The Egyptian Cardiothoracic Surgeon (ECTS - E-Journal)
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Partial versus Full Sternotomy for Aortic Valve Replacement
Full text linkBackground: Minimal invasive approaches are used more frequently for aortic valve replacement (AVR). This study aimed to compare the outcomes of both minimally invasive upper mini-sternotomy and full sternotomy for AVR.
Methods: 100 patients with isolated aortic valve disease were enrolled in this prospective observational study. We grouped the patients according to the technique, group A (n=40) underwent upper J-shaped mini-sternotomy, and group B (n=60) underwent full sternotomy. Study endpoints were operative times and pain score.
Results: The mean age of the patients was 46.4±10.1 years. There was no difference in preoperative data between both groups. There was a significant difference in aortic cross-clamp time (87.2± 8.6 vs. 59.2± 6.6 min in group A and B, respectively, p= 0.001), and total bypass time (115.1± 9.2 vs. 75.3± 4.3 min in group A and B, respectively, p= 0.001) between both groups. The total operative time was 341±11.7 and 196.1±18.4 min in groups A and B, respectively (p= 0.001). The ICU stay was 29.4±8.2 hours in group A and 41.2±13.3 hours in group B (p= 0.001). Patients who had mini-sternotomy had lower pain (p= 0.001) and better patient satisfaction score (p< 0.001).
Conclusion: J-shaped upper mini-sternotomy is a safe and effective strategy for aortic valve replacement. The procedure may be associated with decreased pain and comparable morbidity to the conventional approach
Central extracorporeal membrane oxygenation as a bridge to recovery in patients with myocardial stunning after coronary artery bypass grafting
Full text linkBackground: The role of central extracorporeal membrane oxygenation (ECMO) post coronary artery bypass grafting (CABG) in older patients is debatable. The objectives of our study were to investigate the role of central veno-arterial (V-A) ECMO as a bridge to recovery in patients with myocardial stunning after CABG and its effect on mortality in this group of patients.
Methods: Seventy-five patients had central ECMO as a bridge to recovery after CABG because of myocardial stunning; 45 of them (60%) had survived (group 1), and mortality occurred in 30 patients (40%) (group 2). Preoperative risk factors such as hypertension, stroke, and renal failure were comparable between groups. In non-survivors, left main disease was more common (19 (63.3%) vs. 13 (28.9%); p= 0.003) and SYNTAX score was higher (Median 33 (25th- 75th percentiles); 33 (29- 35) vs. 26 (25- 32); p< 0.001).
Results: Cross-clamp time was shorter in group 1 (58 minutes; (52-62) vs 115.5 minutes; (84- 161) in group 2; p< 0.001). Cardiopulmonary bypass time was shorter in group 1 compared to group 2 (83; (70-90) vs. 155.5; (60 -120) minutes; p< 0.001). ECMO duration was longer in group 2 (6 days; (6-7) vs. 3 days; (3-4); p<0.001). Stroke occurred in 10 patients (33.33%) in group 2 vs. 1 patient (2.22%) in groups 1; p< 0.001. Longer cross-clamp (OR: 1.61, 95% CI: 1.11- 2.31, p= 0.011) and bypass time (OR: 1.76; 95% CI: 1.57- 1.99; p= 0.048) predicted postoperative mortality.
Conclusion: Central ven-arterial extramembrane oxygenation can be used as a bridge to recovery in patients with stunned myocardium post coronary bypass grafting, especially in centers where heart transplantation and ventricular assist devices are not available
Timing of Coronary Artery Bypass Grafting Surgery after Acute Myocardial Infarction
Full text linkBackground: Optimal timing for CABG surgery after myocardial infarction remains a matter of debate. The aim of our study was to analyze the effect of timing of CABG after acute myocardial infarction on operative mortality and morbidity.
Methods: This prospective study included 60 patients who underwent isolated CABG within 30 days of acute myocardial infarction over 20 months (from the first of November 2014 till the end of June 2016) in Kasr Al-Ainy University Hospitals. Patients were divided into two groups; the early group (0 – 3 days) included 14 patients (23.3%) and the late group (4 – 30 days) included 46 patients (76.7%). The primary outcome was all-cause hospital mortality.
