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BACKGROUND: This study examined the characteristics and outcomes of surgical aortic valve replacement (SAVR) both isolated and in combination with other cardiac surgery in Malaysia from 2015 to 2021. METHODS: This was a retrospective study of 1346 patients analyzed on the basis of medical records, echocardiograms and surgical reports. The overall sample was both considered as a whole and divided into aortic stenosis (AS)/aortic regurgitation (AR)-predominant and similar-severity subgroups. RESULTS: The most common diagnosis was severe AS (34.6%), with the 3 most common etiologies being bicuspid valve degeneration (45.3%), trileaflet valve degeneration (36.3%) and rheumatic valve disease (12.2%). The second most common diagnosis was severe AR (25.5%), with the most common etiologies being root dilatation (21.0%), infective endocarditis (IE) (16.6%) and fused prolapse (12.2%). Rheumatic valve disease was the most common mixed disease. A total of 54.5% had AS-predominant pathology (3 most common etiologies: bicuspid valve degeneration valve, degenerative trileaflet valve and rheumatic valve disease), 36.9% had AR-predominant pathology (top etiologies: root dilatation, rheumatic valve disease and IE), and 8.6% had similar severity of AS and AR. Overall, 62.9% of patients had trileaflet valve morphology, 33.3% bicuspid, 0.6% unicuspid and 0.3% quadricuspid. For AS, the majority were high-gradient severe AS (49.9%), followed by normal-flow low-gradient (LG) severe AS (10.0%), paradoxical low-flow (LF)-LG severe AS (6.4%) and classical LF-LG severe AS (6.1%). The overall in-hospital and total 1-year mortality rates were 6.4% and 14.8%, respectively. Pure severe AS had the highest mortality. For AS-predominant pathology, the etiology with the highest mortality was trileaflet valve degeneration; for AR-predominant pathology, it was dissection. The overall survival probability at 5 years was 79.5% in all patients, 75.7% in the AS-predominant subgroup, 83.3% in the AR-predominant subgroup, and 87.3% in the similar-severity subgroup. CONCLUSIONS: The 3 most common causes of AS- predominant patients undergoing SAVR is bicuspid valve degeneration, degenerative trileaflet valve and rheumatic and for AR-predominant is root dilatation, rheumatic and IE. Rheumatic valve disease is an important etiology in our SAVR patients especially in mixed aortic valve disease. Study registration IJNREC/562/2022.
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Insuficiencia de la Válvula Aórtica , Estenosis de la Válvula Aórtica , Endocarditis Bacteriana , Endocarditis , Enfermedades de las Válvulas Cardíacas , Implantación de Prótesis de Válvulas Cardíacas , Cardiopatía Reumática , Humanos , Válvula Aórtica/cirugía , Válvula Aórtica/patología , Estudios Retrospectivos , Enfermedades de las Válvulas Cardíacas/cirugía , Enfermedades de las Válvulas Cardíacas/etiología , Insuficiencia de la Válvula Aórtica/etiología , Insuficiencia de la Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/patología , Estenosis de la Válvula Aórtica/etiología , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico , Endocarditis Bacteriana/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Hemodinámica , Cardiopatía Reumática/complicaciones , Cardiopatía Reumática/cirugía , Endocarditis/cirugía , Endocarditis/complicacionesRESUMEN
INTRODUCTION: There is no consistency in current practice pertaining to the prescription and progression of upper limb resistance exercise following cardiac surgery via median sternotomy. The aim of this study is to investigate whether less restrictive sternal precautions with the addition of early-supervised resistance training exercise improves upper limb function and facilitates recovery following median sternotomy. METHODS AND ANALYSIS: This is double-blind randomised controlled trial, with parallel group, concealed allocation, blinding of patients and assessors, and intention-to-treat analysis. 240 adult participants who had median sternotomy from eight hospitals in Malaysia will be recruited. Sample size calculations were based on the unsupported upper limb test. All participants will be randomised to receive either standard or early supervised incremental resistance training. The primary outcomes are upper limb function and pain. The secondary outcomes will be functional capacity, multidomain recovery (physical and psychological), length of hospital stay, incidence of respiratory complications and quality of life. Descriptive statistics will be used to summarise data. Data will be analysed using the intention-to-treat principle. The primary hypothesis will be examined by evaluating the change from baseline to the 4-week postoperative time point in the intervention arm compared with the usual care arm. For all tests to be conducted, a p value of <0.05 (two tailed) will be considered statistically significant, and CIs will be reported. The trial is currently recruiting participants. ETHICS AND DISSEMINATION: The study was approved by a central ethical committee as well as the local Research Ethics Boards of the participating sites (UKM:JEP-2019-654; Ministry of Health: NMMR-50763; National Heart Centre: IJNREC/501/2021). Approval to start was given prior to the recruitment of participants commencing at any sites. Process evaluation findings will be published in peer-reviewed journals and presented at relevant academic conferences. TRIAL REGISTRATION NUMBER: International Standard Randomised Controlled Trials Number (ISRCTN17842822).
