Hybrid Thoracic Aortic Repair and Aortic Valve-In-Valve Replacement for Chronic Type A Dissection.

We describe a case of hybrid total thoracic aortic repair and valve-in-valve transcatheter aortic valve replacement in a high-risk patient with complicated chronic type A dissection and severe prosthetic aortic stenosis. The patient underwent a three-stage-procedure including aortic arch debranching, thoracic endovascular aortic repair of the ascending aorta, aortic arch and descending thoracic aorta, and direct aortic valve-in-valve replacement using transcatheter heart valve. The details of the procedures are described with a discussion of the challenges and the decision-making process.

Results of Surgical Ablation for Atrial Fibrillation in Patients with Rheumatic Heart Disease.

Background: There is conflicting evidence regarding the success of the Maze procedure to restore sinus rhythm in patients with rheumatic heart disease. Hence, the aim of our study was to describe the results of surgical ablation for atrial fibrillation in patients with rheumatic heart disease undergoing cardiac surgery. Methods: This is a retrospective study that included adult patients with rheumatic heart disease who underwent surgical ablation for atrial fibrillation. The ablation lesions were performed using monopolar radiofrequency ablation in all patients. Results: Fifty-seven consecutive patients were included in the study. Cox Maze IV was performed in 44 patients (77%), while left-sided surgical ablation was performed in 10 patients (17%) and pulmonary vein isolation in 3 patients (5%). The percentage of patients who were in sinus rhythm on discharge, at 1-month, at 3-months, 6-months and 12-months follow up were 56%, 54%, 52%, 56% and 46% respectively. Complete heart block occurred in 21 patients (44%), but only 15 of them (26%) required permanent pacemaker insertion. Freedom from composite endpoint of death, stroke, and readmission for heart failure was 78% at one-year follow up. Conclusion: Despite the suboptimal rates of sinus rhythm at the intermediate and long term follow up, surgical ablation of atrial fibrillation in patients with rheumatic heart disease should continue to be performed. Continuation of Class III antiarrhythmic medications and early intervention for recurrent atrial fibrillation is crucial to the success of this procedure and for maintenance of higher rates of sinus rhythm at intermediate and long-term follow up.

The effect of using the minimized cardio-pulmonary bypass Systems for Coronary Artery Bypass Grafting in diabetic patients.

INTRODUCTION: Multiple studies have shown a decrease in the inflammatory response with minimized bypass circuits leading to less complications and mortality rate. On the other hand, some other studies showed that there is no difference in post-operative outcomes. So, the aim of this study is to investigate the clinical benefits of using the Minimized cardiopulmonary Bypass system in Coronary Artery Bypass Grafting and its effect on postoperative morbidity and mortality in diabetic patients as one of the high-risk groups that may benefit from these systems. METHODS: This is a retrospective study that included 114 diabetic patients who underwent Coronary artery bypass grafting (67 patients with conventional cardiopulmonary bypass system and 47 with Minimized cardiopulmonary bypass system). The patients' demographics, intra-operative characteristics and postoperative complications were compared between the two groups. RESULTS: Coronary artery bypass grafting was done on a beating heart less commonly in the conventional cardiopulmonary bypass group (44.78% vs. 63.83%, p = 0.045). There was no difference between the two groups in blood loss or transfusion requirements. Four patients in the conventional cardiopulmonary bypass group suffered perioperative myocardial infarction while no one had perioperative myocardial infarction in the Minimized cardiopulmonary bypass group. On the other hand, less patients in the conventional group had postoperative Atrial Fibrillation (4.55% vs. 27.5%, p = 0.001). The requirements for Adrenaline and Nor-Adrenaline infusions were more common the conventional group than the Minimized group. CONCLUSION: The use of conventional cardiopulmonary bypass for Coronary Artery Bypass Grafting in diabetic patients was associated with higher use of postoperative vasogenic and inotropic support. However, that did not translate into higher complications rate or mortality.

Assessment of Image Quality of Repeated Limited Transthoracic Echocardiography After Cardiac Surgery.

OBJECTIVES: The use of limited transthoracic echocardiography (TTE) has been restricted in patients after cardiac surgery due to reported poor image quality. The authors hypothesized that the hemodynamic state could be evaluated in a high proportion of patients at repeated intervals after cardiac surgery. DESIGN: Prospective observational study. SETTING: Tertiary university hospital. PARTICIPANTS: The study comprised 51 patients aged 18 years or older presenting for cardiac surgery. INTERVENTIONS: Patients underwent TTE before surgery and at 3 time points after cardiac surgery. Images were assessed offline using an image quality scoring system by 2 expert observers. Hemodynamic state was assessed using the iHeartScan protocol, and the primary endpoint was the proportion of limited TTE studies in which the hemodynamic state was interpretable at each of the 3 postoperative time points. MEASUREMENTS AND MAIN RESULTS: Hemodynamic state interpretability varied over time and was highest before surgery (90%) and lowest on the first postoperative day (49%) (p<0.01). This variation in interpretability over time was reflected in all 3 transthoracic windows, ranging from 43% to 80% before surgery and from 2% to 35% on the first postoperative day (p<0.01). Image quality scores were highest with the apical window, ranging from 53% to 77% across time points, and lowest with the subcostal window, ranging from 4% to 70% across time points (p< 0.01). CONCLUSIONS: Hemodynamic state can be determined with TTE in a high proportion of cardiac surgery patients after extubation and removal of surgical drains.

A case of near fatal asthma: The role of ECMO as rescue therapy.

