABP support before surgery with regards to outcomes and complications. However, there are conflicts with other studies suggesting no significant benefit. Optimal time of insertion, whether preoperative or perioperative (intra-operative and post-operative), has yet to be defined. METHODOLOGY: A retrospective, hospital records-based chart review was conducted for patients admitted to our center from January 2015 to December 2019 for coronary bypass surgery necessitating IABP insertion. Cases were stratified according to the timing of insertion and analyzed according to surgical outcomes and complication rates. RESULTS: Out of 97 patients, 84.5% underwent preoperative IABP insertion while 15.5% of patients received perioperative (Intra-operative or post-operative) insertion. In-hospital mortality was significantly higher in patients with perioperative IABP insertion as compared to the preoperative group (60% vs 20.7%, p = 0.003). However, there were no significant differences between 30-day readmission rates in the two groups (9.8% vs 6.7%, p = 1.000). Length of stay was also higher in patients with preoperative insertion of IABP (p = 0.032), with no significant difference in ICU stay (p = 0.107). Perioperative IABP patients had higher rates of arrhythmias (46.7%, p = 0.042) and reopening of patient (33.3%, p = 0.028). CONCLUSION: Our study shows improved mortality in patients with preoperatively inserted IABP. This may be beneficial for high-risk patients undergoing CABG surgery. Expanding the use of IABP before CABG in third world countries such as Pakistan may improve overall survival for patients.

Mesenchymal Stem Cell Therapy in Ischaemic Heart Failure: Hope or Hype?

Ischaemic heart diseases (IHDs) are the leading contributor to mortality worldwide and more than 60% occur in low-to-middle-income countries (LMICs) and 40% of these are specified as premature. Despite notable improvements in treatment options, premature deaths due to IHDs including ischaemic heart failure (IHF) continue to rise in the South Asian population due to prevalent conventional and inherent cardiovascular risk profiles. Stem cell (SCs) therapy has emerged as a potential frontier in regenerative therapy for acute and chronic illnesses. Among various available sources of SCs, the safety and efficacy of mesenchymal stem cells (MSCs) for non-functional cardiomyocytes have been established, but robust evidence necessitates to endorse these preliminary investigations. Little work has been conducted in resource constraints countries and needs immediate attention of all the stakeholders to explore non-conventional cost-effective and sustainable interventions for long term management of IHDs including IHF. This review article provides an overview of basic technical aspects of SCs therapy and a way forward to inspire the scientific community and health authorities to setup priorities via collaborative public and private partnership toward the formulation and execution of sustainable strategies for IHDs to explore the new contextual destination in the field of SCs therapy.

Polyaniline (PANI)-conjugated tungsten disulphide (WS2) nanoparticles as potential therapeutics against brain-eating amoebae.

Brain-eating amoebae, including Acanthamoeba castellanii and Naegleria fowleri, are the causative agents of devastating central nervous system infections with extreme mortality rates. There is an indisputable urgency for the development of effective chemotherapeutic agents for the control of these diseases that are increasing in incidence. Here, we evaluated the anti-amoebic potential of polyaniline:tungsten disulphide (PANI:WS2) nanocomposite against the infective trophozoite and cyst stages of N. fowleri and A. castellanii. Throughout these evaluations, significant viability inhibition was noted when 100 µg/mL of PANI:WS2 was employed at its 1:5 formulation. These effects were studied to be due to increased levels of reactive oxygen species (ROS) as visualised through fluorescence microscopy. Furthermore, field emission scanning electron microscopy (FE-SEM) analysis pictured disruption to amoeba morphology. The host-cell cytotoxicity of the nanocomposite (PANI:WS2) was studied to be negligible, making it an attractive avenue in the pursuit for effective treatments for brain-eating amoeba infections. KEY POINTS: • Synthesis of polyaniline:tungsten disulphide (PANI:WS2) nanocomposite. • Anti-amoebic potential of PANI:WS2 nanocomposite. • PANI:WS2 nanocomposites are promising anti-amoebic agents in vitro.

Surgeons and ethical challenges in operating room.

Ethics lie in the heart of professionalism. In surgery, it represents an essential element, with surgeons facing ethical challenges in their routine practice. The rapid expansion of surgical technology and innovation along with the use of resources and consideration of conflict of interest have brought up the need for the development of current surgical code of ethics. Operating room represents a stressful environment where patients' lives depend upon careful preparation, planning and execution. The progression of surgery within the operating room must be done in harmony and in line with the ethical principles of autonomy, beneficence, non-maleficence and justice. Discussion of ethical problems arising in the operating room is not a common subject in surgical literature. The current narrative review was planned to cover ethical concerns related to patients' safety and privacy in the operating room and some of the evolving topics, like ethics of overlapping surgery, live surgical broadcast and 'do not resuscitate' policy in the operating room.

