Effects of prehabilitation resistance training in mild to moderate clinically frail patients awaiting coronary artery bypass graft surgery.

Coronary artery disease is one of the main causes of mortality and morbidity among chronic heart diseases worldwide. Patients reported chronic chest pain as the primary symptom of coronary artery disease. Due to its progressive nature, it affects the health status and functional capacity of the patients. The current study was planned to compare the effects of prehabilitation resistance training in mild to moderate clinically frail patients awaiting coronary artery bypass graft (CABG). A randomized controlled trial was conducted on 74 patients awaiting CABG at the Faisalabad Institute of Cardiology, Faisalabad, Pakistan. A Modified Healthy Heart Questionnaire was used for screening of the patients. Interventions applied were resistance training by using cuff weights/dumbbells at light intensity (40%-50%) of a maximum of one repetition (10-15 repetitions for one to three times a day) per major muscle groups of upper and lower limbs of the body on weekly basis. The main outcome measures were the 6-minute walk test (6MWT), the New York Heart Association (NYHA) for heart failure, the clinical frailty score, and the essential frailty toolset. Significant differences between group A (resistance training group) and group B (conventional physical therapy group) patients were observed. The mean ranks for 6MWT in group A and group B were 1.70 and 1.55, respectively. The mean ranks of NYHA in group A and group B were 1.68 and 2.84, respectively. Clinical frailty scores in group A and group B were 2.68 and 2.74, respectively, with the essential frailty toolset in group A and group B were 1.14 and 1.11, respectively. There were significant (p < 0.05) differences within and between groups for prehabilitation resistance training after CABG. The study showed that the resistance training group had improved the clinical frailty score, strength, endurance, and functional capacity in patients who underwent elective CABG.

Combined Effects of Continuous Positive Airway Pressure and Cycle Ergometer in Early Rehabilitation of Coronary Artery Bypass Surgery Patients.

OBJECTIVE: To determine the combined effects of continuous positive airway pressure (C-PAP) and physical exercise rehabilitation on a cycle ergometer on postcoronary artery bypass surgery patients. STUDY DESIGN: Randomised controlled trial. Place and Duration of the Study: Rawalpindi Institute of Cardiology, from December 2020 to May 2021. METHODOLOGY: Patients, who underwent coronary artery bypass graft surgery, were divided into two equal groups of each 51. The control group received standard physiotherapy from the 1st postoperative day which included breathing exercises, passive mobilisation in the sitting position, and ambulation. The interventional group also had standard physiotherapy from 1st postoperative day; but also the 2nd to 4th postoperative day had additional dynamic exercises on cycle ergometry in combination with CPAP (continuous positive airway pressure). RESULTS: There was a significant improvement in functional capacity measured by 6-minute walk test in the interventional group (p<0.001). Length of hospital and ICU stay mean rank (68.88 and 58) were also significantly decreased in the interventional group (p<0.001). There was no improvement in maximum inspiratory pressure and maximum expiratory pressure. One-minute sit-to-stand test was increased on 4th postoperative day in the interventional group. There was no significant difference observed in arterial blood gases between these two groups. CONCLUSION: Cycle ergometry combined with continuous positive airway pressure (C-PAP) applied earlier on patients undergoing coronary artery bypass grafting improves the functional capacity, decreases the ICU and hospital length of stay and also improves lower limb muscle strength. But no difference in respiratory muscle strength and arterial blood gases was observed between the control and interventional groups. KEY WORDS: Aerobic exercise, Coronary artery bypass graft surgery, Continuous positive airway pressure.

Zadek Osteotomy, a Good Treatment Option for Refractory Haglund's Deformity.

