The Egyptian Cardiothoracic Surgeon (ECTS - E-Journal)
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Beating-heart versus conventional mitral valve replacement; a randomized clinical trial
Full text linkBackground: Various methods have been developed to overcome the deleterious effects of ischemia/ reperfusion injury that occurs after cardioplegic arrest. The aim of the study was to assess the safety, efficacy, and applicability of the beating-heart mitral valve replacement (MVR) compared to the conventional MVR.
Methods: Forty patients scheduled for mitral valve replacement were randomly assigned into two groups, conventional MVR as the control group (n= 20) and beating-heart MVR with continuous antegrade coronary perfusion as the study group (n=20). Three patients in the beating-heart group were converted to the conventional technique because of the blood-flooded field and excluded from the analysis.
Results: The preoperative clinical and echocardiographic variables were comparable between both groups. There was no significant difference between both groups regarding cardiopulmonary bypass time (79.4± 14 vs. 75.7± 10.9 minutes; p= 0.398) and total operative time (200± 55.6 vs. 183.9± 67.5 min; p= 0.458) in the conventional and beating-heart group, respectively. Serum troponin I level was significantly higher in the conventional MVR group 6 hours postoperatively (4.9±4 vs. 2.7±1.2 ng/ml; p= 0.036), while there was no significant difference between both groups regarding total CK and CK-MB (p= 0.565 & 0.597 respectively). Eight patients (44%) in the conventional MVR group needed inotropic support compared to 3 patients (19%) in the beating-heart MVR group (P = 0.11). There was no operative mortality or major morbidity in both groups. At 6-months follow-up, there was no difference in NYHA class (1.3±0.3 vs. 1.2±0.3; p= 0.336) and the ejection fraction (60.0±6.3 vs. 63.2±6 %; p= 0.139) in the conventional vs. beating-heart group.
Conclusion: Beating-heart MVR is a safe alternative to the conventional method with comparable outcomes. There is a relatively blood-filled field compared to the conventional technique
The outcomes of Skeletonized and Pedicled Internal Thoracic Artery in Patients undergoing coronary artery bypass grafting: a randomized clinical study
Full text linkBackground: Internal thoracic artery became the cornerstone graft in coronary artery bypass grafting. This study aimed to investigate sternal healing and wound infection in patients undergoing coronary artery bypass graft (CABG) surgery using skeletonized versus pedicled internal thoracic artery.
Methods: 100 patients who underwent isolated CABG were divided into two groups; skeletonized internal thoracic artery (ITA) (50 patients) and pedicled internal thoracic artery (50 patients). The postoperative assessment was performed three months after surgery. Physical and radiological examinations were performed after surgery to assess sternal healing.
Results: There was no significant difference in patients’ demographics between groups. Skeletonized group had more diabetic patients (65% vs 44%; p= 0.016). There was no significant difference between the two groups regarding the number of grafts (2.72 ± 0.89 vs. 2.68 ± 0.90; skeletonized vs pedicled group; p= 0.84). Harvesting time was longer in the skeletonized group (55.69 ± 8.80 vs. 44.28 ± 6.95 minutes; p=0.09). Superficial wound infection occurred more frequently in the pedicled group (24% vs. 8%; p=0.03).
Conclusion: Skeletonization of the internal thoracic artery conduits lowers the risk of superficial and deep sternal wound infection in patients undergoing CABG compared to the pedicled technique. However, skeletonization of internal thoracic artery conduits prolongs the operation time and requires more surgical skills
Antegrade Intermittent Cold Cardioplegia in Comparison to Antegrade Intermittent Warm Cardioplegia in Heart Valve Surgery
Full text linkPaper withdrawn upon authors request:
Request received: 22 May 2020
Paper withdrawn: 22 May 2020
 
Skeletonized versus pedicled left internal mammary artery harvesting and risk of sternal wound infection after coronary artery bypass surgery
Full text linkBackground: The left internal mammary artery (LIMA) is the gold standard conduit for coronary artery bypass grafting (CABG). There are two harvesting methods, either pedicled or skeletonized. The choice of any technique must consider its complication profile, especially sternal wound infections (SWI). This study aims to evaluate and compare the occurrence of SWI after pedicled and skeletonized LIMA harvesting techniques for CABG.
