The Egyptian Cardiothoracic Surgeon (ECTS - E-Journal)
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Surgical Repair versus Conservative Treatment for Moderate Functional Tricuspid Regurgitation in Concomitant with Mitral Valve Surgery
Full text linkBackground: Management of moderate functional tricuspid regurgitation (FTR) secondary to left-sided valve lesion is controversial. The objective of this study was to compare the short-term results of surgical repair versus conservative treatment for moderate functional tricuspid regurgitation in concomitant with mitral valve surgery.
Methods: Our study included 60 patients with mitral valve lesion and moderate functional tricuspid regurgitation. Patients were divided into 2 groups; group A included 30 patients whose tricuspid valve disease were managed conservatively, and group B included 30 patients who had tricuspid valve band annuloplasty.
Results: Preoperative clinical and echocardiographic data were comparable between groups. There was no difference regarding mechanical ventilation time (6 .13 ± 3.02 vs. 7.01 ± 4.14 hours; p= 0.291), or intensive care unit stay (51.42 ± 12.1 vs. 52.31 ± 15.32 hours; p=0.614) in group A and B respectively. There was a significant improvement in the degree of tricuspid valve regurgitation in group B early postoperative (moderate tricuspid regurgitation reported in 22 (73.3%) vs. 4 (13.3%); p<0.001) and at 3 months (moderate tricuspid regurgitation 11 (36.7%) vs. 2 (6.7%); p<0.001) and 6 months follow up (moderate tricuspid regurgitation 10 (30%) vs. 2 (6.7%); p<0.001) in group A and B respectively. After 6-months, 20 (66.7%) patients in group A had dyspnea grade I compared to 26 (86.7%) patients in group B; p=0.021.
Conclusion: Although the correction of the left-sided lesion improved the degree of TR in some patients, concomitant repair of the tricuspid valve could produce better improvement in the clinical outcome when compared to the conservative approach
Percutaneous drainage of delayed post-cardiac surgery pericardial effusion
Full text linkBackground: Pericardial effusion and tamponade are common following valve surgery. The optimal treatment of symptomatic pericardial effusions remains controversial. The objective of this study was to present our experience in non-surgical management of delayed postoperative pericardial effusion.
Methods: This retrospective study was conducted on 64 patients who had delayed pericardial effusion after cardiac surgery from 2016 to 2020. Eight patients were excluded due to the presence of inaccessible posterior or clotted pericardial effusion and were managed surgically, and 56 patients had percutaneous drainage of the pericardial fluid and were included in the analysis.
Results: The mean age was 46.84±11.67 years (range: 22- 68 years), and 46.43% were females. The patients had coronary artery bypass grafting (n= 9), Aortic valve replacements (n= 13), Mitral valve surgery (n= 21), double valve replacements (n= 8) and combined procedures (n= 5). All patients complained of varying degrees of exertional dyspnea. There were statistically significant differences between INR in different cardiac surgeries. Mean INR following mitral valve replacement (4.72±0.63) was significantly higher than in aortic valve replacement patients (3.32±0.34; p<0.001) and aortic valve patients (1.76±0.24; p<0.001). Fifteen patients (26.78%) had a large pericardial effusion. Successful drainage was achieved in all cases. Complications were pneumothorax (n= 2, 3.57%), recurrent effusions (n= 4, 7.14%), arrhythmias (n= 7, 12.5%), myocardial punctures (n= 2, 3.57%) and no mortality was reported.
Conclusions: percutaneous drainage of postoperative pericardial effusion under radiological guidance is generally safe. Pericardial effusion is common after mitral valve surgery, which could be related to higher INR in these patients
Evaluation of the preoperative administration of sildenafil on operative and early postoperative outcome after mitral valve replacement in patients with pulmonary hypertension
Full text linkBackground: Mitral valve diseases are commonly associated with pulmonary hypertension. The aim of this study was to evaluate the effect of preoperative administration of sildenafil on the outcome after mitral valve replacement in patients with pulmonary hypertension.
Methods: This prospective randomized study was carried out on 67 patients who had a mitral valve replacement and associated high systolic pulmonary artery pressure more than 50 mmHg. Patients were randomized into three groups: group A (n= 20) received preoperative sildenafil for one week, group B (n=22) received sildenafil for one month, and group C (n= 25) did not receive sildenafil. All patients had transthoracic echocardiography preoperatively, one week and one month postoperatively.
Results: There was no difference in preoperative and operative variables among groups. Dobutamine support was required in 15 patients (60%) in group C vs. 6 patients (30%) in group A and 5 patients (22.5%) in group B (p= 0.012). Duration of mechanical ventilation was significantly longer in group C (389.2 ± 48.79 minutes) compared to group A and B (295.5 ± 17.01 and 281.4 ± 39.44 minutes, respectively, p<0.001). ICU stay was longer in group C (61.72 ± 13.69 hours) compared to groups A and B (53.55 ± 14.49 and 45.64 ± 13.43 hours, respectively, p=0001). The hospital stay was longer in group C (8.0 ± 1.80 days) compared to group A and B (6.05 ± 0.94 and 6.27 ± 1.24 days, respectively; p< 0.001). The transthoracic echocardiographic study one month after the operation showed that pulmonary artery systolic pressure significantly lower in groups A and B (28.30 ± 3.3 and 28.2 ± 4.98 mmHg, respectively) compared to group C (43.12 ± 4.99 mmHg) (p <0.001). There was no statistically significant difference between groups A and B regarding PASP after five days (p= 0.287) or one month (p= 0.939).
