Advancements in left ventricular assist devices to prevent pump thrombosis and blood coagulopathy.

Mechanical circulatory support (MCS) devices, such as left ventricular assist devices (LVADs) are very useful in improving outcomes in patients with advanced-stage heart failure. Despite recent advances in LVAD development, pump thrombosis is one of the most severe adverse events caused by LVADs. The contact of blood with artificial materials of LVAD pumps and cannulas triggers the coagulation cascade. Heat spots, for example, produced by mechanical bearings are often subjected to thrombus build-up when low-flow situations impair washout and thus the necessary cooling does not happen. The formation of thrombus in an LVAD may compromise its function, causing a drop in flow and pumping power leading to failure of the LVAD, if left unattended. If a clot becomes dislodged and circulates in the bloodstream, it may disturb the flow or occlude the blood vessels in vital organs and cause internal damage that could be fatal, for example, ischemic stroke. That is why patients with LVADs are on anti-coagulant medication. However, the anti-coagulants can cause a set of issues for the patient-an example of gastrointestinal (GI) bleeding is given in illustration. On account of this, these devices are only used as a last resort in clinical practice. It is, therefore, necessary to develop devices with better mechanics of blood flow, performance and hemocompatibility. This paper discusses the development of LVADs through landmark clinical trials in detail and describes the evolution of device design to reduce the risk of pump thrombosis and achieve better hemocompatibility. Whilst driveline infection, right heart failure and arrhythmias have been recognised as LVAD-related complications, this paper focuses on complications related to pump thrombosis, especially blood coagulopathy in detail and potential strategies to mitigate this complication. Furthermore, it also discusses the LVAD implantation techniques and their anatomical challenges.

Foreign body aspiration presenting as a chronic lung disease: a unique finding in an elderly patient.

Foreign body aspiration is a serious clinical manifestation in the elderly and has a significant potential to cause life-endangering harm. In this unique report, we highlight the case of a seventy-year-old conscious male, who reported with complaints of chronic cough initially diagnosed as chronic bronchitis; however, on radiological examination, the infectious nidus was identified as a 5 cm long metallic nail in the right lower lung.

The environment under the knife: A review of current Eco-surgical strategies and recommendations for Pakistan.

The healthcare sector at its core is based on the fundamentals belief to do no harm and bring about betterment in the lives of the people. Paradoxically, hospitals are one of the leading contributors to pollution, greenhouse gas (GHG) emissions and toxic waste material worldwide. Surgical care delivery is quite resource intensive, consuming significant amount of energy and equipment as well as producing large quantities of waste. With climate change being a global priority, it is crucial that hospitals re-evaluate the environmental impact of such practices. The current review was planned to identify areas of improvement in surgical care in terms of sustainability, as well as describe efficient and innovative strategies for hospitals in Pakistan to lessen their impact on the environment. The implementation of the 5 R's strategy for surgical care (Reduce, Reuse, Recycle, Rethink and Research) as well as general measures to improve energy efficiency, waste management and inter-sectoral collaboration will provide significant benefits to the environment and advance efforts to creating a more sustainable future for surgical healthcare in Pakistan.

Radial artery coronary bypass grafting: Surgical outcomes of an unexplored innovation in a developing country.

OBJECTIVE: To explore postoperative outcomes, particularly prolonged length of hospital stay, in radial artery coronary artery bypass graft patients in a tertiary-care setting. METHODS: The pilot prospective cohort study was conducted at the Aga Khan University Hospital, Karachi, from September 2019 to September 2020, and comprised adult patients of either gender due to undergo coronary artery bypass grafting for coronary artery disease involving two or more vessels. The subjects were approached for the use of their radial artery as a conduit. Prolonged length of hospital stay was defined as postoperative stay >9 days. Multivariable logistic regression was used to identify independent predictors of the length of hospital stay. Data was analysed using SPSS 21. RESULTS: Of the 97 patients, 84(86.6%) were males. The overall mean age of the sample was 58.33±8.34 years. Mean length of hospital stay was 8.10±2.37 days, and 23(23.7%) patients had prolonged stay. Higher age was a significant predictor of prolonged hospital stay (p<0.05). Besides, 23(23.7%) patients developed acute kidney injury. There was no incidence of wound, infection or deep venous thrombosis, while 1(1.03%) patient had to be reopened due to excessive postoperative bleeding, and it represented the lone mortality. CONCLUSIONS: Patient age was found to be a significant predictor of prolonged hospital stay in patients undergoing radial artery coronary artery bypass graft, while almost a quarter of the sample was affected by acute kidney injury.