We report a case of an adolescent with near fatal asthma (NFA). He presented with severe hypoxemia and lifethreatening acidemia, who failed to respond to conventional therapy. His hospital course was complicated by barotrauma and hemodynamic instability. Early introduction of extracorporeal membrane oxygenation (ECMO) led to dramatic improvement in gas exchange and lung mechanics. This case illustrates the important role of ECMO as salvage therapy in NFA.

Bentall procedure for an adult patient with supravalvular aortic stenosis and coronary aneurysms.

We describe the surgical management of a 35-year-old male with multiple coronary aneurysms and a diffuse form of supravalvular aortic stenosis who presented with acute myocardial infarction and left ventricular dysfunction. The patient underwent a Bentall procedure with left internal mammary artery to left anterior descending artery bypass grafting with the use of cardiopulmonary bypass utilizing the right axillary artery for arterial cannulation.

Mixed venous versus central venous oxygen saturation in patients undergoing on pump beating coronary artery bypass grafting.

OBJECTIVE: To examine the validity of central venous oxygen saturation (ScvO(2)) as a numerical substitution of mixed venous oxygen saturation (SvO(2)) in adult patients undergoing normothermic on pump beating coronary artery bypass grafting (CABG). MATERIALS AND METHODS: Prospective clinical observational study was done at King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia. Thirty four adult patients scheduled for coronary artery surgery were included. Patients were monitored by a pulmonary artery catheter (PAC) as a part of our routine intraoperative monitoring. SvO(2) and ScvO(2) were simultaneously measured 15 minutes (T1) and 30 minutes (T2) after induction of anesthesia, 15 and 30 minutes after initiation of cardiopulmonary bypass (T3 and T4), and 15 and 30 minutes after admission to intensive care unit (T5 and T6). RESULTS: ScvO(2) showed higher reading than SvO(2) all through our study. Our results showed perfect positive statistically significant correlation between SvO(2) and ScvO(2) at all data points. Individual mean of difference (MOD) between both the readings at study time showed MOD of 1.34 and 1.44 at T1 and T2 simultaneously. This MOD was statistically insignificant, but after on pump beating normothermic bypass was initiated; MOD was 5.2 and 4.4 at T3 and T4 with high statistical significance. In ICU, MOD continues to have high statistical significance, MOD was 6.3 at T5 and at T6 it was 4.6. CONCLUSIONS: In on pump beating CABG patients; ScvO(2) and SvO(2) are not interchangeable numerically. ScvO(2) is useful in the meaning of trend; our data suggest that ScvO(2) is equivalent to SvO(2) , only in the course of clinical decisions as long as absolute values are not required.

Coronary artery bypass grafting on beating heart. Does it provide superior myocardial preservation than conventional technique?

OBJECTIVE: To compare myocardial injury caused by 3 commonly used methods for coronary artery bypass grafting (CABG). METHODS: A prospective randomized study conducted at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. The study started in February 2003 and concluded in April 2004 after including 45 patients (15 patients in each of 3 sub-groups) who fulfilled the inclusion and exclusion criteria. The subgroups included coronary artery bypass surgery performed by: a) conventional technique, b) off-pump technique, and c) on-pump beating-heart techniques. All patients had similar operative risk profiles. Their ages were 70 years or less with an ejection fraction of 30-50%. The creatine kinase, myocardial band (CKMB) levels were determined 2 hours after arrival from the operating room then, at 4 hours, 6 hours, and 12 hours. The comparison of creatine phosphokinase and CKMB levels was carried out using analysis of variance with repeated measures. The p-values were used to evaluate the significance of differences. RESULTS: The pre-operative characteristics including age, gender, ethnic origin, diabetes mellitus, hypertension, and left ventricular function, were similar in the 3 groups. All groups had a median number of 3 bypass grafts. The stay in the intensive care unit and the duration of inotropes were shortest in the off-pump group, but the difference was not significant. There was a peak of CKMB levels at 6 hours in all groups. The trend of CKMB level showed significantly higher values in the conventional CABG group as compared with the other 2 groups. CONCLUSION: This study indicates that the off-pump technique provides better myocardial preservation than other methods.

Comparison of neurological outcomes in patients undergoing conventional coronary artery bypass grafting, on-pump beating heart coronary bypass, and off-pump coronary bypass.

OBJECTIVE: To study the differences in the prevalence of neurological complications following coronary artery bypass (CAB) carried out by conventional, on-pump beating and off-pump techniques. METHODS: A retrospective analysis of all isolated coronary bypass operations (n=127) performed in King Fahad Cardiac Center, Riyadh over a period of one year starting from January 2005. Out of 127 patients, 73 underwent conventional CAB graft (CABG), 33 patents on-pump beating heart coronary bypass, and 21 had off pump coronary bypass grafting (OPCAB). All patients had preoperative carotid scans and those who developed neurological complications underwent CT-brain and expert neuro-psychiatric assessment. RESULTS: Preoperative characteristics of patients in all 3 groups were similar. The bypass times in the conventional CABG group were significantly longer than the on-pump beating group. The maximum number of grafts was in the on-pump beating group, followed by the conventional CABG, and the least in the OPCAB group. Seven out of 73 cases in the conventional bypass group developed neurological events of various severities. Only one out of 33 patients developed acute confusional state in the on-pump beating group and no neurological events were noticed in 21 patients operated by the OPCAB technique. Low ejection fraction, preoperative congestive cardiac failure, non-elective surgery and preoperative catastrophic state were found to be significant risk factors independent of the bypass technique. CONCLUSION: This study shows no significant difference in the prevalence of neurological complications among different types of bypass surgery in our institution. There was a trend towards less neurological outcomes in the OPCAB and on-pump beating groups.