Conclusion: We found that preoperative administration of oral sildenafil in patients with pulmonary hypertension undergoing mitral valve replacement may reduce pulmonary hypertension postoperatively. We could not find a difference in the administration of sildenafil for either one week or one month preoperatively
Early clinical outcome after right anterolateral thoracotomy as an alternative for median sternotomy for mitral valve replacement
Full text linkBackground: The advantages of the right anterolateral thoracotomy (RALT) approach for mitral valve surgery over standard median sternotomy (MS) are still debatable. The objective of this study was to evaluate and compare the postoperative clinical outcome after RALT and MS for mitral valve replacement.
Methods: This prospective observational study included 40 patients who underwent mitral valve replacement between January 2016 and August 2018. Patients were assigned to two groups, the first group included 20 patients who had conventional median sternotomy approach and the second group included 20 patients who had right anterolateral thoracotomy with the complete cannulation and aortic cross-clamping conducted through the same incision.
Results: In comparison to MS, RALT had significantly higher cross-clamp time (77.7±16.1 vs 45.8±8.7 minutes, P < 0.01), total bypass time (105.2±12.7 vs 72.2±10.4 minutes, P < 0.01), and total operative time (287±41 vs 231±36 min, P < 0.01), in addition to significantly lower ventilation time (4.2±1.51 vs 6.1±1.84 hours, P < 0.01), blood loss (229±85 vs 335±137 ml), amount of blood transfusion (1.41±0.6 vs 2.19±1.1 units, P < 0.01), ICU stay duration (2.11±0.49 vs 2.78±0.82 days, P < 0.01), pain scores at 1st and 2nd postoperative days (5.67±0.79 vs 7.81±0.53, p < 0.01), and total hospital stay duration (7.2±1.3 vs 8.4±1.6 days, P = 0.01). Patients' satisfaction about their wound was significantly higher in RALT group compared to MS group (95% vs 30%, P < 0.01).
Conclusion: The RALT approach for mitral valve surgery could be a safe and effective approach when compared to median sternotomy. RALT could be associated with a reduction of blood loss, blood transfusion, wound infection, in addition to shorter ICU and hospital stay
Short-term assessment of left ventricular function after coronary artery bypass grafting
Full text linkBackground: The effect of coronary artery bypass grafting on postoperative left ventricular function is still the subject of ongoing studies. The degree of recovery and its duration have not been precisely determined, and the published data are discordant. The objective of this study was to assess the effect of surgical revascularization on left ventricular systolic function.
Methods: We prospectively studied 50 consecutive patients who underwent elective isolated coronary artery bypass grafting in the period from January 2017 to November 2017. All patients had echocardiography preoperatively, pre-discharge, and at 3 and 6 months postoperatively. Left ventricular end-systolic volume, left ventricular end-diastolic volume, stroke volume, and ejection fraction were measured in all patients.
Results: The mean age was 57.22±7.04 years. The mean number of grafts was 2.60±1.02. Improvement in Canadian Cardiovascular Society (CCS) score from (2.72 ± 1.03) preoperatively to [(0.12 ± 0.39), p<0.001] after six months was achieved. Additionally, improvement in the patient New York Heart Association (NYHA) score occurred from (1.70 ± 0.97) preoperatively to [(0.12 ± 0.33), p<0.001] after six months. A significant improvement in left ventricular function occurred as demonstrated by improvement in mean left ventricular ejection fraction from (54.14±9.80) % to [(62.40 ± 4.18) %, p<0.001] at six months. The mean total hospital stay was 5.62±1.51 days. The mean total intensive care unit length of stay was 47.16±25.73 hours. Two patients (4%) had re-exploration for bleeding, and postoperative myocardial infarction occurred in three patients (6%). One patient (2%) had postoperative neurocognitive dysfunction, and 3 patients (6%) had postoperative atrial fibrillation. Two patients (4%) suffered from superficial wound infection. There was no hospital mortality.
Conclusion: Patients undergoing CABG experienced an improvement in left ventricular contractile function at six months postoperatively. Further studies are required to evaluate the changes after 6 months
Management of Small Aortic Root during Aortic Valve Replacement
Full text linkBackground: Concomitant aortic root enlargement (ARE) increases the risk of aortic valve replacement (AVR). The objectives of this study were to identify the patients who needed aortic root enlargement and compare the outcomes and the risk of adding ARE to AVR.