Methods: This prospective observational study included 300 patients who had CABG between 2016 and 2019. We included patients who had pedicled LIMA (n=200) in group 1 and who had skeletonized LIMA (n=100) in group 2. All patients completed a follow-up period of 3 months after CABG. The evaluation during follow-up included: sternal instability, signs of wound infection, temperature, the microbiological study of wound discharge, and chest computed tomography scan.
Results: There was no significant differences in age (p = 0.20), male to female ratio (p = 0.43), body mass index (p = 0.12), NYHA I/II (p = 0.50), diabetes mellitus (p = 0.28), ejection fraction (p= 0.14), and EuroSCORE II (p= 0.09) between groups. No significant difference in cardiopulmonary bypass time (p = 0.24), and cross-clamp time (p= 0.19) between groups. There was a significant increase in the total operating time in skeletonized LIMA group (212.77±75.25 min vs. 190.78±55 minutes, p= 0.004). Skeletonized LIMA was significantly associated lower incidence of SWI than that with pedicled LIMA (4% vs 15.5%, p= 0.003), and non-significantly lower incidence of deep SWI (1% vs 4.5%, p= 0.11). The risk factors for SWI in patients who had pedicled IMA were obesity (OR: 13.06, 95%CI: 3.98-42.89), diabetes mellitus (OR: 10.51, 95%CI: 2.35-46.84), and excessive diathermy (OR: 12.62, 95%CI: 3.93-40.54).
Conclusion: Obesity, diabetes, and the use of excessive diathermy for hemostasis may increase the risk of sternal wound infection with pedicled LIMA harvest compared to skeletonized LIMA in patients undergoing CABG
Chest Wall Tumors: A Spectrum of Different Pathologies and Outcomes of Reconstruction Techniques
Full text linkBackground: Chest wall resection and further reconstruction for tumors represent a challenging concept for surgeons. Thanks to the evolving reconstruction techniques, good results were obtained after extensive resection and reconstruction.
Patients and methods: This prospective cohort study was conducted at our University Hospitals throughout 5 years. A total of 43 eligible cases with chest wall tumors were included. All cases were subjected to a multidisciplinary team approach, complete history taking, physical examination, radiological evaluation, and biopsy. The details of surgical techniques, complications, and follow up parameters were included.
Results: The mean age of the included cases was 29.45 years. We included a total of 24 males (55.8%). Fibromatosis was the commonest encountered pathology (27.9%), followed by chondrosarcoma (25.5%), and osteosarcoma (21%). Regarding the method of reconstruction, polypropylene mesh was used in 46.5% of cases, followed by direct closure (30.2%). Ten cases were managed by Methyl Methacrylate within the proline mesh (23.3%), while superimposed muscle flap was performed in only 2 cases (4.6%). Post-operatively, bleeding was encountered in 5 cases collectively (11.6%), while wound infection occurred in 11.6% of cases. Pulmonary complications included pneumonia (2.3%) and atelectasis (11.6%). Furthermore, chest wall instability was present in (11.6%) of cases. On follow up, recurrence was diagnosed in (9.3%) of cases (n = 4).
Conclusion: Surgical intervention is very effective if tailored to every patient as per team paln. A multidisciplinary team approach is extremely important especially if an extensive demolition is required. Indeed, radical wide en-bloc resection can achieve satisfactory results provided that the extent of resection is not influenced by any anticipated reconstruction problems
Assessment of left atrial function in dilated cardiomyopathy patients using speckle-tracking echocardiography
Full text linkBackground: The available methods to assess left atrial function (LAF) have some limitations as angle dependence and opposite distortion. The objective of the current study was to evaluate LAF in dilated cardiomyopathy (DCM) of ischemic (IDCM) and non-ischemic etiologies (NIDCM) using speckle tracking echocardiography (STE).