Antimicrobial properties of multifunctional polypyrrole-cobalt oxide-silver nanocomposite against pathogenic bacteria and parasite.

BACKGROUND: Conducting polymer based nanocomposites are known to be effective against pathogens. Herein, we report the antimicrobial properties of multifunctional polypyrrole-cobalt oxide-silver nanocomposite (PPy-Co3O4-AgNPs) for the first time. Antibacterial activities were tested against multi-drug-resistant Gram-negative Escherichia coli (E. coli) and Gram-positive methicillin-resistant Staphylococcus aureus (MRSA) bacteria, while antiamoebic effects were assessed against opportunistic protist Acanthamoeba castellanii (A. castellanii). RESULTS: The ternary nanocomposite containing conducting polymer polypyrrole, cobalt oxide, and silver nanoparticles showed potent antimicrobial effects against these pathogens. The antibacterial assay showed that PPy-Co3O4-AgNPs exhibited significant bactericidal activity against neuropathogenic E. coli K1 at only 8 µg/mL as compared to individual components of the nanocomposite, whereas a 70 % inhibition of A. castellanii viability was observed at 50 µg/mL. Moreover, PPy-Co3O4-AgNPs were found to have minimal cytotoxicity against human keratinocytes HaCaT cells in vitro even at higher concentration (50 µg/mL), and also reduced the microbes-mediated cytopathogenicity against host cells. CONCLUSION: These results demonstrate that PPy-Co3O4-AgNPs hold promise in the development of novel antimicrobial nanomaterials for biomedical applications. KEY POINTS: •Synthesis of polypyrrole-cobalt oxide-silver (PPy-Co3O4-AgNPs) nanocomposite. •Antimicrobial activity of nanocomposite. •PPy-Co3O4-AgNPs hold promise for biomedical applications.

Paradigm shift in the surgical training: The era of innovation, simulation and beyond.

This is an era of transformation of surgical education and training. Modern methods of training are being introduced at a rapid pace and are being adopted in surgical practice not only to improve the outcomes and patient satisfaction, but also to provide an opportunity to develop a new well-structured training curriculum by integrating both traditional and modern approaches to teach and learn surgical skills. Various surgical simulators are in use as training aids and are constantly undergoing further refinement and development. To achieve a smooth transition in surgical training to modern methods, a structured programme has to be developed and validated to bridge the gaps in terms of safety, efficiency and ethics during the training process.

Influence of solvents on the enhancement of thermophysical properties and stability of multi-walled carbon nanotubes nanofluid.

Multi-walled carbon nanotubes (MWCNTs) are a contemporary class of nanoparticles that have a prominent thermal, electrical and mechanical properties. There have been numerous studies on the enhancement of thermophysical properties of nanofluids. However, there is only limited research on thermal and stability analysis of MWCNT nanofluids with various kinds of solvents or base fluids, namely propylene glycol, ethanol, ethylene glycol, polyethylene glycol, methanol and water. This paper reports the enhancement of thermophysical properties and stability of MWCNTs with six different base fluids in the presence of sodium dodecyl benzene sulfonate surfactant with a mass concentration of 0.5 wt%. Thermal and dispersion stabilities were determined using a thermogravimetric analyzer (TGA) and Zeta potential, along with a visual inspection method to evaluate the agglomeration or sedimentation of MWCNT nanoparticles over a period of one month. Ultraviolet-visible spectroscopy and Fourier transform infrared spectroscopy were utilized to identify the molecular components and light absorption of the formulated nanofluids at their maximum wavenumber (4500 cm-1) and wavelength (800 nm). In addition, thermophysical properties such as thermal conductivity, specific heat capacity, viscosity and density with a peak temperature of 200 °C were also experimentally evaluated. The TGA results illustrated that MWCNT/ethylene glycol nanofluid achieved maximum thermal stability at 140 °C and it revealed a maximum zeta potential value of -61.8 mV. Thus, ethylene glycol solution was found to be the best base liquid to homogenize with MWCNTs for acquiring an enhanced thermophysical property and a long-term stability.

Fabrication of biopolymer polyhydroxyalkanoate/chitosan and 2D molybdenum disulfide-doped scaffolds for antibacterial and biomedical applications.