Methods: We retrospectively reviewed 62 patients who underwent isolated mechanical aortic valve replacement between 2017 and 2019. We divided the patients into two groups: group A included patients with small aortic root who had AVR with one of the different surgical strategies for small aortic annulus (n= 32) and group B, which included patients with a normal aortic annulus and underwent conventional AVR (n= 30). Group A was further sub-divided based on the surgical strategy into 4 categories; patients who had supra-annular implantation of size 19 mm St. Jude prosthetic valve (n= 11; 34.4%), Nicks procedure (n= 13 40.6%), Manougian procedure (n= 4; 12.5%), Konno procedure (n= 4; 12.5%).
Results: Group A patients were significantly younger (26.16 ± 11.49 vs. 34.63 ± 8.9 years; p< 0.001) and had lower body weight (55.09 ± 21.41 vs. 69.80 ± 19.20; p= 0.01). Group A had significantly smaller valves (p = 0.03), and total cardiopulmonary bypass (148.65 ± 44.09 vs. 97.46 ± 20.90 minutes; p<0.001) and aortic cross-clamp times (118.13 ± 36.70 vs. 78.06 ± 16.01 minutes; p < 0.001) were significantly longer in group A. There was no significant difference in operative complications between groups. Among patients with small aortic root; Konno procedure had the longest bypass time (236.3 ± 19.70 minutes; p<0.001); cross-clamp time (192.5 ± 22.2 minutes; p <0.001); mechanical ventilation (4.75 ± 0.50 hours; p<0.001) and intensive care unit stay (6.50 ± 0.57 days; p <0.001). Patients with supra-annular implantation of the St. Jude valve had a significantly higher postoperative pressure gradient (14.64 ± 6.84 mmHg; p= 0.02). No difference in procedure complications was observed among aortic root enlargement procedures.
Conclusion: Patients who had aortic root enlargement procedure were younger, with lower weight and body surface area. Surgical procedures used to manage small aortic root had comparable early results, and no technique was superior to the others
The feasibility of surgical patch osteoplasty in isolated left main coronary stenosis.
No full textBackground: Coronary artery bypass grafting (CABG) is perceived as the most common treatment for left main coronary artery (LMCA) disease with good results compared to left-main stenting or medical therapy. Surgical patch angioplasty (SPA) may present a substitute to the standard CABG in patients with isolated LMCA disease, and it offers physiological antegrade myocardial perfusion, keeps ostial patency and saves bypass material. The objective of this study is to demonstrate the feasibility of patch osteoplasty in patients with isolated LMCA stenosis.
Methods: This is a retrospective study performed on eight patients with angiographically proven ostial or proximal LMCA stenosis who underwent surgical patch angioplasty. Two of them had associated right coronary artery bypass grafting. All patients were performed with cardiopulmonary bypass and saphenous vein patch. An anterior approach with transverse aortotomy was utilized in all cases. Patients were followed-up clinically for a mean period of 14 months (ranging from 26 to 6 months) for recurrence of symptoms and any postoperative complications.
Results: The early postoperative period was uneventful in all patients. No perioperative mortality was reported. Two patients had postoperative atrial fibrillation, and one patient with poor left ventricular function required preoperative intra-aortic balloon pump. Angiography was done in the first three cases, and all showed no restenosis and no vein patch dilatation.
Conclusion: Surgical patch angioplasty may be a safe and suitable alternative to CABG in selected patients with isolated ostial LMCA stenosis. Further studies are needed to compare the results of the SPA with those of standard CABG and LMCA stenting
Left atrial diameter in estimating success rates of radio-frequency ablation treating atrial fibrillation.
Full text linkBackground: Ablation devices are being utilized in surgical procedures treating atrial fibrillation. Few studies seek to define a cut-off value for left atrial diameter size beyond which risks of procedure outweigh chance of sinus recovery. This study aims to identify a cut-off value for pre-operative left atrial diameter to assess the efficacy of surgical radio-frequency ablation for treatment of chronic atrial fibrillation in patients undergoing mitral valve surgery. Methods: A prospective 6-month follow-up cohort study was done, in which 40 patients were recruited during the period from May 2016 till April 2018. All patients had rheumatic mitral valve disease and permanent atrial fibrillation. Receiver operator characteristic (ROC) curves were used to calculate the area under the curve and cut-off value for left atrial diameter. The efficacy of the overall survival time was estimated using the Kaplan‐Meier method. Results: Pre-operatively left atrial diameter of 59 mm was significantly associated with decrease in the possibility of reverting to sinus rhythm after surgery (OR 0.292, p-value = 0.001). The cut-off value for left atrial diameter was 59mm (sensitivity = 93.3%, specificity = 96.1%). Kaplan-Meier survival estimates were 175.07 days (156.3 - 193.9) for patients with left atrial diameter < 59mm and 62.64 days (26.6-98.7) for patients with left atrial diameter > 59mm. Conclusion: In patients undergoing mitral valve, higher degrees of success are associated with smaller left atrial diameter in terms of conservation of the sinus rhythm post operatively