The Egyptian Cardiothoracic Surgeon (ECTS - E-Journal)
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The Preoperative Use of Levosimendan in Patients undergoing Coronary Artery Bypass Surgery with Low Ejection Fraction
Full text linkBackground: Levosimendan is a calcium sensitizer with positive inotropic, vasodilatory, and cardioprotective actions. Levosimendan infusion time may affect the outcomes. Our objective was to evaluate its efficacy and safety when used before coronary artery bypass grafting (CABG) in patients with low ejection fraction.
Methods: This prospective observational study included 150 CABG patients with ejection fraction ≤ 40% divided into two groups. In the Levosimendan group (n= 75), it was given preoperatively, and in the conventional group (n= 75), myocardial support was used if indicated.
Results: Operative time (344±28.7 vs. 421.4±34.5 min) and cardiopulmonary bypass time (97±17.4 vs. 127.4±24.5) were significantly shorter in the Levosimendan group (P˂ 0.001, for both). Failure to wean from bypass (13 (17.3%) vs. 23 (30.7%), P=0.06) and the need for intra-aortic balloon pump (6 (8%) vs. 14 (18.7%), P= 0.06) were non significantly lower in the Levosimendan group. The mechanical ventilation duration (12±3.3 vs. 19.6±4.7 h, P= 0.04) and ICU stay (3.8±1.2 vs. 5.3±1.4 days, P ˂ 0.001) were lower with levosimendan. Mortality was non-significantly lower in the Levosimendan group (10 (13.3%) vs. 18 (24%), P= 0.09). There were no differences in atrial and ventricular arrhythmias between groups.
Conclusion: The preoperative use of levosimendan could improve the outcomes in patients undergoing CABG with low ejection fraction. Levosimendan complication profile was comparable to the conventional approac
Aortic valve repair in patients with ventricular septal defect or subaortic membrane
Full text linkBackground: The delay in the surgical intervention of subaortic ventricular septal defect (VSD) and subaortic membrane leads to significant damage in the aortic valve, and multiple surgical interventions may be needed. We aimed to describe the pathology of the aortic valve in patients with subaortic membrane or VSD and different surgical strategies to manage the aortic regurgitation in those patients.
Methods: The study included patients who had surgery for subaortic membrane or VSD from 2017 to 2021. We reviewed strategies and surgical techniques to deal with aortic regurgitation in patients with subaortic membrane or VSD and the short and midterm outcomes.
Results: Twelve cases were included in the study; 5 cases had subaortic membrane, and 7 cases had subaortic VSD. The age ranged from 1.5 to 10 years old. Postoperative follow-up ranged from 1 to 3.5 years. We performed sub-commissural stitches and peeling of the leaflets to correct residual regurgitation. Four patients with subaortic membrane achieved satisfactory outcomes, and one patient had severe aortic regurgitation. Two patients with VSD had progression of the aortic regurgitation. Patients with failed repair had severe prolapse and thickening of the valve.
Conclusion: Severe prolapse and dense thickening of the valve were difficult pathologies to repair. The sub-commissural stitches could be mandatory to achieve good midterm results. Complete freeing and peeling of the leaflets till restoring the natural appearance is crucial
The value of pericardial window in preventing pericardial effusion after cardiac surgery
Full text linkBackground: Pericardial window (PW) is a technique that allows the passage of fluid from the pericardial to the pleural cavity to reduce the postoperative pericardial effusion. The purpose of this study was to evaluate the effectiveness of the pericardial window in decreasing pericardial effusions after cardiac surgery.
Methods: The study included 400 adult patients who underwent cardiac surgery from 2017 to 2020. Patients were randomly assigned into two groups; the pericardial window (PW) group included 200 patients who underwent posterior pericardiotomy, and the control group included 200 patients who did not undergo this procedure.