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Procedimientos Quirúrgicos Cardíacos , Esternotomía , Adulto , Humanos , Esternotomía/efectos adversos , Calidad de Vida , Método Doble Ciego , Tiempo de Internación , Resultado del Tratamiento , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Multicéntricos como AsuntoRESUMEN
Diabetes mellitus (DM) is a well-known risk factor for sternal wound infections (SWIs). However, SWIs are also known to occur in patients without DM. This study aimed to examine the difference in risk factors for SWIs after coronary artery bypass grafting (CABG) between non-diabetic and diabetic patients.We conducted a retrospective observational study including 6,697 patients who underwent CABG at our hospital from 2015-2018. The patients were assigned to the non-diabetic (group N, n = 2,930) or diabetic (group D, n = 3,767) group. A total of 24 potential risk factors were evaluated using univariate and multivariate analyses. Differences between superficial and deep SWIs were also examined.A total of 209 (3.1%) CABG patients, comprising 47 (22.5%) and 162 (77.5%) in groups N and D, respectively, required surgical treatment for SWIs. Univariate analyses indicated that a body mass index (BMI) > 25 kg/m2 was uniquely associated with superficial SWIs in group N. Moreover, married status may have lowered the risk of deep SWIs in group D. Renal failure, intra-aortic balloon pump (IABP) use, and reopening in group N, as well as female sex, emergency admission, and reopening in group D, were independent predictors of SWI in the multivariate analysis.In this study, reopening was a common risk factor associated with SWIs in patients who underwent CABG with and without DM. Female sex and emergency admission were independent predictors of deep SWIs in patients with DM, whereas renal failure and IABP use were independent predictors of deep SWIs in patients without DM.
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Diabetes Mellitus , Insuficiencia Renal , Puente de Arteria Coronaria/efectos adversos , Diabetes Mellitus/epidemiología , Femenino , Humanos , Insuficiencia Renal/complicaciones , Estudios Retrospectivos , Factores de Riesgo , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiología , Resultado del TratamientoRESUMEN
Objective: The objective of this study is to analyse the incidence of postoperative atrial fibrillation (POAF), demography, post-operative outcomes including morbidity and mortality, length of Cardiac Intensive Care Unit (CICU) stay, High Dependency Unit (HDU) stay, and total hospital stay in patients undergoing coronary bypass grafting (CABG) at Institut Jantung Negana (IJN). Methods: We conducted a prospective, randomised, controlled trial. We supplied the treatment group with Tocovid capsules and the control group with placebo containing palm superolein. Results: Since January 2019, we have recruited the target population of 250 patients. However, the result is still blinded as we are still analysing blood samples for tocotrienol levels. 89.2% of patients completed the study with a 3.6% mortality and a 7.6% attrition rate. 35.2% of the patients developed POAF, the mean time being 46.06 ± 26.96 hours post-CABG. We did not observe any statistically significant difference when we compared left atrial size, New York Heart Association (NYHA) functional class, ejection fraction and premorbid history, besides EuroSCORE II (The European System for Cardiac Operative Risk Evaluation II) status except for older age group, right atrial size, and pleural effusion. There was also no difference in bypass time, cross clamp time or number of anastomoses. However, we noted a significant difference in death (p = 0.01) and renal failure requiring dialysis (p = 0.007) among patients with POAF; those patients also had a longer CICU stay (p = 0.005), HDU stay (p = 0.02), and total hospital stay (p = 0.001). Conclusions: POAF is associated with a higher incidence of renal failure and death while it increases CICU, HDU, and total hospital stay. It remains to be seen whether Tocovid reduces POAF and its associated sequelae. Clinical Trial Registration: NCT03807037 (Registered on 16 January 2019).