Atypical presentation of a rare gestational trophoblastic neoplasm: A case report.

A 34-year-old woman had a history of 3 miscarriages and presented with symptoms of an unproductive cough and rising serum beta-human chorionic gonadotropin (b-hCG) levels. There were no gynaecological symptoms. A diagnosis of Choriocarcinoma with pulmonary metastasis was made. In Pakistan, the incidence of Choriocarcinoma remains exceedingly rare, accounting for less than 0.3% of all gynaecologic tumours. Though rare, if managed appropriately, it has a reasonably good prognosis, as demonstrated by the outcome of the current case.

Conceptual framework for a cardiac surgery simulation laboratory and competency-based curriculum in Pakistan - a short innovation report.

Simulation is a commonly utilized technique in healthcare education as it provides trainees a realistic, but safe, environment to learn a variety of skills. Trainees belonging to fields known for high stakes with low margins for error, such as cardiac surgery, can greatly benefit from simulation-based education. We propose the establishment of the first multi-tier high fidelity cardiac surgery simulation lab with a structured curriculum that will eventually provide multidisciplinary training to promising cardiac surgeons across Pakistan. The simulation lab may also be used for research, grant acquisition and patent development. Our setup will include the following levels of simulation: a simple bench model, a virtual reality simulator and a unique human performance simulator. Our multitiered approach allows for appropriate sequential trainee skill progression. Finally, we hope that our model inspires the development of similar curricula and modules for trainees belonging to other surgical fields.

Peer-taught virtual research workshops for surgical residents: Protocol for a novel and sustainable solution to improving surgical research in Pakistan.

OBJECTIVE: To generate a protocol describing the methodology for a study assessing the effectiveness of a comprehensive series of peer-taught online research workshops for surgical residents across Pakistan in terms of improving research-related knowledge and skills, and long-term research involvement and output. METHODS: The quasi-experimental study will consist of a series of six online research workshops conducted over Zoom for surgical residents across Pakistan. An online sign-up form will be circulated on social media to current surgical residents throughout Pakistan. Curricular content covered in the workshops will be developed in collaboration with experienced research faculty at the Departments of Surgery and Community Health Sciences at the Aga Khan University Hospital, Karachi. Facilitators of the workshops will be current surgical residents with a solid track record of research involvement at the hospital. Improvement in research-related knowledge and skills will be assessed through pre- and post-tests for each workshop. A post-series feedback form will assess satisfaction with the organisation, content relevance, peer-teaching and online delivery of the workshops. Long-term research involvement and output will be assessed by follow-up surveys at 6 months and 1 year post-workshop. All data-collection will be done via Google Forms. For ethical purposes, informed consent will be taken from participants prior to enrolment; data will be collected using a unique identifier number to maintain anonymity; and the only incentive provided to participants will be a Certificate of Completion for the research workshop series. RESULTS: We expect that surgical trainees participating in the series of six research workshops will demonstrate a highly significant percentage improvement (p<0.001) in the pre- and post-tests for each of the six core research competencies taught. On post-series feedback, we expect the majority of participants (>80%) to rate the overall organisation, effectiveness of online mode of instruction, and relevance to surgical training of the workshops as excellent/good. We also expect that most participants (>80%) would strongly agree/agree that peer-education is an effective model of teaching in research workshops. Finally, we expect statistically significant improvement (p<0.05) in research involvement and output in terms of publications as assessed in the 6 months and 1year post-workshop follow-up surveys. CONCLUSIONS: In light of the ever-growing need for academic surgeons in Pakistan, this research protocol details a comprehensive strategy for research capacity-building among surgical trainees across the country. By equipping trainees with the knowledge and skills to conduct high-quality research, virtual research workshops provide a novel, grassroots-level and sustainable solution for addressing the surgical research crisis in Pakistan.

