The Egyptian Cardiothoracic Surgeon (ECTS - E-Journal)
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Postoperative Arrhythmia after Total Arterial Coronary Artery Bypass Grafting
Full text linkBackground: Atrial fibrillation (AF) is the most prevalent arrhythmia occurring after cardiac surgery. The occurrence of postoperative AF (POAF) significantly affects patient outcomes, leading to increased morbidity, mortality, and hospital readmission rates. The incidence of POAF following total arterial coronary artery bypass grafting remains a subject of ongoing debate. This study seeks to evaluate the occurrence of early postoperative arrhythmias in patients undergoing total arterial revascularization.
Methods: We studied a cohort of 50 patients who underwent total arterial revascularization at the Cardiothoracic Surgery Department of Benha University Hospitals between October 2023 and October 2024. Data were collected preoperatively and postoperatively, encompassing demographic information, laboratory results, and both intraoperative and postoperative parameters.
Results: The average age of the study population was 52.5 years, with a predominance of male patients. The incidence of postoperative arrhythmias was recorded as follows: 6% for self-contained AF, 6% for uncontrolled AF, 2% for ventricular fibrillation, and 4% for premature ventricular contractions. The mean duration of bypass was 154.9 minutes, and the average length of stay in the intensive care unit (ICU) was 2.1 days. Postoperative complications included wound infections in 28% of patients, and the mortality rate was 4%.
Conclusions: Early postoperative arrhythmias pose a significant concern following total arterial revascularization. Identifying and managing risk factors associated with these arrhythmias could enhance patient outcomes, decrease complications, and ultimately contribute to improved survival and quality of life for individuals undergoing cardiac surgery
Doppler Flowmeter Is a Valuable Tool for Prevention of Early Postoperative Myocardial Infarction
Full text linkBackground: Early postoperative myocardial infarction (MI) remains a critical complication following coronary artery bypass grafting (CABG). The intraoperative use of Doppler flowmetry could improve outcomes by ensuring optimal graft patency and flow. This study evaluated the effect of Doppler flowmetry on early postoperative MI in patients undergoing CABG.
Methods: This double-blinded, randomized controlled study included 120 patients who underwent elective CABG. Patients were divided into two equal groups: Group A underwent CABG with Doppler flowmetry, and Group B underwent CABG without Doppler flowmetry. The patients' ages ranged between 45 and 60 years old, with no difference in gender distribution between groups. The primary outcomes were early postoperative arrhythmias and echocardiographic parameters. Secondary outcomes included mechanical ventilation duration, ICU stay, and complication rates.
Results: There was no difference in postoperative arrhythmias between groups (P= 0.142). Postoperative regional wall motion abnormalities occurred in 90% of Group B versus 5% of Group A (P < 0.001). Difficult weaning (10 (16.7%) vs. 25 (41.7%); P= 0.003), longer ventilation time (8 ±3 vs. 17 ±7 h; P<0.001), and prolonged ICU stay (3 (3 – 10) vs. 5 (2 – 9) days; P<0.001) were all significantly higher in Group B than that of group A. Infection and re-exploration rates were significantly higher in Group B (13.3% and 25%) than in Group A (1.7% and 6.7%) (P = 0.032 and P = 0.006, respectively). The cross-clamp time and total circulatory time were shorter in Group A (55 ± 6 minutes and 87 ± 12 minutes) than in Group B (89 ± 12 minutes and 110 ± 17 minutes) (P < 0.001). Multivariable logistic regression indicated that using Doppler flowmetry reduced the risk of reexploration by 81% (OR: 0.189, 95% CI:0.054 – 0.663, P= 0.009). There was no early mortality in both groups
Conclusion: Using Doppler flowmetry during CABG could improve intraoperative and postoperative outcomes, reducing perioperative myocardial infarction and related complications. This technique could be valuable to standard CABG procedures, enhancing patient recovery and reducing hospital stay duration
Tricuspid valve annuloplasty using autologous pericardial strip versus band for treatment of functional tricuspid regurgitation
Full text linkBackground: Options of tricuspid annuloplasty (TAP) for treatment of functional tricuspid regurgitation (FTR) include suture, ring, and autologous pericardium. The aim of this study was to evaluate and compare outcomes of TAP using pericardial strip versus band during left-sided heart valve surgery.
Methods: This retrospective study included adult patients who had autologous pericardial annuloplasty for FTR using pericardial strip and rolled pericardial band. The primary end-point was residual TR (moderate or more) during 1-year follow-up.
