The Egyptian Cardiothoracic Surgeon (ECTS - E-Journal)
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Impact of the degree of tricuspid valve tethering on the early outcome of tricuspid valve repair with the De-Vega technique
Full text linkBackground: Functional tricuspid regurgitation (TR) is usually caused by leaflet tethering, and annuloplasty is usually recommended to repair annulus dilatation. This work aimed to evaluate the impact of the degree of the tricuspid valve (TV) tethering on the early outcome of tricuspid valve repair with the De-Vega technique.
Methods: This prospective study included 50 patients with De-Vega tricuspid valve repair. Patients were divided into two groups; Group A (n= 25) included patients with tricuspid valve tethering of 8 mm or less, and Group B (n= 25) included patients with tricuspid valve tethering distance of more than 8 mm.
Results: The mean age of Group A was 46.1 ±3.5 years compared to 49.6 ±7 years in Group B. There were significant differences in postoperative ejection fraction (48.7 ±12.5 vs. 39.1 ±9.4 %, P= 0.003), TV tethering distance (0.6 ±0.2 vs. 1.1 ±0.4 cm, P <0.001), and area (1.1 ±0.5 vs. 2.6 ±0.9 cm2; P<0.001), and right ventricle fractional area (32.2± 7.9 vs. 25.4 ±9.7 cm2, P= 0.008) in Group A vs. B, respectively. There were no differences in postoperative complications, ICU, and hospital stay between groups.
Conclusion: Residual tricuspid regurgitation after De-Vega annuloplasty could be related to TV tethering distance. Increased TV tethering distance could be associated with reduced postoperative ejection fraction
May Coronary Artery Bypass Grafting Affect Native Coronary Atherosclerosis progression?
Full text linkBackground: Coronary artery bypass grafting (CABG) continues to be the best standard in the management of severe coronary artery disease (CAD), providing good symptom management and life extension. Although CABG was first performed by reversed saphenous veins (SVGs), surgeons have increasingly adopted arterial conduits because of their longer-term patency and resistance to atherosclerosis. CABG's efficacy may potentially be affected by the extension of atherosclerosis in the native coronary arteries. Few researches have investigated the long-term angiographic disease progression of native coronary arteries after surgical revascularization, or the variables that may impact this progression. Proximal native disease progression was presented to be two to six times more common than distal disease progression, with greater rates of progression in coronaries bypassed by SVGs than arterial grafts. The goal of this research was to determine influence of CABG on the extension of native coronaries atherosclerosis.
Methods: This prospective study was established on 25 patients who were diagnosed to have ischemic heart disease in cardiothoracic surgery department in Faculty of Medicine Menoufia University.
Results: The study showed that according to the risk factors among the studied cases, smoking was (60%), Dyslipidemia was (32%), HTN was (32%) and Diabetes was (32). According to grafts in proximal lesions, there was progression of atherosclerosis up to total occlusion, but in Distal lesions, there was significant regression of atherosclerosis. As result, there was statistically significant difference between proximal with distal lesions. Also, study showed that there was a significant difference between left system (LAD, D, OM) in comparison with right system (PDA) regarding distal lesion. Our results showed that univariate logistic regression analysis for progression in distal lesion regarding Dyslipidemia and Diabetes.
Conclusion: Progression of disease is more evident in coronary segment proximal to anastomosis, while regression of disease is more evident in coronary segment distal to anastomosis with statistically significant difference between them, also the risk of disease progression post CABG was found to be multifactorial, as certain risk factors can affect progression of the disease as Diabetes mellitus and dyslipidemia that were of statistically significance
The performance of the supra-annular Top-Hat aortic valves compared to the standard Carbomedics valves
Full text linkBackground: The CarboMedics Top-Hat aortic valve prosthesis was designed to be implanted in a supra-annular position. This study aimed to compare the hemodynamic performance of the Top-Hat aortic prostheses versus the standard CarboMedics aortic valve prostheses.
Methods: The study included 98 patients who had aortic valve replacement and were divided into two groups. Group A included 60 patients who had standard aortic valve prostheses, and Group B included 38 patients who had the Top-Hat aortic prostheses. The study endpoints were hospital outcomes, the effective orifice area, and the pressure gradient during a one-year follow-up.
Results: There was no significant difference in the baseline echocardiographic data and risk factors between the groups. The patients who had Top-Hat aortic prosthesis were younger, with a mean age of 47.5 (44-55) years, and those who had the standard prosthesis were 53.5 (48-56) years old (P= 0.02). The cardiopulmonary bypass time was significantly less in the Top-Hat prosthesis group with an average of 78 min (75- 81) compared to 88 min (84- 95) in the other group (P ˂0.001). The effective orifice surface area was significantly larger in the group with Top-Hat prosthesis; 0.9 mm/m2 (0.88- 0.92) compared to 0.84 mm/m 2 (0.79- 0.87) for the standard aortic valve prosthesis group (P ˂0.001). The pressure gradient over the aortic valve decreased significantly postoperatively (coefficient -1.98 (-2.21- -1.75); P˂0.001). Patients with Top-Hat valves had significantly lower gradient (coefficient: -4.22 (-6.61- -1.82); P= 0.001), while age had no effect on the pressure gradient (coefficient: 0.1 ( -0.07- 0.27); P= 0.25).