Methods: 52 patients with systolic heart failure were included in our study; 27 with IDCM and 25 with NIDCM along with 15 healthy controls. All patients underwent conventional echocardiography, tissue doppler imaging, and speckle tracking echocardiography. The later modality was used to compare left atrial function in IDCM and NIDCM groups.
Results: We found the left atrial maximum volume and the left atrial total emptying volume to be higher in patients with dilated cardiomyopathy compared to healthy patients (52.19 ± 6.01 vs. 21.87 ± 1.69 cm3/m2; p <0.001 and 28.67 ± 4.34 vs. 15.67 ± 2.02 cm3/m2, respectively). Conversely, left atrial emptying index and left atrial active ejection fraction were lower in patients with DCM compared to healthy controls (9.60 ± 2.29 vs. 8.27 ± 3.01 cm3/m2; p< 0.001 and 23 ± 2.56 vs. 37.47 ± 3.54 %; p<0.001, respectively). When comparing the IDCM group with NIDCM patients, we found no significant difference in left atrial maximum volume and left atrial active emptying volume. However, the NIDCM patients had significantly lower left atrial total emptying volume, and left atrial active ejection fraction (8.93 ± 1.86 vs. 9.60 ± 2.29 cm3/m2 and 23 ± 2.56 vs. 31.19 ± 1.66 %; p<0.001). on comparing strain function, DCM patients had lower systolic (28.22 ± 3.84 vs. 60.87 ± 3.07 %, p<0.001), and left atrial systolic strain rate (-2.66 ± 0.45 vs. -3.81 ± 0.35; p = 0.003) compared to healthy controls. All strains and strain rates were significantly lower in NIDCM patients compared to IDCM patients.
Conclusion: STE is a promising method for evaluating LAF in DCM patients. Patients with DCM had significantly lower left atrial systolic and late diastolic strains and strain rates compared to healthy patients. Moreover, NIDCM could be differentiated from IDCM by having more impairment in the LA dynamic reservoir and booster pump function
Diaphragmatic Plication for Acquired Phrenic Nerve Injury after Congenital Cardiac Surgeries
Full text linkBackground: Phrenic nerve injury and diaphragmatic dysfunction are common after pediatric cardiac surgery leading to failure to wean from ventilatory support. Diaphragmatic plication is the standard management of diaphragmatic paralysis. The aim of this retrospective study is to review our experience with diaphragmatic plication and its effect on the operative outcome.
Methods: This retrospective cohort study included all patients who underwent diaphragmatic plication from June 2010 to June 2017. Seventy-six patients (2.87%) had unilateral diaphragmatic paralysis following 2646 congenital cardiac procedures. Sixty-four patients (2.4%) underwent diaphragmatic plication.
Results: The median age for the patients who had plication was 2.75 months (range 0.5- 36) and 3.7 months (range 0.66 to 123) for non-plicated patients. Thirty-six were males (56.25%), and the most common procedure associated with diaphragmatic plication was modified Blalock Taussig Shunt (n= 13; 20.3%). Left-sided diaphragmatic plication was performed in 44 patients (68.7%). The mean time between the primary surgery and diaphragm plication was 6.42±4.51 days. The mean ventilation period before plication was 4.93±3.71 days, and post plication ventilation median time was 2.11±1.82 days. Two patients (3.1%) required tracheostomy for prolonged respiratory insufficiency. One patient (1.6%) needed surgical revision, and two patients (3.1%) had their diaphragmatic plication during the initial surgery.
Conclusion: Diaphragmatic plication is an effective procedure in the management of postoperative diaphragmatic paralysis. We recommend early plication for patients with symptomatic diaphragmatic paralysis causing prolonged ventilatio
Video-assisted Minimally Invasive Mitral Valve Surgery versus Conventional Mitral Surgery in Rheumatic Patients
Full text linkBackground: Minimally invasive mitral valve surgery became an attractive option because of its cosmetic advantages over the conventional approach. The superiority of the minimally invasive approach regarding other aspects is still debatable. The aim of our study was to determine the potential benefits of minimally invasive mitral valve replacement with intraoperative video assistance over conventional surgery.