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Abstract Introduction: The presence of aortic regurgitation (AR) in the setting of ventricular septal defect (VSD) has always been a management challenge. Methods: This is a retrospective study looking at patients who underwent VSD closure with or without aortic valve intervention between January 1st, 1992 and December 31st, 2014 at the Institute Jantung Negara. This study looked at all cases of VSD and AR, where AR was classified as mild, moderate, and severe, the intervention done in each of this grade, and the durability of that intervention. The interventions were classified as no intervention (NI), aortic valve repair (AVr), and aortic valve replacement (AVR). Results: A total of 261 patients were recruited into this study. Based on the various grades of AR, 105 patients had intervention to their aortic valve during VSD closure. The rest 156 had NI. All patients were followed up for a mean time of 13.9±3.5 years. Overall freedom from reoperation at 15 years was 82.6% for AVr. Various factors were investigated to decide on intervening on the aortic valve during VSD closure. Among those that were statistically significant were the grade of AR, size of VSD, age at intervention, and number of cusp prolapse. Conclusion: We can conclude from our study that all moderate and severe AR with small VSD in older patients with more than one cusp prolapse will need intervention to their aortic valve during the closure of VSD.
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Humanos , Anciano , Insuficiencia de la Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/complicaciones , Prolapso de la Válvula Aórtica/cirugía , Prolapso de la Válvula Aórtica/complicaciones , Prolapso de la Válvula Aórtica/diagnóstico por imagen , Defectos del Tabique Interventricular/cirugía , Defectos del Tabique Interventricular/complicaciones , Prolapso , Síndrome , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: Post-operative atrial fibrillation (POAF) is associated with poorer outcomes, increased resource utilisation, morbidity and mortality. Its pathogenesis is initiated by systemic inflammation and oxidative stress. It is hypothesised that a potent antioxidant and anti-inflammatory agent such as tocotrienol, an isomer of Vitamin E, could reduce or prevent POAF. AIMS: The aim of this study is to determine whether a potent antioxidative and anti-inflammatory agent, Tocovid, a tocotrienol-rich capsule, could reduce the incidence of POAF and affect the mortality and morbidity as well as the duration of ICU, HDU and hospital stay. METHODS: This study was planned as a prospective, randomised, controlled trial with parallel groups. The control group received placebo containing palm superolein while the treatment group received Tocovid capsules. We investigated the incidence of POAF, the length of hospital stay after surgery and the health-related quality of life. RESULTS: Recruitment commenced in January 2019 but the preliminary results were unblinded as the study is still ongoing. Two-hundred and two patients have been recruited out of a target sample size of 250 as of January 2021. About 75% have completed the study and 6.4% were either lost during follow-up or withdrew; 4% of participants died. The mean age group was 61.44 ± 7.30 years with no statistical difference between the groups, with males having a preponderance for AF. The incidence of POAF was 24.36% and the mean time for developing POAF was 55.38 ± 29.9 h post-CABG. Obesity was not a predictive factor. No statistically significant difference was observed when comparing left atrial size, NYHA class, ejection fraction and the premorbid history. The mean cross-clamp time was 71 ± 34 min and the mean bypass time was 95 ± 46 min, with no difference between groups. There was a threefold increase in death among patients with POAF (p = 0.008) and an increase in the duration of ICU stay (p = 0.01), the total duration of hospital stay (p = 0.04) and reintubation (p = 0.045). CONCLUSION: A relatively low incidence rate of POAF was noted although the study is still ongoing. It remains to be seen if our prophylactic intervention using Tocovid would effectively reduce the incidence of POAF. Clinical Registration Number: US National Library of Medicine. Clinical Trials - NCT03807037. Registered on 16th January 2019. Link: https://clinicaltrials.gov/ct2/show/NCT03807037.
