Total arterial multivessels minimal invasive direct coronary artery bypass grafting via left minithoracotomy.

BACKGROUND: Minimal Invasive Direct Coronary Artery Bypass Surgery (MIDCAB) is becoming popular and an important armamentarium for cardiac surgeons. We aimed to evaluate the result of MIDCAB total arterial revascularization. METHODS: We have evaluated 216 patients who underwent MIDCAB multivessel total arterial revascularization through a left anterolateral mini thoracotomy. LIMA harvested in every patient, RIMA or radial artery used as second conduit. LIMA-RIMA Y or LIMA-RADIAL Y was made to accomplish multivessels total arterial revascularization. Post-operative graft patency was evaluated in all patients by CT coronary angiography at 6 months following discharge. RESULTS: Mean age of patients was 52.5 ± 9.8 years. Average number of anastomosis performed were 2.34 ± 0.75. Multivessels total arterial CABG was accomplished in all individuals. There was no mortality or deep wound infection. Re-exploration was done in two patients for bleeding. In one patient emergency CPB was required. Average ICU and hospital stay was 1.52 ± 0.77 and 4.92 ± 1.46 days, respectively. Patients were mobilized earlier due to less pain. Wound healing of anterolateral thoracotomy was faster. In the follow up CT angiography 100% of the LIMA grafts were patent. CONCLUSIONS: Multivessels total arterial MIDCAB can be accomplished safely in selected individuals. RIMA can be harvested in long standing diabetic patients with no concern for sternal wound healing. MIDCAB patients experience better cosmetics and early return to daily activities.

Challenges and possibilities of developing cardiac surgery in a peripheral hospital of low- and middle-income countries.

OBJECTIVE: Over a million cardiac surgeries are performed every year around the globe. However, approximately 93% of world population living in low- and middle-income countries have no access to cardiac surgery. The incidence of rheumatic and congenital heart disease is high in Nepal, while only 2,500-3,000 cardiac surgeries are performed annually. The aim of our study is to analyze challenges and opportunities of establishing a cardiac surgery program in a peripheral hospital of Nepal. METHODS: We analyzed our effort to establish a cardiac surgery program in a peripheral hospital in Nepal. RESULTS: Out of 2,659 consulted and diagnosed patients, we performed 85 open-heart surgeries in 4 years. Mean age of patients was 38.35 ± 14.13 years. The majority of patients were male (62.4% of patients) with 65.9% suffering from rheumatic heart disease. Average intensive care unit stay and hospital stay were 2.32 ± 1.1 and 8.29 ± 2.75 days, respectively. No in-hospital mortality was observed. CONCLUSION: We conclude that developing cardiac surgical care in a peripheral hospital of a developing country is feasible with support from government, foreign colleagues, local teams, and non-governmental organizations. The availability of a regular cardiac surgery service in the periphery of the country makes such services more accessible for the patients and helps in reducing the long waiting lists and unmanageable workload in the established cardiac centers in the capital city.

Rheumatic Heart Disease Screening Among School Children in Central Nepal.

Rheumatic heart disease is the most common heart disease in developing countries. This Global Health Report uses the results of screening 28,050 school children clinically with 2-dimensional echocardiography. A total of 1,739 students had cardiac murmur, with the most dominant lesion being rheumatic mitral regurgitation. This report concluded that the burden of rheumatic heart disease is decreasing, but it is still significant in Nepal. That is why echocardiographic screening is important in early diagnosis and management. (Level of Difficulty: Beginner.).

Aorta-to-right ventricular outflow tract fistula with coronary cusp prolapse.

We describe a rare case of aorta-to-right ventricular fistula in a 20-year-old man who presented with signs and symptoms of congestive heart failure. He was successfully treated by closing the fistula with a Dacron patch from the aortic side. At follow-up, he was asymptomatic with no left-to-right shunt.