Antibiotic resistance in pathogenic bacteria is a major health challenge, as Infectious Diseases Society of America (IDSA) has recognized that the past simply drugs susceptible pathogens are now the most dangerous pathogens due to their nonstop growing resistance towards conventional antibiotics. Therefore, due to the emergence of multi-drug resistance, the bacterial infections have become a serious global problem. Acute infections feasibly develop into chronic infections because of many factors; one of them is the failure of effectiveness of antibiotics against superbugs. Modern research of two-dimensional nanoparticles and biopolymers are of great interest to attain the intricate bactericidal activity. In this study, we fabricated an antibacterial nanocomposite consisting of representative two-dimensional molybdenum disulfide (2D MoS2) nanoparticles. Polyhydroxyalkanoate (PHA) and chitosan (Ch) are used to encapsulate MoS2 nanoparticles into their matrix. This study reports the in vitro antibacterial activity and host cytotoxicity of novel PHA-Ch/MoS2 nanocomposites. PHA-Ch/MoS2 nanocomposites were subjected to time-dependent antibacterial assays at various doses to examine their antibacterial activity against multi-drug-resistant Escherichia coli K1 (Malaysian Type Culture Collection 710859) and methicillin-resistant Staphylococcus aureus (MRSA) (Malaysian Type Culture Collection 381123). Furthermore, the cytotoxicity of nanocomposites was examined against spontaneously immortalized human keratinocyte (HaCaT) cell lines. The results indicated significant antibacterial activity (p value < 0.05) against E. coli K1 and MRSA. In addition, PHA-Ch/MoS2 showed significant host cytocompatibility (p < 0.05) against HaCaT cells. The fabricated PHA-Ch/MoS2 nanocomposites have demonstrated effective antibacterial activity against both Gram-positive and -negative bacteria and exhibited better biocompatibility. Finally, PHA-Ch/MoS2 nanocomposites are shown to be suitable for antibacterial applications and also hold potential for further biomedical studies. Graphical Abstract.

Impact of brain atrophy on tDCS and HD-tDCS current flow: a modeling study in three variants of primary progressive aphasia.

BACKGROUND: During transcranial direct current stimulation (tDCS), the amount and distribution of current that reaches the brain depends on individual anatomy. Many progressive neurodegenerative diseases are associated with cortical atrophy, but the importance of individual brain atrophy during tDCS in patients with progressive atrophy, including primary progressive aphasia (PPA), remains unclear. OBJECTIVE: In the present study, we addressed the question whether brain anatomy in patients with distinct cortical atrophy patterns would impact brain current intensity and distribution during tDCS over the left IFG. METHOD: We developed state-of-the-art, gyri-precise models of three subjects, each representing a variant of primary progressive aphasia: non-fluent variant PPA (nfvPPA), semantic variant PPA (svPPA), and logopenic variant PPA (lvPPA). We considered two exemplary montages over the left inferior frontal gyrus (IFG): a conventional pad montage (anode over F7, cathode over the right cheek) and a 4 × 1 high-definition tDCS montage. We further considered whether local anatomical features, specifically distance of the cortex to skull, can directly predict local electric field intensity. RESULTS: We found that the differences in brain current flow across the three PPA variants fall within the distribution of anatomically typical adults. While clustering of electric fields was often around individual gyri or sulci, the minimal distance from the gyri/sulci to skull was not correlated with electric field intensity. CONCLUSION: Limited to the conditions and assumptions considered here, this argues against a specific need to adjust the tDCS montage for these patients any more than might be considered useful in anatomically typical adults. Therefore, local atrophy does not, in isolation, reliably predict local electric field. Rather, our results are consistent with holistic head anatomy influencing brain current flow, with tDCS producing diffuse and individualized brain current flow patterns and HD-tDCS producing targeted brain current flow across individuals.

Ultrasonication-facilitated synthesis of functionalized graphene oxide for ultrasound-assisted magnetic dispersive solid-phase extraction of amoxicillin, ampicillin, and penicillin G.