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Fibrilación Atrial , Tocotrienoles , Anciano , Fibrilación Atrial/epidemiología , Fibrilación Atrial/etiología , Fibrilación Atrial/prevención & control , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , Calidad de Vida , Factores de RiesgoRESUMEN
INTRODUCTION: The presence of aortic regurgitation (AR) in the setting of ventricular septal defect (VSD) has always been a management challenge. METHODS: This is a retrospective study looking at patients who underwent VSD closure with or without aortic valve intervention between January 1st, 1992 and December 31st, 2014 at the Institute Jantung Negara. This study looked at all cases of VSD and AR, where AR was classified as mild, moderate, and severe, the intervention done in each of this grade, and the durability of that intervention. The interventions were classified as no intervention (NI), aortic valve repair (AVr), and aortic valve replacement (AVR). RESULTS: A total of 261 patients were recruited into this study. Based on the various grades of AR, 105 patients had intervention to their aortic valve during VSD closure. The rest 156 had NI. All patients were followed up for a mean time of 13.9±3.5 years. Overall freedom from reoperation at 15 years was 82.6% for AVr. Various factors were investigated to decide on intervening on the aortic valve during VSD closure. Among those that were statistically significant were the grade of AR, size of VSD, age at intervention, and number of cusp prolapse. CONCLUSION: We can conclude from our study that all moderate and severe AR with small VSD in older patients with more than one cusp prolapse will need intervention to their aortic valve during the closure of VSD.
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Insuficiencia de la Válvula Aórtica , Prolapso de la Válvula Aórtica , Defectos del Tabique Interventricular , Anciano , Insuficiencia de la Válvula Aórtica/complicaciones , Insuficiencia de la Válvula Aórtica/cirugía , Prolapso de la Válvula Aórtica/complicaciones , Prolapso de la Válvula Aórtica/diagnóstico por imagen , Prolapso de la Válvula Aórtica/cirugía , Defectos del Tabique Interventricular/complicaciones , Defectos del Tabique Interventricular/cirugía , Humanos , Prolapso , Estudios Retrospectivos , Síndrome , Resultado del TratamientoRESUMEN
BACKGROUND: Absent pulmonary valve syndrome (APVS) is a variant of tetralogy of Fallot characterized by aneurysmal pulmonary arteries, which compresses the tracheobronchial tree, leading to respiratory symptoms. We report the mid-term outcomes of surgical correction of patients with APVS. SUBJECT AND METHODS: A total of 27 patients underwent surgery between 2001 and 2015, and they were followed up for a mean period of 6.4 ± 4.1 years. Out of the 27 patients, 14 (51.9%) were infants. The median age at repair was 9.8 months. Preoperative intubation was required in six patients (22.2%), and 11 patients (40.7%) had symptoms of respiratory distress. The pulmonary valve was replaced with a valved conduit in 15 patients (55.6%), monocusp valve in 6 patients (22.2%), and a transannular patch in 6 patients (22.2%). Reduction pulmonary arterioplasty was done in all patients. RESULTS: The overall 10-year survival was 82.1%. There was 81.1% overall freedom from re-intervention at 10 years. No statistically significant difference was found in 10-year survival (P = 0.464) and reoperation rates (P = 0.129) between valved conduit, monocusp, or transannular patch techniques. Older children had statistically significantly longer survival (P = 0.039) and freedom from re-intervention (P = 0.016) compared to infants. Patients without respiratory complications had 100% 10-year survival and 93.3% freedom from reoperation at 10 years compared to 55.6% and 60.1%, respectively, for patients with respiratory complications. CONCLUSION: There has been improvement in surgical results for APVS over the years. However, it still remains a challenge to manage infants and patients with persistent respiratory problems.
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BACKGROUND: Our study is aimed at evaluating the mid-term surgical outcomes of mitral valve repair in children using various chordal reconstructive procedures (autologous in situ chords or artificial chords). METHODS: A retrospective analysis of 154 patients who underwent mitral valve repair using various chordal reconstructive procedures from 1992 to 2012. Patients were divided into group A and group B based on use of artificial chords and autologous in situ chords, respectively, for the repair. There were 102 (66.2%) patients in group A and 52 (33.8%) patients in group B. The mean age at repair was 11.1 ± 4.5 years. Associated cardiac anomalies were found in 94 (61%) patients. RESULTS: The median follow-up period was 4.2 years (Interquartile range: 2.0-9.9). There were two (1.3%) early deaths and five (3.2%) late deaths. There was no significant difference in survival at 15 years between the two groups (group A: 91.8% vs group B: 95.1%; P = .66). There was no significant difference in the freedom from reoperation at 15 years between group A (79.4%) and group B (97.2%; P = .06). However, there was significant difference in freedom from valve failure between group A (56.5%) and group B (74.1%; P = .03). Carpentier functional class III and postoperative residual mitral regurgitation (2+ MR, ie, mild-moderate MR) were the risk factors for valve failure. CONCLUSIONS: Severity of the disease and its progression has profound effect on the valve repair than the technique itself. Both chordal reconstructive procedures can be used to produce satisfactory results in children.