Results: The study included 80 patients with mean age of 52.06±11.01 years and most of them were female (63.8%). Tricuspid annuloplasty was performed using pericardial strip (n=50) or band (n=30). During follow-up period, there were no re-operation for TR, severe TR, late complications, mortality, and degeneration or retraction of the pericardial patch. The incidence of residual TR was 7.5% postoperatively and 2.5% during follow-up with no significant differences between both techniques of annuloplasty. Pericardial strip showed higher incidence of postoperative mild TR than band. There was no significant differences in postoperative complications and NYHA class. Follow-up TR grade was significantly correlated with preoperative NYHA class, pulmonary artery systolic pressure, left ventricular ejection fraction, and tricuspid annular plane systolic excursion.
Conclusion: Autologous pericardial strip or band for moderate and severe FTR had similar and acceptable rates of residual TR (moderate or more) postoperatively and at 1-year of follow-up, but pericardial band had temporally lower frequency of postoperative mild TR. Further evaluation is recommended
Endoscopic versus Open radial artery harvesting for Coronary Bypass Grafting; one-year patency rates
Full text linkBackground: Research is ongoing on the effects of endoscopic radial artery harvesting (ERAH) on clinical outcomes and patient satisfaction. This study evaluated the clinical outcomes, patient satisfaction, and radial artery graft patency of ERAH compared with the open technique (ORAH) for coronary artery bypass grafting (CABG).
Methods: We conducted a randomized controlled clinical trial involving 100 patients who underwent on-pump elective CABG with three or four vessels. Patients were randomly allocated into two groups: the ERAH group consisted of 50 individuals who underwent radial artery harvesting via endoscopy, whereas the ORAH group included 50 patients whose radial arteries were harvested via the conventional open technique. The study outcomes included the length of radial artery harvest, operating time, and postoperative outcomes, including hematoma formation, wound infection, and local neurological issues related to lesions of the dorsal radial nerve.
Results: Hospital stays were significantly shorter in the ERAH group than in the ORAH group (7.06 ± 0.79 days vs. 7.9 ± 0.81 days, P < 0.001). Additionally, peripheral neurological complications were significantly different between the groups, occurring in none of the patients in the ERAH group but in 6 patients (12%) in the ORAH group. Wound healing was also significantly better in the ERAH group than in the ORAH group (100% vs. 88%, P = 0.027), with all patients in the ERAH group experiencing seamless wound healing. In the ORAH group, two patients (4%) had wound infections, and four patients (8%) developed hematomas. Both groups presented similar rates of perioperative ischemia and radial artery graft patency. Patient satisfaction was significantly better in the ERAH group (P<0.001).
Conclusion: After one year, the patency rates of ERAH and ORAH were similar. However, patient satisfaction and wound healing were better in the ERAH group
Surgical Management of Pulmonary embolism : Single-center study
Full text linkBackground: Pulmonary embolism (PE) is considered one of the highest risk cardiovascular diseases. It is managed using medical (anticoagulants, thrombolytics) and/or surgical or catheter embolectomy. The indications and outcomes of the surgical embolectomy is a matter of controversy. So, the aim of the present work is to evaluate the outcomes of surgical embolectomy through median sternotomy with cardiopulmonary bypass surgery.
Methods: The current study is a prospective longitudinal cohort study for (17patients) who underwent surgical embolectomy at Assiut University Heart Hospital of Egypt during the period from September 2021 until September 2023.
A medical history, full examination, and thoracic echocardiography with pulmonary angiography were performed. All patients underwent surgical embolectomy through median sternotomy.
Results: The study included (17 patients), 5 males and 12 females, ranging from 38 to 60 years of age. Four patients presented with massive PE, and 13 suffered from submassive PE. The mean operative time was 172.65 + 24.76 min., and the mean clamp time was 42.59±13.70 min. The mean hospital stay for all patients was 8.65+1.22 days, and the mean Intensive Care Unit (ICU) stay was 2.3+0.6 days. Respiratory complications, stroke, and bleeding were present in 23.5%, 11.7%, and 17.6% of cases respectively. while congestive heart failure, fever, and melena were present in 11.76%, 11.76%and 5.88%. Four patients died postoperatively due to stroke (2 patients), bleeding (1 patient), and acute respiratory distress with multiorgan failure (1 patient). The mortality rate reported in our cases was about 24% (4/17 patients)
Conclusion: Surgical embolectomy through median sternotomy and cardiopulmonary bypass had favorable outcomes in cases of submassive PE, especially when other treatments are contraindicated or are not available
Conventional left atriotomy versus the superior atrial approach for mitral valve replacement
Full text linkBackground: The optimal atrial approach for exposing the mitral valve with optimized patient outcomes is still controversial. This study compared conventional left atriotomy with the superior atrial approach for mitral valve replacement (MVR).