A simplistic approach is presented for the synthesis of ultrasonically fabricated graphene oxide functionalized with polyaniline and N-[3-(Trimethoxysilyl)propyl]ethylenediamine. The synthesized nanocomposite was then employed for the facile, green, ultrasound-assisted, magnetic dispersive solid-phase extraction of amoxicillin, ampicillin, and penicillin G in milk samples and infant formula prior to high-performance liquid chromatography-ultraviolet determination. The designed nanocomposites were comprehensively characterized using field emission scanning electron microscopy, energy-dispersive X-ray spectroscopy, transmission electron microscopy, X-ray powder diffraction, and Fourier transform infrared spectroscopy. In order to achieve the best extraction efficiencies, the influential parameters including pH, amount of magnetic sorbent, type and volume of elution solvent, extraction time, sample volume, and desorption time were assessed. At the optimum conditions, linear ranges of 2.5-1000 (µg L-1) for ampicillin and penicillin G and a linear range of 2.5-750 (µg L-1) were obtained for amoxicillin at optimum conditions. Moreover, the limits of detection (S/N = 3) of 0.5, 0.8, and 0.9 (µg L-1) were obtained for amoxicillin, ampicillin, and penicillin G, respectively. The precision (relative standard deviations (%)) values of 3.1, 2.6, and 2.5 at the concentration of 50 µg L-1 for seven replicates were obtained for ampicillin, amoxicillin, and penicillin G, respectively. The efficiencies of ≤ 96% and relative standard deviations of less than 3.1% were also obtained thereby confirming the high potential of the synthesized nanocomposites for simultaneous preconcentration and separation of the ß-lactam antibiotics in complex matrixes. Graphical Abstract.

Direct true lumen versus conventional cannulation for acute type-A aortic dissection.

Acute type-A aortic dissection is a surgical emergency and has a high rate of short-term mortality. Aortic dissection is highly under-reported in Pakistan. With the technological developments in its management, arterial cannulation technique of direct true lumen cannulation has emerged with improved outcomes. We aimed to compare the mortality and morbidity outcomes between direct true lumen and conventional cannulation techniques for arterial access in patients with acute type- A aortic dissection under a single-centre retrospective review from 2007 to 2017. Mean age of the participants was 43.3±11.6 vs 45±12.4 years with males being dominant in both groups. Frequency of overall morbidity was high in conventional cannulation group (Group-B), though it did not attain statistical significance, (p>0.999). Mortality rate was also high in Group-B (10% vs 30%), (p=0.582). Direct true lumen cannulation is an equally reliable option for establishing cardiopulmonary bypass due to reduced mortality and morbidity and may be given preference when dissection is extending into femoral and innominate arteries.

Comparison of figure of eight and traditional simple wire closure method to prevent dehiscence after sternal closure.

OBJECTIVE: To investigate significant differences, if any, between figure of-eight method and simple wire closure technique in reducing the incidence of infectious and non-infectious sternal dehiscence in patients undergoing sternal closure. METHODS: The systematic review was conducted in the Cardiothoracic Surgery Department at Aga Khan University from 1st December 2015 to 13th December 2017. The review was registered with PROSPERO, the International Prospective Register of Systematic Reviews. Pubmed, Cochrane Library (Wiley) and Scopus databases were searched for articles published up to December 13, 2017. The search was limited to randomised control trials, clinical trials, retrospective cohort studies, journal analyses, systematic reviews and meta analyses. Cadaveric or animal studies and articles published in languages other than English were excluded. RESULTS: Of the 286 articles retrieved, 265(92.6%) were excluded on the basis of study title and abstract. Another 15(5.2%) were excluded for being irrelevant to the topic n hand, and 6(2.1%) formed the final sample. Of them, 4(66.6%) studies showed no significant difference between the two techniques, while 2(33.3%) found figure-of-eight technique to be superior of the two. CONCLUSIONS: There was no significant difference between the figure-of eight method and the simple wire technique in reducing the risk of dehiscence in patients undergoing sternal closure.

Traumatic aortic transection repair with distal perfusion - single center experience.

Blunt aortic injury is associated with significant mortality. A large number of patients lose their lives before reaching the hospital, those who survive half die within a day. Isthmus is the commonest site of aortic injury. Aortic injury is usually associated with other injuries of the body hence a multidisciplinary approach is required. For aortic transection the treatment options have evolved from proximal and distal aortic cross clamping and repair with distal perfusion technique using shunt or partial heart bypass (extracorporeal circulation) to endovascular stenting depending upon the available facilities andexpertise. Distal perfusion technique helps in avoiding paraplegia. We present our institutional experience of polytrauma associated with blunt aortic injuries managed with open surgical repair with distal perfusion using cardiopulmonary bypass.

Iatrogenic trauma following percutaneous and minimally invasive surgical interventions.