Results: Preoperative data were comparable between both groups. More patients in the PW group had chest tube drainage more than 500 cc/ 24 hours (40 (20%) vs. 5 (2.5%), respectively; p=0.005). The drainage of 500 cc/24 hours or more in the mediastinal tube was lower in the PW group (10 (5%) vs. 40 (20%) patients in the PW and control groups, respectively; p<0.001). Early pericardial collection occurred in 6 patients in the PW group (3%) vs. 46 (23%) in the control group (p<0.001), and no patient had late effusion in the PW group vs. 26 (13%) in the control group (p< 0.001). Six patients in the PW group (3%) had postoperative atrial fibrillation and 12 patients (6%) in the control group (p= 0.23). Pulmonary complications were nonsignificantly higher in the PW group (Lung collapse: 40 (20%) vs. 26 (13%); p=0.08 and pleural effusion: 34 (17%) vs. 26 (13%); p= 0.3, in the PW vs. control groups, respectively).
Conclusion: Posterior pericardiotomy is a simple technique that could reduce postoperative pericardial effusion, atrial fibrillation, and the pericardial tamponade. The technique did not increase the postoperative complications compared to the standard method
Right mini-thoracotomy versus median sternotomy for mitral valve replacement
Full text linkBackground: The advantages of minimally invasive mitral valve surgery over the conventional approach is still debated. This study aimed to evaluate early outcomes after mitral valve replacement (MVR) using the right mini-thoracotomy (RMT) versus median sternotomy (MS).
Methods: We prospectively included 60 patients who had MVR from May 2015 to June 2017. We classified patients into two groups; Group A (n= 30) had RMT, and Group B (n= 30) had MS. Postoperative pain score, wound satisfaction, and clinical and echocardiographic outcomes were compared between both groups.
Results: The mean age was 39.90 ± 12.34 years in Group A and 45.75 ± 13.10 years in Group B (p= 0.08). Preoperative and echocardiographic data showed no statistical significance difference between the groups. Group A had longer aortic cross-clamp (118.85 ± 40.56 vs. 70.75 ± 24.81 minutes, p<0.001) and cardiopulmonary bypass times (186.70 ± 67.44 vs. 104.65 ± 42.60 minutes, p<0.001). Group B had more blood loss (565 ± 344.3 vs. 241.5 ±89.16 ml/24 hours, p<0.001). The median pain score was 1 (range: 1- 3) in Group A and 4 (2- 8) in Group B (p<0.001), and the median wound satisfaction was 1.5 (1- 4) in Group A and 4 (1- 7) in Group B (p<0.001). Wound infection occurred in 1 (3.3%) patient in Group A and 6 (20%) patients in Group B (p=0.04).
Conclusion: Mitral valve replacement through the right mini-thoracotomy could be a safe alternative to median sternotomy. The right mini-thoracotomy was associated with longer operative times but better pain and wound satisfaction scores and lower wound infection
Predictors of Failure after DeVega Repair for Functional Tricuspid Regurgitation
Full text linkBackground: Untreated tricuspid regurgitation during mitral valve surgery may progress to severe symptomatic tricuspid regurgitation. Concomitant repair may increase the operative risk; however, re-operative tricuspid valve surgery is a high-risk procedure. This study's objective was to identify the predictors of DeVega repair failure in patients with functional tricuspid regurgitation and concomitant mitral valve surgery.
Methods: This research is a retrospective comparative study that included 140 patients who underwent tricuspid valve repair concomitant with mitral valve replacement. We divided the patients into two groups; the first group (n=106) included patients with no DeVega failure at six-months follow-up (The sustained repair group). The second group included 34 patients who developed moderate or higher TR after the DeVega and was named the failed repair group.
Results: The demographic data and comorbidities were not statistically different between both groups. The preoperative atrial fibrillation (73 (69%) vs. 30 (88%)’ p= 0.027) pulmonary artery pressure (64.8±3.6 vs. 81±6.5 mmHg; p= 0.02), right ventricular dimension (4.85±0.24 vs. 5.23±0.37 cm; p= 0.03), and time between the indication of surgery and operation (8.3 ± 3.1 vs. 14.7 ± 5.4 months; p = 0.003) were higher in patients with failed DeVega repair. There was no statistically significant difference regarding the mean bypass time, cross-clamp time, ICU and hospital stay, and postoperative complications between both groups. Predictors of failure after six months were preoperative heart failure (OR: 15.4 (95% CI: 3- 92.3); p= 0.003), long time between diagnosis and surgery (OR: 12.3 (95% CI: 2.1- 84.7); p= 0.007), and postoperative severe pulmonary hypertension (OR: 24.7 (95% CI: 3.1- 199.6); p= 0.003).