Results: Our study included 43 males (71.7%) and 17 females (28.3%). The mean age was 58.4 ± 7.3 years. The total mortality rate was 8.3%. Patients undergoing early CABG experienced a higher mortality rate than those undergoing late CABG (21.4% vs 4.3%, P = 0.043). Also, early CABG was associated with more postoperative complications. Cardiogenic shock and early CABG were independent risk factors of mortality.
Conclusion: CABG in the first 3 days after acute myocardial infarction was associated with high mortality and morbidity in comparison with late CABG. This suggests that CABG may best be deferred for more than 3 days after acute MI in non-urgent cases
Sternal healing after bilateral internal mammary arteries use for Coronary artery bypass grafting in diabetic Patients; short-term results
Full text linkBackground: Bilateral internal mammary artery (BIMA) use may improve long-term outcomes after coronary artery bypass grafting (CABG); however, the risk of infection is high. Skeletonization of the internal mammary may decrease the risk of infection, especially in patients with diabetes. Our study aimed at evaluation of sternal healing in diabetic patients with different techniques of bilateral internal mammary artery harvesting.
Methods: This prospective randomized study included 200 diabetic patients who underwent CABG using BIMA between 2017 and 2019. We divided patients into two groups; Group A had skeletonization of both internal mammary arteries, and Group B had pedicled left mammary and skeletonized right mammary. Patients were observed for three months, post-operatively for any sternal wound problems.
Results: There was no significant difference regarding the baseline variables. Type I diabetes mellitus was present in 25% in group A (n= 24) and 13.64% in group B (n= 12) (p= 0.324). There was no difference in harvest time between groups (83 ±4 vs. 81 ±3 minutes in group A vs. B, respectively. P= 0.1). The mean number of grafts was 3± 0.5 in Group A and 3± 0.6 in Group B (p= 0.8). Postoperative drainage was 402.9 ± 174.1 ml in Group A vs. 387.2 ± 153.6 ml in Group B (p= 0.474). The duration of ICU stay did not differ significantly between groups (2± 0.7 in Group A vs. 2± 0.5 in Group B; p= 0.8). Deep sternal wound infection occurred in 4.17% in group A (n= 4) and 4.55% in group B (n= 4) (p= 0.705). Superficial wound infection occurred in eight patients in group A (8.33%) and eight patients in group B (9.1%) (p= 0.59). No patient had sternal dehiscence in group A vs. four patients in group B (4.55%) (p= 0.39).
Conclusion: We did not find differences between bilateral mammary artery harvest with skeletonization of both arteries versus skeletonization of the right mammary only on sternal healing nor wound infection in diabetic patients undergoing CABG. A larger study is recommended
Single versus bilateral chordo-papillary apparatus preservation in mitral valve replacement: a hemodynamic study
Full text linkBackground: It has been postulated that disruption of the mitral valve apparatus at the time of mitral valve replacement (MVR) is a risk factor for postoperative ventricular dysfunction. The aim of this study was to evaluate the effect of single versus bilateral chordo-papillary preservation on the left ventricular function in comparison to no preservation.
Methods: This study was conducted from 2015 to 2018 on sixty patients who had MVR. The patients were classified into group I included 20 patients who underwent MVR with complete excision of the subvalvular chordae and tips of papillary muscles, group II: included 20 patients who underwent MVR with preservation of posterior chordo-papillary apparatus, and group III: included 20 patients who underwent MVR with preservation of both posterior and anterior chordo-papillary apparatus.
Results: There were 20 males (33.3%), and the mean age was 48.76± 8.91 years. Patients in group III were significantly older (37.15 ±4.92, 39.8 ± 5.49, and 57.25 ± 6.93 years in groups I, II, and III, respectively; p< 0.001). The left ventricular end-diastolic (5.40 ±0.34, 4.96 ± 0.43, and 4.44 ± 0.55 mm in group I, II and III, respectively, p<0.001) and end-systolic diameter (4.33 ±0.48, 3.58 ±0.43 and 3.20 ±0.43 mm in group I, II and III; respectively, p<0.001) were significantly reduced in partial and complete preservation groups after 6 months. Left ventricular ejection fraction improved in the bilateral preservation and partial preservation groups after 6 months (45.32 ±9.78, 56.79 ±10.14, and 56.60 ±11.68 % in groups I, II and III respectively, p<0.001). Mechanical ventilation was significantly longer in group I (24.10 ± 6.6, 16.80 ± 5.97, and 15.80 ± 5.24 hours in groups I, II and III, respectively, p<0.001) and the duration of ICU stay was significantly longer in group I (78.65 ± 15.32, 65.40 ± 14.21, and 60.20 ± 12.58 hours in groups I, II and III, respectively, p<0.001).