Frequency of Renal Dysfunction and its effects on outcomes after open heart surgery.

OBJECTIVES: In this study we determined the frequency of renal dysfunction and its outcomes in terms of morbidity and mortality in patients who underwent open heart surgery at the Aga Khan University Hospital, Karachi, Pakistan. METHODS: A total of 175 patients aged between 15-80 years having open heart Surgery(OHS) were included. Preoperative and postoperative serum creatinine (SCr) was noted and the glomerular filtration rate (GFR) calculated by Cockcroft-Gault equation. Their hospital course was charted and followed-up for 30-day. RESULTS: The mean age and mean BMI were 58.1±12.6 years and 26.4±4.3 kg/m2 respectively. Females were 18.3%, out of which 51.4% hypertensive, 46.9% diabetics, 45.1% had dyslipidemia, 2.9% had preoperative renal dysfunction and 40% had moderate ejection fraction. On follow up, 30.3% developed postoperative renal dysfunction within 30-days after OHS with mean SCr and GFR as 1.6±0.7 and 56.9±24.5, respectively. In RD group more patients showed positive outcomes i.e. prolonged inotropic requirement (75.5% vs. 18%, p-value <0.005), diuretic infusion usage (47.2% vs. 3.3%, p-value <0.005), dialysis/renal replacement therapy (17% vs. 0%, p-value <0.005), requirement for prolonged ventilation (35.8% vs. 6.6%, p-value <0.005), prolonged ICU and hospital stay (15.4% vs. 1.6%, p-value <0.005 and 41.5% vs. 17.2%, p-value <0.005), sepsis (20.8% vs. 1.6%, p-value <0.005) and death (9.4% vs. 2.5%, p-value 0.05). CONCLUSION: Timely recognition of renal dysfunction, early renal replacement therapy, diuretics or dialysis and proper nutritional and inotropic support to maintain adequate hemostasis shows survival benefits.

Ruptured mycotic reverse saphenous vein graft aneurysm: A late complication of mediastinitis.

Reverse saphenous vein graft aneurysm (RSVGA) is a rare complication that occurs after coronary bypass grafting surgery. Mycotic aneurysm of reverse saphenous vein graft is even more rare. We describe the case of a 76-year-old man who underwent coronary artery bypass grafting 10 years back and had mediastinitis four to five months after surgery. He presented with chest pain in July 2017 and was diagnosed as NSTEMI. Angiography showed left main coronary artery disease (90%) with aneurysm of reverse saphenous vein graft to right posterior descending artery(RPDA). Emergent percutaneous coronary intervention (PCI) of the left main artery was performed as the patient suffered ventricular arrhythmia for which cardiopulmonary resuscitation (CPR) was done. After CPR, haematoma appeared on the left side of the sternum subcutaneously. CT scan of the chest was conducted which showed a pseudoaneurysm measuring 35 mm in the mid-segment of reverse saphenous vein graft (RSVG) to the right posterior descending artery (RPDA) with a surrounding mediastinal haematoma communicating with subcutaneous haematoma, so RSVGA to RPDA was coiled. As blood culture grew candida, antifungal medication was started. When the patient's condition stabilised he was discharged.

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.

Delay between onset of indication and definitive surgery for tracheal trauma.

Tracheal stenosis is rare but a recognized complication after traumatic injury or prolonged intubation. We assessed the time lag between onset of indication for tracheal reconstruction surgery following trauma and actual surgical intervention. We reviewed our operative records for all patients undergoing tracheal reconstruction over the past 10 years. Files were reviewed retrospectively to collect all the relevant data. Surgically all patients were operated via cervical approach. Series 12 cases were identified with an equal split between external trauma and iatrogenic tracheal trauma from prolonged intubation. On, an average patients presented 185 days after initial indication of surgery however there was a wide range of time lag which leads to the importance of early diagnosis of such injuries to reduce delay of definitive management.

When surgeons are rarer than resources - our experience with improving access to thoracic surgery in an urban setting: A special report.