Methods: This is a single-center prospective cohort study that included 60 patients with rheumatic heart disease who underwent mitral valve replacement. Patients were divided into two groups: group (A) included patients who had conventional sternotomy (n= 30), and group (B) included patients who had video-assisted minimally invasive mitral valve replacement (n= 30). Intraoperative and postoperative outcomes were compared between both groups.
Results: Mortality occurred in one patient in the group (A). Cardiopulmonary bypass time was 118.93 ± 29.84 minutes vs. 64.73 ± 19.16 minutes in group B and A respectively (p< 0.001), and ischemic time was 102.27 ± 30.03 minutes vs. 53.67± 18.46 minutes in group B and A respectively (P < 0.001). Ventilation time was 2.77± 2.27 vs. 6.28 ± 4.48 hours in group B and A respectively (p< 0.001) and blood transfusion was 0.50 ± 0.63 vs. 2.83 ± 1.34 units in group B and A respectively (p< 0.001). ICU stay was 1.73 ± 0.64 days in the group (B) vs. 4.47 ± 0.94 days in group A (p< 0.001). Postoperative bleeding was 353.33 ± 146.77 ml in the group (B) vs. 841.67 ± 302.03 ml in group A (p <0.001). No conversion to full sternotomy was reported in group B. In group (B), two cases (6.6%) required re-exploration for bleeding vs. four cases (13.2%) in group (A) (p=0.67). The hospital stay was 6.13 ± 1.59 days in the group (B) vs. 13.27 ± 7.62 days in group A (p< 0.001). Four cases (13.3%) developed mediastinitis in group A and in the group (B), there was one case of acute right lower limb embolic ischemia.
Conclusion: Video-assisted minimally invasive mitral operations could be a safe alternative to conventional sternotomy with the potential of lesser morbidity and earlier hospital discharge
On-Pump versus Off-Pump Coronary Artery Bypass Grafting in The Surgical Management of High-Risk Patients, A Clinical Randomized Study
Full text linkBackground: Surgical treatment modalities of coronary artery diseases (CAD) include on-pump or off-pump coronary artery bypass grafting (CABG). CABG performed on the beating heart can avoid complications that might occur on cardiopulmonary bypass. Our objective was to compare the effectiveness of on-pump versus off-pump CABG in high-risk patients stratified according to the EuroSCORE scoring system.
Methods: This randomized clinical study included 80 high-risk patients who underwent CABG and assigned into two groups; each contains 40 patients. Patients with valvular affection, ischemic ventricular septal defect or left ventricle and aortic aneurysms, and/or those exhibiting significant neurological pathology were excluded from the study. Study outcomes were blood loss, length of ICU and hospital stay, inotropic use, re-exploration rate, and operative mortality.
Results: The study showed significant higher use of inotropic drugs intra and post-operatively (57.5% vs 40%, p = 0.021), more low cardiac output (12.5% vs 2.5%, p = 0.031), lower blood loss (337±67 vs 498±68 ml, p = 0.01), lower blood transfusion (1.1±0.2 vs 1.2±0.4 unit, p = 0.024), more prolonged ICU stay (4.0±1.6 vs 3.0±0.9 day, p = 0.001) and the higher re-exploration rate (17.5% vs 7.5%, p = 0.035) in the on-pump group. Hospital stay (8.7±2 vs 8.1±1, p = 0.121) and early mortality (7.5% vs 2.5%, p = 0.451) did not differ significantly between the two groups.
Conclusion: Management of coronary artery disease is still challenging, and there is still a place for off-pump CABG in CAD in high-risk patients due to its advantages in the early complications while has the same total hospital stay when compared with on-pump CABG