Conclusion: Preservation of the annulo-papillary continuity may preserve left ventricular geometry and performance. Total preservation of chordae could be superior to partial preservation with better left ventricular remodeling and improvement in the left ventricular functions
Sutureless Perceval versus Bioprosthetic Aortic Valve, Single Center Experience
Full text linkBackground: High-risk patients are currently presenting for aortic valve replacement (AVR). Sutureless valves may decrease the operative risk in those patients. The objective of this study was to compare the short-term and one-year follow-up results of the sutureless Perceval valve versus bioprosthetic aortic valve.
Methods: The data of patients who underwent elective AVR with bioprosthesis were collected From March 2012 to March 2017. The patients were divided into two groups; group 1 included the patients who had a sutureless aortic valve (Perceval) (n= 25; 3.57% of total AVR patients), and group 2 included patients who had conventional bioprosthesis (n= 50; 7.1% of total AVR patients).
Results: The median age of patients in group 1 was 67 years (25th- 75th percentiles; 64-71), and in group 2 was 66 years (25th- 75th percentiles: 63 to 69). There is no significant difference in the patients’ comorbidities between the two groups. The median duration of the ischemic time was significantly lower in group 1 (33 (25th- 75th percentiles: 32- 35) vs. 60.5 (58- 66), respectively; p< 0.001). Perceval valve was used more commonly in patients who had minimally invasive AVR (n= 21 (84%) in group 1 vs. 11 (22%) in group 2; p<0.001). Postoperative complications were comparable between both groups. The early paravalvular leak was non-significantly higher in group 1 (12% vs. 2%; p= 0105). The mean postoperative gradient was lower in group 1 (7 (7-9) vs. 10 (8-12) mmHg; p<0.001). The changes in valvular gradient were not significantly different between both groups (p= 0.5). The hospital stay was lower in patients received Perceval valve (Coefficient: -1.3; 95% Cl: -2.3- -0.29; p=0.012)
Conclusion: Sutureless aortic valve (Perceval) is a new surgical technique for AVR, with potential advantages of reducing cross-clamp time and a subsequent reduction in myocardial ischemia, duration of cardiopulmonary bypass, and maintaining satisfactory hemodynamic outcomes through reducing patient prosthesis mismatch. All these advantages could help in decreasing postoperative hospital stay. 
Effect of Alpha-Lipoic Acid on Atrial Fibrillation after Open Heart Surgery
Full text linkBackground: Postoperative atrial fibrillation (POAF) is associated with increased morbidity and mortality, and an inflammatory process is involved in its pathogenesis. We aimed to study the possible effect of alpha-lipoic acid (ALA) as an antioxidant on atrial fibrillation after cardiac surgery.
Methods: The study included ninety patients who underwent cardiac surgery, either valvular or coronary artery bypass grafting using cardiopulmonary bypass, and were randomized into two groups: Control and ALA groups. Blood samples were obtained to measure preoperative and postoperative levels of malondialdehyde (MDA), glutathione, C-reactive protein (CRP) and interleukin-6 (IL-6). The patients were monitored for the occurrence of atrial fibrillation until the day of discharge.
Results: POAF occurred in 33% in the control group versus 11% in the ALA group (p=0.011). When compared to the control group, ALA significantly decreased the postoperative levels of MDA (4.78±0.91 vs. 5.36±1.03 nmol/ml; p= 0.006) CRP (19.44±3.14 vs. 26.56±6.29 mg/dl; p <0.001) and IL-6 (22.25±2.2 vs. 25.37±2.5 pg/ml; p< 0.001) while glutathione level increased significantly in patients who received ALA (26.4±4.59 vs. 23.44±5.11 mg/l; p= 0.005).
Conclusion: ALA may help in the prevention of atrial fibrillation following cardiac surgery through exerting antioxidant and anti-inflammatory effects
Off-pump coronary bypass grafting with or without the use of intracoronary shunts
Full text linkBackground: There is scarce literature comparing the role of the intracoronary shunt during off-pump coronary artery bypass grafting (CABG). This study aimed to compare off-pump CABG using intracoronary shunt versus the coronary clamp during distal coronary artery anastomosis.