INTRODUCTION: Haglund's deformity (a prominence in the posterosuperior aspect of the calcaneum) is a known cause of posterior heel pain. Surgery is reserved for patients after failed conservative treatment. Zadek osteotomy is a dorsal-closing wedge osteotomy that reduces the posterior heel prominence. Zadek osteotomy is becoming a favored procedure, however, there are still relatively few studies focusing on patient-reported outcomes. Our main aim was to assess patient-reported outcomes following the Zadek osteotomy in refractory Haglund's deformity. Our secondary aim was to evaluate the correlation between patient outcomes and changes in their pre and postoperative Fowler-Philip and calcaneal pitch angles. METHODS: We conducted a retrospective review of 19 patients (20 heels) who underwent Zadek osteotomy by a single surgeon at a tertiary hospital over six years. Patient-reported outcomes were collected preoperatively and at 12 months postoperatively using the validated Manchester-Oxford foot questionnaire (MOXFQ) scoring system. We also calculated the difference in their pre and postoperative Fowler-Philip angles and calcaneal pitch using the picture archiving communication system. RESULTS: There was an average improvement of 108 points in the MOXFQ score at 12 months (P<0.05). There was no statistically significant change in calcaneal pitch. However, the Fowler-Phillip angle dropped with an average of 11.4 º (P<0.05). A decrease in the Fowler-Philip angle does improve patient-related outcome measurement scores, however, the relationship is not directly proportional with "r" measured at 0.23. CONCLUSION: Our results show that Zadek osteotomy is a useful procedure to consider in patients with symptomatic refractory Haglund's deformity, with an improvement in patient outcomes at 12 months. However, further studies are needed to give stronger evidence for the efficacy of this procedure and its radiological correlations.

Effectiveness of Pre-operative Respiratory Muscle Training versus Conventional Treatment for Improving Post operative Pulmonary Health after Coronary Artery Bypass Grafting.

OBJECTIVE: To evaluate the Effectiveness of Pre-operative Respiratory Muscle Training versus Conventional Treatment for Improving post-operative pulmonary health after Coronary Artery Bypass Graft Surgery (CABG). METHODS: A Prospective Randomized clinical trial was performed on sixty patients who underwent elective CABG at Faisalabad Institute of Cardiology. At the time of admission all patients were subjected to 6-minutes' walk test (6MWT) as baseline. The subjects were then divided into two groups. The Group-I was subjected to respiratory muscle training whereas the Group-2 received the routine preoperative care. The 6-minute walk test (6MWT) was then repeated a day before surgery (pre-operative) and before discharge (post-operatively). Duration of post-operative mechanical ventilation, oxygen therapy and hospital stay were also noted as outcome measures of this study. RESULTS: The pre-operative and post-operative readings showed that the patients in the interventional group performed better than the control group in their 6MWT with P-value of less than 0.05. Similarly the interventional group had shorter duration of mechanical ventilation, dependence on oxygen therapy and postoperative hospital stay as compared with the control group showing P-values below 0.05. CONCLUSION: The results showed that respiratory muscle training results in improved postoperative functional capacity and reduces of hospital stay.

Intracranial Mimics of Cauda Equina Syndrome: Heads or Tails?

BACKGROUND: To report cases of extraspinal mimics of cauda equina syndrome (CES) to enable prompt diagnosis and treatment in the future. CES results from compression of spinal nerve roots. Current practice mandates lumbosacral magnetic resonance imaging (MRI) scanning to diagnose CES. However, it may not reveal compression or provide an explanation for the presentation. We present 3 cases of suspected CES who went on to have intracranial pathology. METHODS: Retrospective review of all patients presenting with CES-type features who were subsequently found to have causative intracranial pathology over a 6-month period. RESULTS: Three cases were found, and these are hereby presented. CASE PRESENTATION: Case 1: A 57-year-old lady presented with urinary retention and bilateral leg weakness. She underwent an MRI spine which showed no evidence of CES. She was diagnosed with haemorrhagic intracranial metastases. Case 2: A 52-year-old lady presented with lower back and right buttock pain, with right-sided leg numbness, saddle hypoesthesia, and bowel and bladder incontinence. MRI spine showed no cauda equina compression. MRI neuraxis revealed a subdural haematoma. Case 3: A 69-year-old lady presented with a 6-day history of urinary incontinence, right foot drop, and leg weakness. MRI spine was negative for CES. She was diagnosed with an intraparenchymal haematoma of posterior left frontal lobe. CONCLUSIONS: Negative lumbosacral MRI will not exclude extraspinal mimics of CES and, although rare, these cases should be considered.

Neurological complications are avoidable during CABG.