Technological progress has changed the landscape of surgical practice. Minimally invasive surgery (MIS) and percutaneous interventions (PC) are constantly replacing open procedures. This reduces hospital stay and allows quicker recovery. The application of MIS should follow the good medical practice dictum by Hippocrates i.e. "First do no harm". To remain abreast with new procedures, the medical personnel are required to update and enhance their knowledge and skill. To ensure safety, the innovations are rigorously tested and tried. The learning curve of MIS is shortened by simulator training and proctorship. Credentialing processes are in place to enhance safe delivery of care. Despite of all these measures MIS and PCI are associated with adverse effects. The purpose of this article is to overview the iatrogenic trauma associated with MIS and PCI in major surgical subspecialties.

New N-benzhydrylpiperazine/1,3,4-oxadiazoles conjugates inhibit the proliferation, migration, and induce apoptosis in HeLa cancer cells via oxidative stress-mediated mitochondrial pathway.

N-benzhydrylpiperazine and 1,3,4-oxadiazoles are pharmacologically active scaffolds which exhibits significant inhibitory growth effects against various cancer cells, however, antiproliferation effects and the underlying mechanism for inducing apoptosis for aforementioned scaffolds addressing HeLa cancer cells remains uncertain. In this study, N-benzhydrylpiperazine clubbed with 1,3,4-oxadiazoles (4a-4h) were synthesized, subsequently characterized using high resolution spectroscopic techniques and eventually evaluated for their antiproliferation potential by inducing apoptosis in HeLa cancer cells. The MTT assay screening results revealed that among all, compound 4d ( N-benzhydryl-4-((5-(4-aminophenyl)-1,3,4-oxadiazol-2-yl)methyl)piperazine) in particular, exhibited IC 50 value of 28.13 ± 0.21 µg/mL and significantly inhibited the proliferation of HeLa cancer cells in concentration-dependent manner. The in vitro anticancer assays for treated HeLa cells resulted in alterations in the cell morphology, reduction in colony formation, and inhibition of cell migration in concentration-dependent treatment. Furthermore, G2/M phase arrest, variations in the nuclear morphology, degradation of chromosomal DNA confirmed the ongoing apoptosis in treated HeLa cells. Increase in the expression of cytochrome C and caspase-3 confirmed the involvement of intrinsic mitochondrial pathway regulating the cell death. Also, elevation in reactive oxygen species level and loss of mitochondrial membrane potential signified that compound 4d induced apoptosis in HeLa cells by generating the oxidative stress. Therefore, compound 4d may act as a potent chemotherapeutic agent against human cervical cancer.

Piperazine clubbed with 2-azetidinone derivatives suppresses proliferation, migration and induces apoptosis in human cervical cancer HeLa cells through oxidative stress mediated intrinsic mitochondrial pathway.

Piperazine scaffolds or 2-azetidinone pharmacophores have been reported to show anti-cancer activities and apoptosis induction in different types of cancer cells. However, the mechanistic studies involve in induction of apoptosis addressing these two moieties for human cervical cancer cells remain uncertain. The present study emphasizes on the anti-proliferating properties and mechanism involved in induction of apoptosis for these structurally related azoles derivatives in HeLa cancer cells. 1-Phenylpiperazine clubbed with 2-azetidione derivatives (5a-5h) were synthesized, characterized using various spectroscopic techniques and evaluated for their in-vitro anti-proliferative activities and induction of apoptosis. Further, we also evaluated oxidative stress generated by these synthetic derivatives (5a-5h). Cell viability studies revealed that among all, the compound N-(3-chloro-2-(3-nitrophenyl)-4-oxoazetidin-1-yl)-2-(4-phenylpiperazin-1-yl) acetamide 5e remarkably inhibited the growth of HeLa cells in a concentration dependent manner having IC50 value of 29.44 ± 1.46 µg/ml. Morphological changes, colonies suppression and inhibition of migration clearly showed the antineoplasicity in HeLa cells treated with 5e. Simultaneously, phosphatidylserine externalization, DNA fragmentation and cell-cycle arrest showed ongoing apoptosis in the HeLa cancer cells induced by compound 5e in concentration dependent manner. Additionally, generation of intracellular ROS along with the decrease in mitochondrial membrane potential supported that compound 5e caused oxidative stress resulting in apoptosis through mitochondria mediated pathway. Elevation in the level of cytochrome c and upregulation in expression of caspase-3 clearly indicated the involvement of the intrinsic pathway of programmed cell death. In brief; compound 5e could serve as a promising lead for the development of an effective antitumor agent.

Palm Fatty Acid Functionalized Fe3O4 Nanoparticles as Highly Selective Oil Adsorption Material.

