Incidence and Outcomes of Postoperative Atrial Fibrillation after Coronary Artery Bypass Grafting of a Randomized Controlled Trial: A Blinded End-of-cycle Analysis.

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).

Diagnostic performance of various familial hypercholesterolaemia diagnostic criteria compared to Dutch lipid clinic criteria in an Asian population.

BACKGROUND: Familial hypercholesterolaemia (FH) is a genetic disorder with a high risk of developing premature coronary artery disease that should be diagnosed as early as possible. Several clinical diagnostic criteria for FH are available, with the Dutch Lipid Clinic Criteria (DLCC) being widely used. Information regarding diagnostic performances of the other criteria against the DLCC is scarce. We aimed to examine the diagnostic performance of the Simon-Broom (SB) Register criteria, the US Make Early Diagnosis to Prevent Early Deaths (US MEDPED) and the Japanese FH Management Criteria (JFHMC) compared to the DLCC. METHODS: Seven hundered fifty five individuals from specialist clinics and community health screenings with LDL-c level ≥ 4.0 mmol/L were selected and diagnosed as FH using the DLCC, the SB Register criteria, the US MEDPED and the JFHMC. The sensitivity, specificity, efficiency, positive and negative predictive values of individuals screened with the SB register criteria, US MEDPED and JFHMC were assessed against the DLCC. RESULTS: We found the SB register criteria identified more individuals with FH compared to the US MEDPED and the JFHMC (212 vs. 105 vs. 195; p < 0.001) when assessed against the DLCC. The SB Register criteria, the US MEDPED and the JFHMC had low sensitivity (51.1% vs. 25.3% vs. 47.0% respectively). The SB Register criteria showed better diagnostic performance than the other criteria with 98.8% specificity, 28.6% efficiency value, 98.1% and 62.3% for positive and negative predictive values respectively. CONCLUSION: The SB Register criteria appears to be more useful in identifying positive cases leading to genetic testing compared to the JFHMC and US MEDPED in this Asian population. However, further research looking into a suitable diagnosis criterion with high likelihood of positive genetic findings is required in the Asian population including in Malaysia.

An atypical case of right ventricular myxoma, a paradox of pulmonary valve endocarditis with right ventricular outflow tract obstruction. From a surgeon's perspective.

Intracardiac tumour is rare, and intracardiac myxoma is the most common intracardiac tumour of the heart. The majority of these tumours arise at the left and right atrium, and a presentation of such a tumour other than the mentioned is atypical and very rare. Due to the rare occurrence, clinicians often misdiagnose it as infective endocarditis especially if the tumour is located near the valves and causing outflow gradient stenosis on echocardiography. A multi-modal cardiac imaging and a multi-disciplinary approach are paramount to make a correct diagnosis and treatment strategies. We would like to report a rare case of a right ventricular myxoma of a young girl, who was initially treated with infective endocarditis, which turned out to be a rare atypical Right ventricular myxoma, which was then surgically excised. The patient was successfully discharged after 3 years of follow up echocardiography showed free of tumour recurrence.

Outcome of adult cardiac surgery following COVID-19 infection in unvaccinated population in a national tertiary centre.

BACKGROUND: Ever since COVID-19 was declared a pandemic, the world medical landscape has changed dramatically. As cardiac surgeons we not only have the duty to protect our patients and staff from COVID-19 infection, but we are also tasked with the responsibility to ensure those cardiovascular patients awaiting surgery are not harmed from an extended delay in surgery as the world comes to a halt from COVID-19. Currently there is limited literature on the outcome of cardiac surgery in the pre-operative Covid positive group. In this study we aim to assess the safety and outcome of patients undergoing cardiac surgery following Covid-19 infection. PATIENTS AND METHODS: This was a single centre retrospective observational study. All patients undergoing open heart surgery at Institut Jantung Negara from June 2020 to July 2021 were included in this study. Patients who were Covid positive pre-operatively were identified. Data from patient medical records collected contemporaneously were reviewed and analysed, supplemented by telephone call interviews after discharge. RESULTS: 2368 patients underwent open heart surgery from June 2020 until July 2021 in our centre. Of these, 0.5% (12 patients) were identified as Covid positive pre-operatively. Mean age of patients were 59.1 ± 14.8 years old. Mean Ejection Fraction was 46.4 ± 12.9. Most patients (75%) were asymptomatic with covid infection and only one patient were admitted to hospital for Covid infection. Mean duration from Covid PCR positive swab to surgery were 46.3 ± 32.7days. Most of the patients (66.7%) underwent operation on an emergency or urgent basis. Median time to extubation was 1 day. Median ICU length of stay was 1 day. 25% patients required non-invasive ventilation post-operatively and one patient was discharged home on long term oxygen therapy. There were 2 deaths- none of which were covid related mortality. CONCLUSION: Cardiac surgery could be performed safely in patients with pre-operative Covid-19 infection after a period of recovery, especially in the asymptomatic to mild category of infection. Multi-disciplinary team approach may be useful in deciding the timing of surgery for complex cases.

A double-blind randomised controlled trial on the effect of Tocovid, a tocotrienol-rich capsule on postoperative atrial fibrillation at the National Heart Institute, Kuala Lumpur: an interim blinded analysis.

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.