OBJECTIVE: To review the incidence of stroke in patients undergoing CABG and the impact of a preventive strategy adopted at tertiary care unit of cardiac surgery. METHODS: The data of all patients who underwent isolated CABG (N= 722) from July 2016 to August 2017 at Faisalabad Institute of Cardiology was retrieved for this retrospective study. All operations were done on cardiopulmonary bypass and cold blood cardioplegia. Numeric data was summarized as Mean ± Standard Deviation while categoric variables were summarized into frequency and percentage. RESULTS: Mean age of patients was 53.83±8.8 years. Mean Parsonnet and Logistic EuroScore were 4.3±3.2 and 3.3±0.9 respectively. Forty nine patients (6.78%) had significant carotid artery disease. Mean number of grafts was 2.8±0.82. Diabetes was present in 27.8% patients. Neurological complications were noticed in 14 patients (1.94%) who included 12 permanent paralyses. Further subgroup analysis revealed that 67 patients who were operated by single clamp technique remained free of neurological complications. This is clinically remarkable finding but due to small population size it is statistically non- significant. CONCLUSION: The incidence of neurological complications can be reduced significantly by adopting the appropriate preventing measures. Use of Single Clamp technique may be the reasons of such a low incidence of stroke in this study.

Firm productivity, pollution, and output: theory and empirical evidence from China.

Using a theoretical model, this paper argues that as firm productivity increases, there is a decrease in firm-level pollution intensity. However, as productivity increases, firms tend to increase their aggregate output, which requires the use of additional resources that increase pollution. Hence, an increase in productivity results in two opposing effects where increased productivity may in fact increase pollution created by a firm. We describe the joint effect of these two mechanisms on pollution emissions as the "productivity dilemma" of pollution emission. Based on firm-level data from China, we also empirically test this productivity dilemma hypothesis. Our empirical results suggest that, in general, firm productivity has a positive and statistically significant impact on pollution emission in China. However, the impact of productivity on pollution becomes negative when we control for increases in firm output. The empirical evidence also confirms the positive influence of productivity on output, which suggests that the main determinant of pollution is the firm's output. The empirical results provide evidence of the existence of, what we describe as, the productivity dilemma of pollution emission.

Total arterial myocardial revascularization: analysis of initial experience.

BACKGROUND: Total arterial myocardial revascularization is an attempt to overcome the problems of late vein graft atherosclerosis, occlusion and need for coronary re-operations. Despite increasing evidence of efficacy, the use of arterial conduits has not been accepted as a primary practice in most of the centers in Pakistan for various reasons. We analyze our initial experience to assess the feasibility of total arterial revascularization as a primary strategy in patients requiring first time coronary artery bypass grafting. METHODS: Two hundred patients undergoing first time CABG at our institution, from January 2000 to April 2001, were studied. Group 1 consisted of 100 patients undergoing total arterial revascularization (using bilateral internal thoracic and radial arteries) and Group 2 consisted of 100 patients undergoing conventional CABG (using one internal thoracic artery and supplemental veins). Thirty-day mortality and early morbidity with particular reference to resternotomy for bleeding, cerebrovascular accidents, renal failure, and sternal dehiscence were the main outcome measures. RESULTS: Patients in Group 1 were younger (56.2 +/- 10.4 vs. 60.3 +/- 9.8 years; P < 0.001), had lower Parsonnet scores (4.8 +/- 0.4 vs. 9.6 +/- 1.8; P < 0.001), and had better left ventricular function. Both groups received a similar number of grafts. The percentage of patients undergoing total arterial revascularization rose from 20% in the first three months to over 65% in the three later three-month periods. Overall 30-day mortality was 1.5%, one patient (1%) in Group 1 and two patients (2%) in Group 2. There was a similar incidence of postoperative complications and length of median postoperative stay in both groups. CONCLUSION: Total arterial revascularization can be adopted as a primary strategy in most patients undergoing CABG with no increase in mortality or morbidity.

Off-pump coronary artery bypass surgery: analysis of 5-year experience.