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Procedimientos Quirúrgicos Cardíacos/métodos , Cuerdas Tendinosas/trasplante , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Adolescente , Niño , Preescolar , Cuerdas Tendinosas/diagnóstico por imagen , Cuerdas Tendinosas/cirugía , Ecocardiografía , Femenino , Estudios de Seguimiento , Humanos , Lactante , Masculino , Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/diagnóstico , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
Berry syndrome is a rare congenital cardiac lesion consisting of a distal aortopulmonary window, the aortic origin of the right pulmonary artery (PA), intact ventricular septum and an interrupted or hypoplastic aortic arch. Different repair techniques have been described in the literature. We report a case of Berry syndrome, in whom myocardial ischaemia developed following direct implantation of the right PA to the main PA, which was resolved using an interposition tube graft.
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Aorta Torácica/cirugía , Defecto del Tabique Aortopulmonar/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Isquemia Miocárdica/etiología , Complicaciones Posoperatorias , Arteria Pulmonar/cirugía , Humanos , Lactante , Masculino , Enfermedades Raras , SíndromeRESUMEN
Sinus of Valsalva aneurysm (SVA) is a relatively rare cardiac condition, in which the patient is usually asymptomatic. However, once this aneurysm ruptures, patients present with acute symptoms of heart failure. Timely surgical intervention is essential. We present the case of a 27-year-old woman, who had a ruptured SVA with a ventricular septal defect (VSD). The patient collapsed before the emergency operation and needed cardiopulmonary resuscitation. The patient required preoperative high inotoropic support and postoperative management was difficult because of multiple organ dysfunction. However, the patient recovered after using inhaled nitric oxide and veno-venous hemofiltration and tracheostomy, and was discharged with no further complications. To the best of our knowledge, no such case of a ruptured SVA with VSD, complicated by preoperative cardiac arrest and multiple organ dysfunction that culminated in a successful recovery, has been reported to date.
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OBJECTIVE: Vascular prostheses for small caliber bypass grafts in cardiac and vascular diseases or for access surgery are still missing. Poly (Æ-caprolactone) (PCL) has been previously investigated by our group and showed good biocompatibility and mechanical properties in vitro and rapid endothelialisation, cellular infiltration and vascularisation in vivo yielding optimal patency in the abdominal aortic position. The aim of the present study is to evaluate our PCL graft in the carotid position and to compare its outcome to the grafts implanted in the abdominal aortic position. METHODS: PCL grafts (1â¯mm ID/10â¯mm long) were implanted into the left common carotid artery in 20 Sprague-Dawley rats and compared to our previously published series of abdominal aortic implants. The animals were followed up to 3, 6, 12 and 24â¯weeks. At each time point, in vivo compliance, angiography and histological examination with morphology were performed. RESULTS: PCL grafts showed good mechanical properties and ease of handling. The average graft compliance was 14.5⯱â¯1.7%/ mmHg compared to 7.8⯱â¯0.9% for the abdominal position and 45.1⯱â¯3.2%/ mmHg for the native carotid artery. The overall patency for the carotid position was 65% as compared to 100% in the abdominal position. Complete endothelialisation was achieved at 3â¯weeks and cell invasion was more rapid than in the aortic position. In contrast, intimal hyperplasia (IH) and vascular density were less pronounced than in the aortic position. CONCLUSION: Our PCL grafts in the carotid position were well endothelialised with early cellular infiltration, higher compliance, lower IH and calcification compared to the similar grafts implanted in the aortic position. However, there was a higher occlusion rate compared to our abdominal aorta series. Anatomical position, compliance mismatch, flow conditions may answer the difference in patency seen.