The present work highlights the facile synthesis of hydrophobic palm fatty acid functionalized Fe3O4 nanoparticles (MNP-FA) for the efficient removal of oils from the surface of water. An intense hydrophobic layer was introduced on the surface of Fe3O4 nanoparticles functionalized by the palm fatty acid obtained from the hydrolysis of palm olein. Scanning electron microscopy (SEM), vibrating sample magnetometer (VSM), Energy dispersive X-ray spectroscopy (EDX) and water contact angle analysis (WCA) measurements were used to characterize the newly fabricated palm fatty acid adorned magnetic Fe3O4 nanoparticles (MNP-FA). The obtained results confirmed the successful synthesis of palm fatty acid-functionalized magnetic nanoparticles. Oil removal tests performed with MNP-FA revealed that this newly prepared material could selectively adsorb lubricating oil up to 3.5 times of the particles' weight while completely repelling water. The main parameters affecting the adsorption of oil i.e., sorption time, mass of sorbent and pH of water were optimized.

Is Grown Up Congenital Heart (GUCH) disease different in a developing country?

In the current era grown up congenital heart disease (GUCH) patients undergoing surgical interventions are increasing. Most of the interventions in the developed countries are either complex or redo-operations in patients who had previously undergone repair, palliation or correction. However, in the developing countries most of the interventions are primary and corrective. This descriptive retrospective study comprised GUCH patients who underwent surgical intervention for congenital heart disease (CHD) at Aga Khan University Hospital, Karachi, from January 2006 to December 2015. A total of 195 patients had been treated surgically with a mean age of 31.0±13.5 years. Majority of the patients underwent surgical interventions for closure of atrial 109(55.3%) and ventricular 51(26.2%) septal defect. The most common complications were prolonged ventilation 16(8.1%). Overall mortality was 4(2.1%). GUCH in our practice is for primary procedure with simple diagnosis that should have been treated before reaching adulthood as is done in the developed countries.

Cervical mediastinoscopy in the diagnosis of lymphadenopathy in South Asia.

We planned to determine the clinical utility and safety of mediastinoscopy in the pathologic diagnosis of mediastinal lymphadenopathy and to determine disease patterns in a tertiary care setting in Karachi. The retrospective review comprised record of patients who underwent mediastinoscopy over 25 years between July, 1990 and August, 2015. Of the 122 patients, records were complete for 88(72%). Mean age was 42.5±12.9 years and 55(62.5%) were male. Overall, 60(68.2%) patients had benign inflammatory diseases; 25 (28.4%) had lymphoma or lung cancer which was accurately staged; 26(29.5%) had tuberculosis; 13(14.8%) sarcoidosis; and 11 (12.5%) had concomitant tuberculosis and sarcoidosis. No mortality or significant morbidity was recorded. Mediastinoscopy was useful in staging bronchogenic carcinoma and influenced the management in this series. It was found to be accurate in the diagnosis of other malignant as well as benign mediastinal pathologies, all of which were treatable.

Towards excellence in cardiac surgery: experience from a developing country.

OBJECTIVE: The objective of this study is an attempt to measure the performance in terms of comparing results with a large internationally recognized database used as a benchmark. DESIGN: Cross-sectional (prospectively collected data analysed and compared retrospectively). SETTING: Aga Khan University Hospital, Karachi, Pakistan. PARTICIPANTS, INTERVENTIONS AND MAIN OUTCOME MEASURES: From January 2006 to December 2010, information of the 2198 CABGs performed at Aga Khan University Hospital (AKU) was collected prospectively. This included patient characteristics and specific intra- and post-operative outcomes and compared with findings from the American Society of Thoracic Surgeons' National Cardiac Database (STS-NCD). RESULTS: There were more male patients in the AKU cohort and more diabetics. In AKU, more cases involved three or more grafts (85 vs. 78%), and in both groups, an internal mammary artery graft was used over 90% of the time. The overall 30-day mortality was 2.7% at AKU, compared with 1.5% in the STS-NCD data. AKU had a lower incidence of permanent stroke (0.5 vs. 1.2%), prolonged ventilation (10.5 vs. 11.0%), deep sternal wound infection (0.2 vs. 0.4%) and reoperation (4.0 vs. 4.7%). It had more cases of renal failure (5.4 vs. 3.6%). Readmission rates within 30 days were also less in AKU (3.9 vs. 9.1%). CONCLUSIONS: The outcomes of this study compare very favourably with the benchmark (STS). This demonstrates that high level of quality care can be achieved in this part of the world.