Continuous versus interrupted technique of ventricular septal defect (VSD) closure in total correction for tetrology of Fallot pertaining to residal VSD.

OBJECTIVE: To analyze the outcome of continuous versus interrupted closure technique of ventricular septal defect (VSD) closure in Tetrology of Fallot with reference to postoperative residual VSD after total correction. METHODS: A randomised control study was conducted between January 2008 to December 2008 at The Department of Cardiac Surgery, National Institute of Cardiovascular Diseases (NICVD), Karachi. The results of total correction (T.C) of VSD in patients with Tetralogy of Fallot, with emphasis on the suturing technique and eventually on the occurrence of residual ventricular septal defect(VSD) were analyzed. Transventricular as well as transatrial route was used to approach VSD. In thirty patients VSD was closed with 5/0 proline continuous double ended suture while in remaining 30 (50%) patients VSD was closed with interrupted 5/0 prolene double ended sutures. Postoperative echocardiography was done in all patients as a routine on second postoperative day, to document residual VSD. RESULTS: The study included 60 (100%) patients with T.O.F. There were 20 (33.3%) females and 40 (66.6%) males with ages ranging between 04 to 18 years (mean 13.025 +/- 2.123 years). Postoperative echocardiography showed residual VSD in 05 (8.3%) patients at posteroinferior rim of VSD. Of these 05 cases, in four VSD had been closed with continuous 5/0 proline double ended sutures, and one had VSD closed with interrupted 5/0 double ended sutures. CONCLUSION: Residual VSD is common with continuous suturing technique as compared to interrupted suturing technique. This is perhaps because of poor myocardium quality and higher RV pressures in our patients presenting at a late age. Small (less than 05 milimeter) residual VSD can be treated conservatively in haemodynamically stable patients.

Early effects of coronary artery bypass grafting on left ventricular regional wall motion abnormalities.

OBJECTIVE: To determine the early effects of Coronary Artery Bypass Grafting (CABG) on regional left ventricular wall motion abnormality in patients undergoing surgery for proven Coronary Artery Disease (CAD). DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Department of Cardiac Surgery, National Institute of Cardiovascular Diseases, Karachi. from October 2005 to April 2006. PATIENTS AND METHODS: A total of a 100 adult patients who underwent elective CABG were selected. Pre-operative echocardiography was done to note if segmental left ventricular wall motion at basal, mid and apical levels were normal, hypokinetic, akinetic, dyskinetic, or aneurysmal. Postoperative echocardiography was done between 4th and 6th day and change in left ventricular segmental wall motion was noted. RESULTS: Seventy-five patients (n=75) were included in the analysis. These results showed that effect of CABG on anterior segmental wall motion abnormalities was insignificant (p=.609), the effect on the anterior IVS showed deterioration of segmental wall motion and this effect was significant (p=.001), effect is insignificant on anteriolateral segmental wall motion abnormalities (p=.078), normal pre-operative segments in posterior wall showed stability (p=.664) while disappearance of dyskinetic, reduction in akinetic segments postoperatively and inferior wall motion have same effects as of posterior wall. Comparison of pre-operative and postoperative echocardiographic data revealed early improvement in segmental wall motion of posterior and inferior wall, while alterations in segmental wall motion of anterior, anterior-lateral and septal wall. CONCLUSION: Myocardial revascularization by CABG improves early left ventricular regional wall motion abnormalities where SVG is used as conduit for revascularization whereas no significant improvement occurs in early segmental wall motion in areas revascularized by LIMA.

Frequency and predictors of cognitive decline in patients undergoing coronary artery bypass graft surgery.

OBJECTIVE: To determine the frequency of cognitive impairment and its predictors in patients, who underwent first time coronary artery bypass graft surgery (CABGS). STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: The National Institute of Cardiovascular Diseases (NICVD), Karachi, from December 2008 to December 2009. METHODOLOGY: Study included patients > 18 years, who underwent first-time elective CABGS. Emergency CABGS, with additional cardiac procedures, myocardial infarction (MI) within one month and known psychiatric illness were excluded. Patients were evaluated for their socio-demographic profile, medical history, intra-operative, anesthetic and surgical techniques and postoperative complications/therapy in ICU. Cognitive functioning, before the surgery, at discharge, 6 weeks and 6 months post-CABG was evaluated by McNair's and MMSE scales. HDRS was added to see if depression was a confounding factor for cognitive decline. RESULTS: One hundred and thirty four patients were followed-up at discharge, 74 at 6 weeks and 73 at 6 months. There were 113 (84.3%) males and 21 (15.7%) females, with mean age of 53.7 ± 8.36 years. Prevalence of cognitive disturbance at baseline was 44.8%, which increased to 54.5% at discharge, and improvement was seen at 6 months, it was 39.7%. Older age, female gender, higher bleeding episodes, and high post-surgery creatinine level were more frequently associated with cognitive decline. CONCLUSION: Postoperative cognitive deficit was common and remained persistent at short-term. Older age, females and high postoperative creatinine were identified as its important predictors. There was high frequency of acute depression before surgery with significant reduction over time.

Acute type a aortic dissection: a pathology under diagnosed

To compare the frequency of acute type A aortic dissection with chronic dissections, at two large cardiac surgery centers of the country. Acute type an aortic dissection: a pathology under diagnosed. This study was conducted at Rehman Medical Institute, Peshawar and National Institute of Cardiovascular diseases, Karachi, between January 2001 and January 2007. All patients with type A aortic dissection are studied retrospectively. Patients with aortic aneurysm, undergoing aortic root surgery, were not included in the study. Out of 13 patients who underwent aortic root surgery for various pathologies of the aorta, 9 cases had type A aortic dissection. Eight patients were diagnosed by trans-thoracic and trans-esophageal echocardiography and one patient was diagnosed on contrast enhanced computerized tomography [CT] scan. None of the patients had cardiac catheterization or MRI. Six of the nine dissections were chronic. One patient had Marfan Syndrome. Eight patients were hypertensive. One patient had aortic valve repair with supra coronary tube graft interposition for ascending aortic dissection; while eight patients had aortic root replacement with prosthetic composite grafts. There was one in-hospital death. Post operative echocardiogram of the patient with aortic valve repair, revealed mild aortic regurgitation. Seven of the eight surviving patients are in NYHA class I while one patient is in NYHA class two. Aortic root surgery can be safely performed with results comparable to the published data. Hypertension needs to be controlled to avoid its potentially lethal complications, like aortic dissection