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Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/métodos , Prótesis Vascular/efectos adversos , Arterias Carótidas/cirugía , Animales , Aorta Abdominal/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Caproatos/química , Arterias Carótidas/fisiopatología , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/fisiopatología , Lactonas/química , Modelos Animales , Poliésteres/química , Ratas , Ratas Sprague-Dawley , Grado de Desobstrucción VascularRESUMEN
OBJECTIVES: Contemporary experience in mitral valve (MV) repair for children with rheumatic heart disease (RHD) is limited, despite the potential advantages of repair over replacement. We reviewed our long-term outcomes of rheumatic MV repair and compared them with the outcomes of MV replacement in children with RHD. METHODS: This study is a review of 419 children (≤18 years) with RHD who underwent primary isolated MV surgery between 1992 and 2015, which comprised MV repair (336 patients; 80.2%) and MV replacement (83 patients; 19.8%). The replacement group included mechanical MV replacements (MMVRs) (n = 69 patients; 16.5%) and bioprosthetic MV replacements (n = 14 patients; 3.3%). The mean age with standard deviation at the time of operation was 12.5 ± 3.5 (2-18) years. Mitral regurgitation (MR) was predominant in 390 (93.1%) patients, and 341 (81.4%) patients showed ≥3+ MR. The modified Carpentier reconstructive techniques were used for MV repair. RESULTS: Overall early mortality was 1.7% (7 patients). The mean follow-up was 5.6 years (range 0-22.3 years; 94.7% complete). Survival of patients who underwent repair was 93.9% both at 10 and 20 years, which was superior than that of replacement (P < 0.001). Freedom from reoperation at 10 and 20 years after MV repair was 81.7% and 72.6%, respectively, compared to 83.2% for MV replacement (P = 0.580). Forty patients underwent reoperation after the initial surgery with no operative deaths. Mixed mitral lesion and postoperative residual MR (≥2+) were the predictors for reoperation in the repair group, whereas lower body surface area and usage of bioprosthesis were significant factors for the replacement group. Freedom from thrombotic, embolic and haemorrhagic events at 10 and 20 years for patients with repair was 98.2% compared to 90.1% in patients with replacement and 67.6% for patients with MMVR (P = 0.004). CONCLUSIONS: Twenty-three years of follow-up shows that MV repair is superior to MMVR in children with RHD. Hence, the rheumatic MV should be repaired when technically feasible to maximize the survival and reduce the valve-related morbidity with comparable durability to MMVR.
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Predicción , Implantación de Prótesis de Válvulas Cardíacas/métodos , Anuloplastia de la Válvula Mitral/métodos , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Cardiopatía Reumática/cirugía , Adolescente , Niño , Femenino , Estudios de Seguimiento , Humanos , Masculino , Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/etiología , Periodo Posoperatorio , Cardiopatía Reumática/diagnóstico , Resultado del TratamientoRESUMEN
Background: Atrial fibrillation (AF) is common after cardiac surgery and has been associated with poor outcome and increased resource utilization. The main objective of this study is to determine the incidence of POAF in Malaysia and identify the predictors of developing POAF. The secondary outcome of this study would be to investigate the difference in mortality and morbidity rates and the duration of intensive care unit (ICU), high dependency unit (HDU) and hospital stay between the two. Methods: This is a retrospective single-center, cross sectional study conducted at the National Heart Institute, Malaysia. Medical records of 637 who underwent coronary artery bypass grafting (CABG) surgery in 2015 were accrued. Pre-operative, operative and post-operative information were subsequently collected on a pre-formulated data collection sheet. Data were then analyzed using IBM SPSS v23. Results: The incidence of POAF in our study stands at 28.7% with a mean onset of 45±33 hours post operatively. Variables with independent association with POAF include advancing age, Indian population, history of chronic kidney disease, left ventricular ejection fraction and beta-blocker treatment. The mortality rate is significantly higher statistically ( p < 0.05), and similarly the incidence of stroke. The incidence of other post-operative complications was also significantly higher statistically. The duration of ICU, HDU and hospital stays were statistically longer ( p < 0.001) with higher rates of ICU readmissions and reintubations seen. Conclusion: We conclude that the incidence of POAF in Malaysia is comparable to the figures in Western countries, making POAF one of the most commonly encountered condition after CABG with similar higher rates of mortality, poor outcomes and longer duration of stay, and therefore increased cost of care. Strategies to reduce the incidence of AF after cardiac surgery should favorably affect surgical outcomes and reduce utilization of resources and thus lower cost of care.