Might type A acute dissection repair with the addition of a frozen elephant trunk improve long-term survival compared to standard repair?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with an acute type A dissection (TAAD) is a frozen elephant trunk in addition to standard aortic dissection repair advantageous in terms of improved long-term mortality and closure of the distal false lumen? Altogether more than 138 papers were found using the reported search, of which six represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Jakob et al. (23 patients stented vs. 22 patients non-stented), showed similar early outcome but lower false lumen patency rate and lower need of reintervention in the stented group. Pochettino et al. (36 patients stented vs. 42 patients non-stented) reported higher circulatory arrest time and higher incidence of spinal cord and bowel ischemia but a lower false lumen patency rate in stented group. Uchida and co-workers (65 patients stented vs. 55 patients non-stented) reported similar early outcome but better long-term survival and freedom from aortic events in the stented group. Consecutively, Uchida et al. reported the follow-up of the stented group demonstring false lumen thrombosis in all patients one month postoperatively, and complete after three years. Sun and co-workers (107 patients operated with an hybrid approach) showed a hospital mortality of 4.67% and neurological complications rate of 5.6%. At follow-up (35+/-14 months), 95% of the patients had false lumen thrombosis and no distal reoperations were needed. We conclude that the frozen elephant trunk is still rarely adopted during TAAD repair. However, this procedure can be performed safely without increase the operative mortality and morbidity but with an overall higher cardiopulmonary bypass and circulatory arrest time. Spinal cord ischemia and malperfusion syndrome represents the main complications associated with this procedure. Despite few studies, this procedure seems to allow early thrombosis of the false lumen and a reduction of late thoraco-abdominal aneurysm formation and reoperations rate.

Which cannulation (ascending aortic cannulation or peripheral arterial cannulation) is better for acute type A aortic dissection surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Which cannulation (ascending aortic cannulation or peripheral arterial cannulation) is better for acute type A aortic dissection surgery?' Altogether 393 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Femoral artery cannulation has the highest rate of mortality, stroke rate and other complications including retrograde cerebral embolization, organ malperfusion and perfusion of the false lumen. Five out of 14 papers were found to be reporting in favour of axillary (or subclavian) artery cannulation over femoral artery cannulation. In a total of 1829 patients evaluated in these studies, 1068 patients demonstrated a significantly lower complication rate with axillary artery cannulation than femoral artery cannulation. Some of the larger studies showed femoral artery cannulation has higher mortality and stroke rates ranging from 6.5% to 40% and 3% to 17%, respectively. Meanwhile, mortality and stroke rates were ranging from 3% to 8.6% and 1.75% to 4%, respectively, in the favour of axillary artery cannulation. A total of seven studies evaluated direct aortic cannulation for the establishment of cardiopulmonary bypass (CPB). They demonstrated mortality and stroke rates from 0% to 15% and 3.8% to 21%, respectively. Central cannulation has promising results with a lower mortality rate but a higher stroke rate. Direct cannulation of the true lumen is a promising method for quick and easy establishment of CPB. Axillary artery cannulation with a side graft, although it takes more time to construct, is proven to be safe and straightforward, with fewer local and systemic complications including lower mortality and neurological complications.

Minimally invasive mitral valve surgery through right thoracotomy in patients with patent coronary artery bypass grafts.

We report our institutional experience, with 25 consecutive patients with patent coronary artery bypass grafts (71.8+/-12.7 years), who underwent video-assisted minithoracotomic approach for mitral valve surgery. The surgical technique includes: right minithoracotomy, femoral cannulation and hypothermic ventricular fibrillation. Mean preoperative EuroSCORE was 10.2+/-2.4 and mean ejection fraction was 45+/-9%. Operative mortality was 4% (1/25). No patient required a conversion to sternotomy. Procedures performed were: mitral valve repair in 15 patients (60%), replacement in 10 (40%) and associated tricuspid repair in seven (28%). Mean blood transfusion was 1.2 package/patient. No cardiological, neurological, vascular and wound complications were observed. Postoperative major morbidity includes: severe pulmonary dysfunction in two patients (8%) and acute renal failure in one (4%). Mean ICU and hospital stay were 3.4+/-2.9 and 10.6+/-7.9 days. Echocardiographic follow-up (22.8+/-14.9 months) revealed trace or mild mitral valve regurgitation in all the mitral repair patients. When interrogated, all the surviving patients preferred the minithoracotomic approach rather than the sternotomy. In conclusion, minimally invasive right thoracotomy can be safely performed in patients with functioning coronary bypass grafts requiring mitral valve operation. Low blood transfusion, the avoidance of deep wound infection and the high patient satisfaction are the main advantages of this approach.