Conclusion: The Top-Hat CarboMedics prostheses could be superior to the standard CarboMedics aortic valve prosthesis regarding the effective orifice area and pressure gradient over the valve
Rescue of a Child with Fatal Cardiothoracic Injuries from an Air Gun: A Case Report
Full text linkBackground: Mortalities resulting from firearms to the chest are still common worldwide. Although relatively uncommon compared to other age groups, gunshots that occur in children are fatal catastrophic events especially those that penetrate the thoracic cage. Air guns (pellets) are less devastating than conventional fatal firearms, but they can be fatal particularly in children. Case presentation: We present successful management for a child presented with major cardiothoracic injuries caused by an air gunshot (pellet) that penetrated the chest and passed through the heart and lung to the posterior mediastinum. Conclusions: The young age and penetration into the thoracic cage could make air guns as lethal as conventional firearms
Autologous Pericardial Band for Tricuspid Valve Annuloplasty: Midterm Results
Full text linkBackground: Even though tricuspid regurgitation (TR) is a frequent cardiac valve disorder, and tricuspid valve annuloplasty (TVA) has been evolved to manage TR for more than 50 years, there is still a substantial controversy regarding the best durable method for TVA. We reported our midterm (3 years) outcomes of TVA using autologous pericardial (AP) band comparing it with DeVega annuloplasty for the management of functional TR.
Methods: Between January 2017 and November 2018, about 175 cases with moderate or more TR underwent TVA as a part of primary left-sided valve replacement surgery. Autologous pericardial (AP) TVA was performed in 100 patients, and DeVega TVA in 75 patients.
Results: Both groups are comparable as regards preoperative characteristics. Immediate postoperatively, regarding NYHA class, degree of TR, ejection fraction, and pulmonary artery systolic pressure, there was a marked improvement within the 2 groups compared to the preoperative values, without a significant difference between both groups. 94% of patients completed the follow-up period. In hospital death was 2% in the AP group, and 1% in the DeVega group. The AP group showed a marked improvement in the mean degree of TR at the same follow-up period compared to the DeVega group, 12% patients of the AP group and 21% patients of the De Vega group had 3+ or 4+ TR at 3 years postoperative follow up. There was a marked improvement in the Diastolic tricuspid annuloplasty diameter in the AP group compared to the DeVega group. There were 6.3% late deaths in our study.
Conclusion: TVA with an AP was more durable than the DeVega in avoiding postoperative TR progression on the midterm results
Early results of combined aortic arch debranching and thoracic endovascular re-pair
Full text linkBackground: The hybrid technique for managing aortic arch diseases has been introduced recently into the surgical armamentarium. We aimed to evaluate the early postoperative outcomes after aortic arch debranching and endovascular repair (TEVAR) of aortic arch aneurysms or dissection.
Methods: Between March 2015 and September 2020, 17 patients underwent elective aortic arch debranching concomitant with TEVAR. Thirteen patients had aortic arch aneurysms, and four had chronic dissection. Study outcomes were early postoperative complications such as stroke, paraplegia, renal insufficiency, and 30-day mortality.
Results: The mean age of our patients was 61.2± 7.6 years; 12 of them were males (70.6%). Five patients underwent total debranching (29.4%). All debranching procedures were followed with TEVAR. 30-day mortality, stroke, permanent paraplegia, and renal failure occurred in one patient (5.9%), while transient neurological deficit occurred in two patients (11.8%).
Conclusion: Hybrid management of aortic arch pathologies showed encouraging early results. The combination of surgical aortic arch debranching and TEVAR could be an option for managing aortic arch diseases. However, larger studies with longer follow up are recommended
Indications and outcomes of pneumonectomy for benign diseases: A single-center experience
Full text linkBackground: Pneumonectomy can be used to manage destroyed lung; however, it is associated with a high risk of complications. This study analyzed the outcomes of pneumonectomy in patients with destroyed lungs.
Methods: The study included 28 patients who had pneumonectomy for benign lung diseases from January 2011 to December 2017. Descriptive analysis was used to present patients' demographics, surgical details, and postoperative outcomes. Intraoperative blood loss was compared in tuberculous vs. non-tuberculous patients and those who had extrapleural vs. intrapleural pneumonectomy.
Results: The study included 11 (39%) males, and the mean age was 36.6 ± 9.8 years (range: 5– 61). The persistent cough was the presenting symptom in 93% of cases, expectoration in 78.6%, hemoptysis in 46.4%, and chest pain in 28.6% of patients. Indications for pneumonectomy were tuberculosis in 13 (46.4%), septic bronchiectasis in 10 (35.7%), invasive opportunistic infections in 3 (10.7%), neglected endobronchial foreign body in 1 (3.6%), and neglected rupture bronchus in 1 (3.6%) patient. Pneumonectomy was left-sided in 21 (75%) patients. We performed extrapleural pneumonectomy in 7 (25%) patients, intra-pericardial isolation in 5 (17.9%) patients, and two patients (7.2%) had completion pneumonectomy. Mean perioperative bleeding was 390.7± 233.8 ml. The intraoperative blood loss was more in patients with tuberculosis and extrapleural pneumonectomy (P< 0.05). Postoperative complications occurred in 7 patients (25%), and we reported one operative mortality.