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Fibrilación Atrial/cirugía , Puente de Arteria Coronaria/efectos adversos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Complicaciones Posoperatorias/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Incidencia , Malasia/epidemiología , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
OBJECTIVE: We introduced primary arterial switch operation for the patient with transposition of great arteries and intact ventricular septum (TGA-IVS) who had more than 3.5 mm of posterior left ventricle (LV) wall thickness. METHODS: Between January 2013 and June 2015, a total of 116 patients underwent arterial switch operation. Of the 116 patients, 26 with TGA-IVS underwent primary arterial switch operation at more than 30 days of age. RESULTS: The age and body weight (mean ± SD) at the operation were 120.4 ± 93.8 days and 4.1 ±1.0 kg, respectively. There was no hospital mortality. The thickness of posterior LV wall (preoperation vs postoperation; mm) was 4.04 ± 0.71 versus 5.90 ± 1.3; P < .0001; interval: 11.8 ± 6.5 days. The left atrial pressure (mm Hg; postoperative day 0 vs 3) was 20.0 ± 3.2 versus 10.0 ± 2.0; P < .0001; and the maximum blood lactate level (mmol/dL) was 4.7 ± 1.4 versus 1.4 ± 0.3; P < .0001, which showed significant improvement in the postoperative course. All cases had delayed sternal closure. The patients who belonged to the thin LV posterior wall group (<4 mm [preoperative echo]: n = 13) had significantly longer ventilation time (days; 10.6 ± 4.8 vs 4.8 ± 1.7, P = .0039), and the intensive care unit stay (days) was 14 ± 9.2 versus 7.5 ± 3.5; P = .025, compared with thick LV wall group (≥4.0 mm: n = 13). CONCLUSIONS: The children older than 30 days with TGA-IVS can benefit from primary arterial switch operation with acceptable results under our indication. However, we need further investigation for LV function.
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Transposición de los Grandes Vasos/cirugía , Operación de Switch Arterial , Femenino , Ventrículos Cardíacos/fisiopatología , Ventrículos Cardíacos/cirugía , Humanos , Lactante , Recién Nacido , Masculino , Periodo Posoperatorio , Resultado del Tratamiento , Función Ventricular Izquierda , Tabique Interventricular/cirugíaRESUMEN
Background: Hyperhidrosis is due to the hyperactive autonomic stimulation of the sweat glands in response to stress. Primary hyperhidrosis is a common yet psychologically disabling condition. This study will describe our experience in managing hyperhidrosis via endoscopic thoracic sympathectomy (ETS). Methods: The information was obtained from the patient records from 1 st January 2011 until 31 st December 2016. Pertinent information was extracted and keyed into a study proforma. Results: 150 patients were operated on but only 118 patients were included in this study. The mean age was 22.9±7.3 years. The majority (54.2%) had palmar-plantar hyperhidrosis and 39.8% had associated axillary hyperhidrosis. Excision of the sympathetic nerve chain and ganglia were the main surgical technique with the majority (55.9%) at T2-T3 level. Mean ETS procedure time was 46.6±14.29 minutes with no conversion. Surgical complications were minimal and no Horner's Syndrome reported. Mean hospital stay was 3.5±1.05 days. The majority of patients (67.8%) had only one follow-up and only half of the study sample (58.5%) complained mild to moderate degree of compensatory sweating, even though the long-term resolution is yet to be determined by another study. Following ETS, 98.3% of patients had instant relief and resolved their palmar hyperhidrosis. Predictors of CS were sympathectomy level and follow-up. The odds of reporting CS was 2.87 times in patients undergoing ETS at the T2-T3 level compared to those undergoing ETS at the T2-T4 level. The odds of reporting CS was 13.56 times in patients having more than one follow-up compared to those having only one follow-up. Conclusion: We conclude that ETS is a safe, effective and aesthetically remarkable procedure for the treatment of primary hyperhidrosis with only half of the patients developing mild to moderate degree of CS. Significant predictors of CS were sympathectomy level during ETS and frequency of follow-up after ETS.