With progressive globalisation enabled by technology, there is an increased interest in finding viable solutions to the myriad health problems faced by developing countries. In countries like Pakistan, occasionally the challenge is not a dearth of material resources but rather unavailability of expertise. The current paper was planned to share a model that was successfully implemented in the urban setting of Karachi, Pakistan, from 2012 onwards which significantly improved access to thoracic surgery for underprivileged individuals. Our model focussed on a qualified thoracic surgeon reviving a defunct thoracic surgical unit thereby optimising the use of resources already available in the community. The key to efficient outcomes was direct managerial control by the surgeon who first educated himself in the various processes involved. The model, with its challenges and solutions, has good potential foradaptation in other urban settings in the developing world..

Superior septal approach versus left atrial approach for mitral valve replacement: A retrospective cohort study.

OBJECTIVE: To compare the outcomes of superior septal approach and left atrial approach for mitral valve replacement. METHODS: This retrospective cohort study was conducted at the Aga Khan University Hospital, Karachi, and comprised records of patients who had undergone isolated mitral valve replacement from May 2003 to April 2012. Cases were reviewed for the outcomes [primary: loss of normal sinus rhythm; secondary: complications, residual defect and mortality]. Patients with prior history of dysrhythmia, low ejection fraction (<30%), emergency/redo mitral valve replacement and concomitant coronary artery bypass grafting were excluded. SPSS 19 was used for data analysis. RESULTS: Of the 78 patients, 52(66.67%) were of superior septal approach and 26(33.33%) of left atrial approach. Both groups were comparable for baseline variables except cardiopulmonary bypass and cross-clamp times, which were significantly shorter in the superior septal approach group than the left septal approach group (p<0.05). No residual atrial septal defect was found in any approach. Although loss of normal sinus rhythm was observed more frequent in superior septal approach 25(48%) compared to left septal approach 10(38.4%), but the difference was statistically insignificant (p=0.28). Age was the only significant variable affecting loss of normal sinus rhythm after adjusting for approaches. The difference of post-operative complications was also statistically insignificant between superior 9(17.3%) and left septal approach 4(15.38%) (p=1.0)]. CONCLUSIONS: The operative durations were significantly higher in left atrial approach compared to superior septal approach.

Management Of Penetrating Injury To Thoracic Inlet And Lower Neck With Retained Foreign Body Using Video Assisted Thoracoscopic Surgery.

Penetrating neck and chest injuries are a common form of occupational injuries. We hereby report a unique case in which a metallic rod had penetrated the left chest and neck of a plastic factory worker. The patient was vitally stable when he presented to Emergency Room. Chest X-ray was performed and the patient was rushed to the operating room. VATS (video assisted thoracoscopic surgery) and neck dissection was done for retrieval of the metallic rod. On table, endoscopy was also done to rule out injury to oesophagus. No injury to vital structures was found and the subsequent recovery was uneventful.

Unusual case of non-resolving necrotizing pneumonia: A last resort measure for cure.

To our knowledge, this is an unusual case of a community-acquired pneumonia (CAP) with sepsis secondary to Streptococcus pneumoniae that required lung resection for a non-resolving consolidation. A 74 year old previously healthy woman, presented with acute fever, chills and pleuritic chest pain in Emergency Department (ED). A diagnosis of CAP was established with a Pneumonia Severity Index CURB-65 score of 5/5. In the ER, she was promptly and appropriately managed with antibiotics and aggressive supportive therapy. She remained on ten days of intravenous antibiotics. However, 48 hours post antibiotic course, she returned to ER with fever and signs of sepsis. Despite timely and appropriate management, the consolidated lobe remained the focus of sepsis for over four weeks. The patient recovered after the offending lobe was resected. Histopathology of the lung tissue revealed acute and chronic inflammation. However, no malignancy, bacterial infection or broncho-pleural fistula was found. Eighteen months post-surgery, the patient remains well.

Enteric cyst in the left posterior mediastinum mimicking a hydatid cyst on chest Computed Tomography scan.

Mediastinal enteric cysts are a rare occurrence among adults and are usually asymptomatic. In most cases they are an incidental finding in the right hemi-mediastinum and are associated with vertebral anomalies. We report the unusual case of a 23 year old male who had a mediastinal mass on chest X-ray as an incidental finding. Chest Computed Tomography (CT) scan revealed no vertebral anomalies and a cystic mass in the left posterior mediastinum with features similar to those of a hydatid cyst.Posterolateral thoracotomy was done and the cyst was excised. Histopathology report revealed it to be an enteric cyst.