Conclusions: DeVega repair is associated with a high failure rate after six months. The study of predictors of failure could change our management plans to reach the best results for repair
A Clinical Score to Predict Acute Renal Failure after Cardiac Surgery in Egypt
Full text linkBackground: Acute Kidney Injury (AKI) after cardiac surgery is a serious complication. AKI could occur in 30% of patients, and 1-5% develop severe kidney injury. The present study aimed to evaluate the use of the Cleveland Clinic Score (CCS) to identify patients at higher risk of AKI after cardiac surgery.
Methods: This study included 100 patients, 83 were males, and the mean age was 52.47±11.3 years. All patients had elective operations; 30% had isolated valve surgery, 64% had isolated coronary artery bypass grafting (CABG), and 6% had combined CABG and valve operation.
Results: Creatinine serum level ranged between 0.5-2 mg/dL with a mean of 0.98±0.32 mg/dL. Seventy-four patients had good renal function postoperatively, and their CCS was 1.45±0.36, while 26 patients had renal impairment, and their CCS was 12.5±0.44 (P= 0.001). Patients who had AKI were older (62.87±8.7 vs. 49.9±13.9; P<0.001) and had higher preoperative creatinine (1.1±0.32 vs. 0.94±0.31; P= 0.03). AKI was more common in diabetics (23 (88.5%) vs. 28 (37.85, P<0.001) and patients with COPD (6 (23.1%) vs. 3 (4.1%); P= 0.004). CCS score was significantly higher among the different degrees of severity of AKI.
Conclusion: Cleveland Clinic Score could be good for predicting acute kidney injury after cardiac surgery
Comparative study between aortic valve replacement through full sternotomy versus mini-sternotomy
Full text linkBackground: The superiority of minimally invasive aortic valve replacement (AVR) over the standard approach is the subject of ongoing research. The aim of this study was to compare the outcomes of AVR through full sternotomy versus mini-sternotomy.
Methods: We included 60 patients who had AVR; 30 patients underwent AVR through J- or T-shaped mini-sternotomy, and 30 patients had a full sternotomy. We included patients who had isolated AVR and excluded patients who had a concomitant cardiac procedure, redo surgery, or those who needed annular dilatation. All patients had aortic and right atrial cannulation for cardiopulmonary bypass. Study endpoints were operative times, postoperative complications and duration of ICU and hospital stays.
Results: There were no differences between the two groups preoperatively. Cardiopulmonary bypass time was longer in the mini-sternotomy group (median: 100 (range: 65- 170) vs. 85 (55-160) min, respectively; p= 0.024). Operative time was non-significantly longer in the mini-sternotomy group 5 (4-6) hours vs. 4.5 (4-6) hours in the full sternotomy group (p=0.62). Ventilation time was 10 (4- 50) hours in the mini-sternotomy group vs. 14 (8- 45) hours in the full sternotomy group (p<0.001). ICU stay was shorter in the mini-sternotomy group (2 (1-6.5) vs. 2.5 (1-7) days, respectively, p= 0.014). The total mediastinal drainage was 100 (50 400) ml in the mini-sternotomy group vs. 275 (50- 1000) ml in the full sternotomy group (p= <0.001). There was no difference in wound infection (p= 0.35), tamponade (p˃0.99), and hemothorax (p˃0.99) between both groups.