We retrospectively evaluated the perioperative results of off-pump coronary artery bypass surgery performed in our center. Over a 5-year period, 520 patients were operated off-pump through a median sternotomy with the aid of a cardiac stabilizer and retractor. A total of 1,117 distal anastomoses were made with a mean of 2.2 +/- 1.0 bypass grafts per patient. Only 12 patients (2.3%) required conversion to cardiopulmonary bypass, while 10 patients (1.9%) were re-operated for bleeding or graft failure. Perioperative myocardial infarction occurred in 10 patients (1.9%), and postoperative stroke in 3 patients (0.6%). The overall operative mortality was 2.5%, while the rate for the 48 patients who had previous bypass surgery was 2.1%. The results show that off-pump coronary surgery produces low mortality and morbidity, even in the treatment of multivessel disease or high-risk patients.

Emergency off-pump coronary artery surgery.

BACKGROUND: Off-pump coronary artery bypass grafting is fast-becoming a procedure of choice for elective revascularization in high-risk patients with multi-vessel coronary artery disease. However, the role of off-pump coronary artery bypass grafting for patients with acute coronary syndromes requiring emergency revascularization still requires validation. We present our experience to show the feasibility of off-pump coronary artery surgery as an emergency revascularization technique. METHODS: From April 2001 to September 2003, emergency (operation within 24 hours after hospitalization) coronary artery bypass grafting without cardiopulmonary bypass (CPB) was performed in 66 patients with a mean age of (66.9 +/- 5.4) years (range 49-72 years). They presented acute coronary syndromes with 38 patients on platelet glycoprotein IIb/IIIa receptor antagonists. All patients underwent off-pump coronary artery bypass surgery via sternotomy with the intention of complete coronary revascularization. RESULTS: An average of 2.9 grafts per patient were performed and the posterior descending artery and marginal branches of the circumflex artery were grafted in 83.3% of the patients. There were 4 events of intraoperative cardiac instability, precipitated by occlusion of right coronary artery or positioning of a cardiomegaly heart, leading to immediate conversion to CPB. The mortality rate was 3% (2/66). Two patients suffered postoperative stroke while three needed hemofiltration for acute renal failure. Post surgery elective coronary angiography (n = 46) showed no significant stenosis. CONCLUSION: Emergency off-pump coronary artery surgery with complete revascularization is feasible in patients with acute coronary syndrome with low morbidity and mortality and excellent early results.

Saphenous vein grafts: to use or not to use?

The choice of the graft conduit is crucial to the success of coronary artery bypass grafting (CABG) because the patency of a coronary conduit is closely associated with an uneventful postoperative course and better long-term patient survival. From the beginning of coronary bypass surgery venous conduits particularly the great saphenous vein (GSV) has been the most frequently used coronary conduit. However, over the last decade or so, coronary bypass graft surgery with arterial revascularization of all diseased coronaries has shown to be efficient because arterial grafts have better long-term patency, especially left internal mammary artery (LIMA), compared with venous grafts. Early vein graft failure coupled with occlusion is the most important limitation of saphenous vein grafts. Nevertheless, vein grafting is still an integral part of cardiac surgical practice. This review provides a summary of the patency rates, technical features and certain characteristics of the venous conduits. It also examines the current understanding and knowledge of venous histology, vein graft pathology and the associated endothelial and smooth muscle cell physiology and pharmacology. In addition, the existing and the emerging strategies to combat and control vein graft intimal hyperplasia and accelerated atherosclerosis are reviewed in detail.

Saphenous vein grafts: to use or not to use?

The choice of the graft conduit is crucial to the success of coronary artery bypass grafting (CABG) because the patency of a coronary conduit is closely associated with an uneventful postoperative course and better long-term patient survival. From the beginning of coronary bypass surgery venous conduits particularly the great saphenous veins (GSV) have been the most frequently used coronary conduit from the beginning of the coronary bypass surgery. However, over the last decade or so, coronary bypass graft surgery with arterial revascularization of all diseased coronaries has shown to be efficient because arterial grafts have better long-term patency, especially left internal mammary artery (LIMA), compared with venous grafts. Early vein graft failure coupled with occlusion is the most important limitation of saphenous vein grafts. Nevertheless, vein grafting is still an integral part of cardiac surgical practice. This review provides a summary of the patency rates, technical features and certain characteristics of the venous conduits. It also examines the current understanding and knowledge of venous histology, vein graft pathology and the associated endothelial and smooth muscle cell physiology and pharmacology. In addition, the existing and the emerging strategies to combat and control vein graft intimal hyperplasia and accelerated atherosclerosis are reviewed in detail.