RESUMEN
Background: The European System for Cardiac Operative Risk (EuroSCORE) II was developed in 2011 to replace the aging EUROScore for predicting in-house mortality after cardiac surgery. Our aim was to validate EuroSCORE II in Malaysian patients undergoing coronary artery bypass graft (CABG) surgery at our Institute. Methods: A retrospective single-center study was performed. A database was created to include EuroSCORE II values and actual mortality of 1718 patients undergoing CABG surgery in Malaysia from 1st January to 31st December 2016. The goodness-of-fit of EuroSCORE II was determined by the Hosmer-Lemeshow goodness-of-fit test and discriminatory power with the areas under the receiver operating characteristics (ROC) curve (AUC). Results: Observed mortality rate was 4.66% (80 out of 1718 patients). The median EuroSCORE II value was 2.06% (Inter Quartile Range: 1.94%) (1st quartile: 1.45%, 3rd quartile: 3.39%). The AUC for EuroSCORE II was 0.7 (95% CI 0.640 - 0.759) indicating good discriminatory power. The Hosmer-Lemeshow goodness-of-fit test did not show significant difference between expected and observed mortality in accordance to the EuroSCORE II model (Chi-square = 13.758, p = 0.089) suggesting good calibration of the model in this population. Cross-tabulation analysis showed that there is slight overestimation of EuroSCORE II in low-risk groups (0-10%) and slight underestimation in high-risk groups (>20%). Multivariate logistic regression analysis showed that gender, age, total hospital stay, serum creatinine and critical pre-operative state are significant predictors of mortality post-CABG surgery. Conclusion: This study indicated that the EuroSCORE II is a good predictor of post-operative mortality in the context of Malaysian patients undergoing CABG surgery. Our study also showed that certain independent variables might possess higher weightage in predicting mortality among this patient group. Therefore, it is suggested that EuroSCORE II can be safely used for risk assessment while ideally, clinical consideration should be applied on an individual basis.
RESUMEN
Physiologically, blood ejected from the left ventricle in systole exhibited spiral flow characteristics. This spiral flow has been proven to have several advantages such as lateral reduction of directed forces and thrombus formation, while it also appears to be clinically beneficial in suppressing neurological complications. In order to deliver spiral flow characteristics during cardiopulmonary bypass operation, several modifications have been made on an aortic cannula either at the internal or at the outflow tip; these modifications have proven to yield better hemodynamic performances compared to standard cannula. However, there is no modification done at the inlet part of the aortic cannula for inducing spiral flow so far. This study was carried out by attaching a spiral inducer at the inlet of an aortic cannula. Then, the hemodynamic performances of the new cannula were compared with the standard straight tip end-hole cannula. This is achieved by modeling the cannula and attaching the cannula at a patient-specific aorta model. Numerical approach was utilized to evaluate the hemodynamic performance, and a water jet impact experiment was used to demonstrate the jet force generated by the cannula. The new spiral flow aortic cannula has shown some improvements by reducing approximately 21% of impinging velocity near to the aortic wall, and more than 58% reduction on total force generated as compared to standard cannula.
Asunto(s)
Aorta/cirugía , Cánula , Puente Cardiopulmonar/instrumentación , Cateterismo/instrumentación , Aorta/anatomía & histología , Aorta/fisiología , Velocidad del Flujo Sanguíneo , Simulación por Computador , Diseño de Equipo , Hemodinámica , Humanos , Hidrodinámica , Modelos Anatómicos , Modelos CardiovascularesRESUMEN
A 55-year-old man developed severe mitral regurgitation with persistent fungal infective endocarditis 8 months after coronary artery bypass grafting with a left internal mammary artery and 2 saphenous veins, as well as mitral valve repair with a prosthetic ring. Echocardiography demonstrated severe mitral regurgitation and a valvular vegetation. Computed tomography coronary arteriography indicated that all grafts were patent and located intimately close to the sternum. Median resternotomy was not attempted due to the risk of injury to the bypass grafts, and therefore, a right anterolateral thoracotomy approach was utilized. Mitral valve replacement was performed with the patient under deep hypothermia and ventricular fibrillation without aortic cross-clamping. The patient`s postoperative course was uneventful. Thus, right anterolateral thoracotomy may be a superior approach to mitral valve surgery in patients who have undergone prior coronary artery bypass grafting.