Conclusion: Mini-sternotomy AVR had longer cardiopulmonary bypass times; however, there were no differences in the postoperative complications compared to the full sternotomy approach. Mini-sternotomy could be a safe alternative approach to the full median sternotomy for aortic valve replacement
Heparin versus No Heparin before Endoscopic Vein Harvesting using Angioscopy
Full text linkBackground: Endoscopic vein harvesting (EVH) became a standard technique with several advantages over open vein harvesting (OVH). Thrombus formation inside the vein lumen is one of the main concerns after EVH. It is not known whether heparin use before EVH could prevent this complication. The study aimed to assess the safety of not giving intravenous heparin before starting the open system EVH procedure using the PeriVu™ Disposable Angioscopy (LeMaitre® VASCULAR- France) as a modality to assess the intraluminal vein clots.
Methods: This research is a randomized study that compared two groups of patients undergoing CABG. One group had 2500 IU heparin before EVH using (Virtusaph plus, Terumo) (n=50) and the other group had EVH without giving heparin (n=50). Intraluminal clots in the vein segments were evaluated using PeriVu Disposable Angioscopy ( LeMaitre-VASCULAR).
Results: Preoperative data were comparable between groups with no statistically significant difference. The mean duration of the procedure in the heparin group versus the non-heparin group was 30.6±5.8 and 28.7±5.9, respectively (P= 0.11). Intraluminal clots were detected in two segments out of 103 segments (1.94%) in the No heparin group, while none was detected in the heparin group (P= 0.24).
Conclusion: There was no difference between heparin versus no heparin during endoscopic vein harvest regarding intraluminal thrombus formation. Further studies are recommended to confirm our findings
Fascist Modernism in Italy.:Arts and Regimes.
No full textDrawing on a wide-ranging set of modernist journals and artefacts - spanning public building, newsreels, artworks and novels -, this book explores how the Italian Fascist regime’s participation in an aesthetic movement (modernism) and in its transformation into a social phenomenon (modernization) created a distinctive system of the arts, which, in the 1930s, also had a profound influence across the whole of Europe. During the Ventennio, the Italian Fascist regime created totalitarian aesthetic apparatuses together with new forms of social and cultural patronage for the control of the individual/citizen in the social sphere, seeking mass consensus and the constitution of the ‘new man/woman’ as the foundation of a modern collective social identity. In its claims, the regime adopted modernist aesthetics, albeit not unproblematically, as the privileged paradigm for the modernization of the public sphere, while understanding modernity as a progressive as well as reactionary force. If on the one hand, the specific value of Fascist arts consisted in their capacity to shape the collective, social identity of the new individual; on the other hand, Italian modernist literary and cultural reviews engendered productive aesthetic and cultural debates questioning primarily but not exclusively the role of the arts in relation to the political and cultural doctrine of the totalitarian state. Despite their different ideological orientations, the official debate on state art as well as that on liberal arts shared a similar concern: the imperative of using the arts as a platform for fostering social modernisation in the civic sphere to accommodate the new Fascist man/woman. Realism in particular was the key aesthetic principle for such a construction and for creating a new national novel embedded within the international field. Contrary to many existing studies, this one does not treat modernism exclusively as either a literary or a strictly cultural endeavour. Rather, it is understood as sets of aesthetic activities and artefacts, which are largely, but not exclusively, based on rationalist principles. Such principlesare shaped in the total work of art, which was designed to represent modern forms of total power and technologies different from those championed by the avant-gardes. In the 1920s and 1930s, the total work of art found its implementation in: 1) the new theorization of the relationship between subjectivity and objectivity; 2) the sacralisation of the new man’s total politics though the arts; 3) the construction of the new man’s urban reality; 4) the new man’s/citizen’s media manipulation; and 5) the legitimization of the artist/intellectual participation in the civic sphere.In the theory and the practice of the modernist/Fascist dialectics of modernity andmodernization, architecture, the novel, the visual arts, realism, newsreels, and the futurist avant-gardes functioned for the regime and for Italian writers, artists and intellectuals, as core drivers for building a new society. We thereforeargue that these debates and artistic expressions were of key importance for the existence of the regime, for they played a foundational role in shaping the aesthetics orientations of Italian culture, in creating its transnational profile, and in strengthening the power of the arts during political repression.<br/