Methods: We conducted this randomized study between January and June 2018. We randomized 30 patients into two groups. Group A (n= 15) included patients who had coronary clamping during off-pump CABG, and Group B (n= 15) included patients who had intracoronary shunt during off-pump CABG. Study endpoints were anastomosis time and postoperative cardiac enzyme levels.
Results: The mean age of the shunt group was higher than the mean age of the clamp group (61.06 ± 7.26 vs. 56.72 ± 12.44, respectively, p=0.03). Our study showed no statistical difference between the two groups regarding sex (p˃0.99), hypertension (p˃0.99), and diabetes (p=0.14). The distal anastomosis time was longer in the shunt group than in the clamp group (39.80±4.55 vs. 32.27±6.06 minutes, respectively, p=0.001). The postoperative troponin I (0.61±0.11 vs. 0.26±0.089 ƞg/ml, p<0.001), and CK-MB levels (44.27±5.34 vs. 35.5±4.86 IU/L, p<0.001) were significantly higher in the clamp group.
Conclusion: The intracoronary shunt could be associated with lower cardiac enzyme release compared to the clamp technique. However, it was associated with a longer distal anastomosis time
Routine versus selective plasma exchange before thymectomy in myasthenia gravis
Full text linkBackground: Prethymectomy plasma exchange may improve the outcome of surgery; however, the technique is associated with an increased risk of complications. Therefore, the objective of this study was to compare selective versus routine plasma exchange before thymectomy in patients with myasthenia gravis.
Method: We conducted a prospective multi-center cohort study to compare two protocols for plasma exchange before thymectomy. We compared the routine plasma exchange in all patients undergoing thymectomy for myasthenia gravis (group I; n= 30) versus selective exchange (Group II; n= 30). Endpoints were the duration of postoperative mechanical ventilation, plasma exchange, and operative complications.
Results: There was no difference in age between both groups (30± 10.1 vs. 29± 9.2 years in Group I and II, respectively; p= 0.69). There were 17 females in Group I (56.67%) vs. 16 in group II (53.33%) (p= 0.8). Comorbidities are comparable between groups. All patients preoperative pyridostigmine, and 27 patients (90%) in Group I and 26 patients (87%) in Group II received glucocorticoids. There was no difference in pulmonary function tests between groups. Plasma exchange related complications were not different between groups. Immediate extubation was achieved in 29 patients (97%) in Group II, and after 6 hours in one patient (3.33%). In Group I, 28 patients (93%) extubated immediately, and two patients were ventilated for 7-12 hours. The mean ICU stay was 1.5 days in Group I and 1.4 days in group II (p= 0.615). The mean hospital stay was 8.5 days in Group I and 9.2 days in group II (p= 0.118). There was no significant difference in pathology between groups (p= 0.137).
Conclusion: Selective plasma exchange is feasible before thymectomy for myasthenia gravis. Selective plasma exchange may decrease exchange related complications without affecting the operative outcomes
The relation between the timing of coronary angiography and renal function post coronary artery bypass grafting
Full text linkBackground: Acute kidney injury is a serious complication after coronary artery bypass grafting (CABG). This work aimed to assess the impact of the timing of coronary angiography on kidney function after on-pump coronary artery bypass grafting.
Methods: We included 60 patients who underwent elective isolated on-pump coronary artery bypass grafting from 2017 to 2018 at the National Heart Institute and Benha University Hospital. We divided the patients into two groups; group І included 30 patients with coronary angiography performed less than seven days prior to CABG, and Group ІІ included 30 patients who had coronary angiography more than seven days prior to CABG. Postoperative acute kidney injury was defined according to the consensus kidney disease: Improving Global Outcomes Definition and Staging criteria.
Results: The mean body mass index was significantly higher in group I (35.89±5.15 Kg/ m² vs. 31.72±4.99 Kg/ m², P = 0.002). The mean preoperative hemoglobin was higher in group II (12.7 ± 1.5 g/dl vs. 13.9 ± 1.5 g/dl, P = 0.004). The frequency of acute kidney damage was higher in patients who had coronary angiography less than seven days before CABG but did not reach a significant level (46.7 % vs. 30%, P =0.184). There was no difference in the creatinine postoperatively between both groups (1.2 ±0.5 vs. 1 ±0.3 mg/dl; p= 0.214).
Conclusions: We found no association between the timing of coronary angiography before on-pump coronary artery bypass graft surgery and postoperative acute kidney injury