Peri-operative determinants of prolonged CICU stay after coronary artery bypass graft surgery in elderly at a private tertiary care hospital: A case control study.

OBJECTIVE: To explore peri-operative risk factors associated with prolonged stay in cardiac intensive care unit among patients undergoing isolated coronary artery bypass grafting. Methods: This retrospective case control study was conducted at the Aga Khan University Hospital, Karachi, comprised medical records of patients who had undergone cardiothoracic revascularisation surgery from January 2006 to December 2013. The patients were grouped into cases and controls at a ratio of 1:2 on the basis of length of stay at cardiac intensive care unit, i.e. >72 hours and <72 hours. Independent risk factors for prolonged cardiac intensive care unitstay were evaluated. SPSS 20 was used for data analysis. Results: Of the 999 patients, 333(33.3%) were cases and 666(66.6%) were controls. The mean age of cases was 62.5±9.7 years and that of controls was 60.8±9.6 years (p=0.007). The number of males was 280(84.1%) among the cases and 489(73.4%)among the controls. Adjusted odds ratio and 95% confidence interval for age and male gender were 1.02 (1.0,1.03) and [1.90 (1.32,2.74)]; diabetics were at high risk of staying longer [1.51 (1.13,2.02)]; previous cardiovascular interventions [1.65 (1.05,2.59)], intra-aortic balloon pump insertion [1.45 (1.01,2.08)], initial ventilation time and post-operative bleeding tamponade were independently associated with prolonged cardiac intensive care unit stay [1.01 (1.00, 1.01)] and [1.9 (1.13,3.2)], respectively. The risk of dying among the cases was three times more after adjusting for all covariates in the model [3.1 (1.52,6.31)]. Conclusion: Advanced age, male gender, diabetes, previous cardiovascular interventions, post-operative intra-aortic balloon pump insertion, initial ventilation support and post-op bleeding tamponade were found to be the independent risk factors for prolonged cardiac intensive care unit stay.

Retrograde bullet migration from inferior vena cava into right common iliac vein following gunshot: A case report.

Bullet embolization cases are rare and even rarer are its retrograde migration in the veins. We report the case of a 14 year old male with a gunshot wound to the left side of his chest. CT scan revealed bilateral haemothorax and foreign body in the right common iliac vein. The patient was immediately taken to the operating theatre and median sternotomy performed. Bullet entry tear was found in the inferior vena cava however, the bullet was found lodged in the right common iliac vein and slipped down against the flow of blood. The bullet was left in situ and after the necessary repair the chest was closed and the patient shifted to the CICU and discharged after 4 days in stable condition. Patient was followed after 1 week and reassured and advised for one year follow-up.

Myxoid Liposarcoma Originating In The Anterior Mediastinum.

Myxoid liposarcomas of the head and neck are mostly metastatic in nature, with the primary lesion usually in lower extremities or retroperitoneum. Primary mediastinal liposarcomas are even rarer. Although there have been previous cases reporting their incidence, there is no evidence of any case comprising of both the neck and the mediastinal region yet. We here present a case of a 43 year old male with a primary liposarcoma of the myxoid subtype originating in the anterior mediastinum. This is the first time such a case has presented in literature. The patient presented with a right sided neck swelling associated with pain and shortness of breath upon lying down. CT neck revealed an enhancing mass extending from right cervical region to axilla and encasing the subclavian artery and involving a portion of the right lung. The patient underwent wide local excision of the mass along with chemoradiotherapy to prevent recurrence.

Near complete aortic transection and its successful repair using a novel cardiopulmonary bypass technique.

The case of a 38-year old female, victim of a road traffic accident who presented with a near complete aortic transection is presented. An emergent repair employing cardiopulmonary bypass was attempted in the operating room. Anticipating a high-risk of compromise to cerebral perfusion from air micro-emboli, the bypass was attempted with an innovative approach involving the successful cannulation of the pulmonary artery and descending aorta. The patient survived and was found to be doing well on subsequent post-operative visits.