Conclusions: Pneumonectomy for benign lung disease is a challenging procedure. Destroyed lung due to TB and bronchiectasis are the most common indications. The outcome could be improved with careful patient selection, appropriate preoperative preparation, meticulous operative techniques, and high postoperative care standards
Comparison of automated fastener (Cor-Knot) versus manually tied knots in patients undergoing minimally invasive mitral valve replacement
Full text linkIntroduction: Automated knot fastener has been used in minimally invasive valve surgery to alleviate the longer total operating time and improve outcomes. Their advantages over manual knot tying remain questionable. This study aims to compare automated knot fasteners' efficacy with conventional knot-pushers in minimally invasive mitral valve replacements (MiMVR).
Methods: Between 2016 and 2020, 50 patients underwent isolated mechanical mitral valve replacement via right mini-thoracotomy in rheumatic or degenerative mitral valve disease. The patients were grouped into two groups. Group I (n= 25) included patients who had MiMVR using the Cor-knot device, and Group II (n= 25) had MiMVR using the conventional knot-pusher. Primary endpoints were cross-clamp, cardiopulmonary bypass, and total operative times and the secondary outcomes were paravalvular leak and reoperation. There were no significant differences in the demographic data between the two groups.
Results: Cross-clamp time (79± 1.11 vs. 98.88± 1.34 min; P<0.001), cardiopulmonary bypass time ( 132 (Q1- Q2: 129- 134) vs. 148 (140- 155) min; P<0.001) and operative times ( 206 (203- 209) vs. 228 (223- 234) min; P<0.001) were significantly shorter in Group I. There was no difference in postoperative complications between groups. The early paravalvular leak occurred in one patient (4%) in Group I and required valve re-exploration. In Group II, four patients (16%) had a paravalvular leak; 3 of them were severe and required valve re-exploration (P= 0.35). Transthoracic echocardiography at discharge revealed no evidence of a paravalvular leak in both groups.
Conclusion: Automated fastener device (Cor-knot) could reduce operative times during minimally invasive mitral valve replacement. Operative complications are comparable between both techniques, and follow-up studies are recommended
Minimally invasive approach for the management of right atrial angiosarcoma; A case report
Full text linkCardiac angiosarcoma is a rare primary cardiac tumor. Outcomes of minimally invasive resection of cardiac angiosarcoma are rarely reported in the literature
A male patient aged 28 years old presented with a right atrial mass compressing the superior vena cava and associated with pericardial effusion. Pericardiocentesis was done, and a preoperative workup revealed no distant metastasis. We planned excision of the mass through a right mini-thoracotomy approach. Intraoperatively, we found the mass invading the entire atrial wall thickness, and excision of the mass with a reconstruction of the right atrial wall was performed. Minimally invasive resection of atrial angiosarcoma could be feasible. Atrial angiosarcoma could present with vague signs and symptom
Revisiting Factors that Influence Length of Stay and Wound Infection after Coronary Artery Bypass Grafting
Full text linkBackground: Diabetes is common among patients undergoing Coronary Artery Bypass Grafting (CABG). This study aims to revisit the predictive significance of diabetes, elevated HbA1c, low serum albumin levels, and gender on wound infection and hospital stay after CABG.
Methods: This retrospective study included patients who had CABG from June 2019 to March 2020. We included patients who underwent elective CABG and excluded emergency CABG surgeries and combined surgeries. Elevated HbA1c is defined as an HbA1c level above 5.8%, and the normal range for serum albumin level is at 33-54 gm/L
Results: A total of 87 patients were included, 81 males (93%) and six females (7%) with a mean age of 58 ± 8.5 years. Sixt-eight patients (78%) had diabetes mellitus Type 2 (D.M.). Mean Hb1Ac level was at 8.3 ± 1.8 %; mean preoperative serum albumin level was 34.7 ± 3.3 gm/L, mean postoperative serum albumin level was 16± 0.37 gm/L; preoperative EF of <50% (31%), 50-55% (14%) and >55% (55%). Mean hospital length of stay was 8.3±10.1 days, mean bypass duration was 110.9±35.4 minutes, the mean number of grafts was 3.15±.829; 98% of patients had LIMA to L.A.D. Female gender was a significant predictor of length of stay (coefficient: 4.38 (1.63- 7.13); P= 0.002) and postoperative wound infection (OR: 38.5 (5.35- 276.80); P<0.001).
Conclusion: Females could be associated with increased length of stay and wound infection after CABG. Identifying factors that influence the length of stay and wound infections could facilitate recovery and reduce complications