Methods: A randomized clinical trial was conducted on 60 patients who underwent MVR during the period 2022-2024. Patients were randomized into: Group A (n= 30, left atriotomy) and Group B (n=30, superior atrial approach).
Results: The mean age in Group A was 43.17 ± 8.57 years, whereas that in Group B was 47.63 ± 10.35 years (P = 0.07). No significant differences in sex, smoking status or associated comorbidities were noted between the groups. Echocardiographic findings revealed no significant differences in left ventricular functions and dimensions. Preoperative laboratory data revealed no significant differences in hemoglobin levels, platelet counts, or INRs. The total cardiopulmonary bypass time was shorter in Group B than in Group A but did not reach a significant level (P= 0.08). The cross-clamp times were significantly shorter in Group B (64 ± 5.7 min) than in Group A (69 ± 9.5 min) (P = 0.02). There were no differences in the rate of postoperative complications or duration of hospitalization between the groups. Follow-up echocardiographic evaluations revealed no significant difference between Group A and B in regarding ejection fraction (β: -0.003, 95% CI: -0.04-0.03, P = 0.82). Similarly, the left atrial diameter decreased significantly over time (β-0.05, 95% CI: -0.07- -0.03, P < 0.001), with no significant difference between the groups (β: -0.11, 95% CI: -0.29- 0.06, P = 0.21). Changes in left ventricular end-systolic diameter decreased over time (β: -0.05, 95% CI: -0.06- -0.03, P < 0.001), with no significant difference between groups (β: -0.01, 95% CI: -0.21-0.19, P = 0.92).
Conclusions: The superior atrial approach provided comparable clinical and echocardiographic outcomes to those of left atriotomy for MVR, with shorter cross-clamp times. The superior atrial approach is a good alternative to left atriotomy with comparable safety and efficacy profiles
Reconstruction of the Pulmonary Trunk With A Homograft In Patients With Previous Tetralogy of Fallot Repair: A Case Report
Full text linkBackground: Tetralogy of Fallot (TOF) is a common congenital heart defect often requiring pulmonary valve replacement due to complications like pulmonary regurgitation. We present a case of a TOF patient with prior valve replacement admitted for prosthetic valve dysfunction.
Case presentation: At Sechenov University, the patient underwent successful reconstruction of the right ventricular outflow tract and pulmonary trunk using cryopreserved homografts. Postoperative recovery was uneventful, with discharge on day 14.
Conclusion: Pulmonary homografts provide favorable outcomes and reduced reinterventions, though degeneration remains a challenge. Future research should focus on factors affecting implant durability, such as age and size, to optimize long-term outcomes
Negative Pressure Wound Therapy versus Conventional Treatment in Post cardiac Surgery Sternal Wound Infection
Full text linkBackground: Deep sternal wound infection (DSWI) remains a severe complication after cardiac surgery, with direct association with increased morbidity and mortality. This study evaluated the efficacy and safety of negative pressure wound therapy (NPWT) compared with conventional treatment in managing DSWI.Methods: This randomized study included 40 patients with DSWI postcardiac surgery, which were randomly divided into NPWT (n=20) and conventional treatment (n=20) groups. Patients underwent cardiac surgery between 2019 and 2023 in a single tertiary referral center. The outcomes included wound culture clearance, C-reactive protein (CRP) reduction, complications, and hospital stay.Results: Preoperative and operative data were comparable between both groups. During treatment, NPWT significantly reduced the percentage of positive cultures to 5% compared with 30% in the conventional group (p=0.037). C-reactive protein (CRP) levels decreased significantly in the NPWT group from 210.14 ± 41.03 mg/L to 5.5 ± 6.42 mg/L (p<0.001), whereas the conventional group presented a minimal reduction from 194.28 ± 18.95 mg/L to 176.85 ± 28.19 mg/L (p=0.125). There were notably fewer complications in the NPWT group than in the conventional group, with only 5% experiencing re-infection (p=0.018). The incidence of necrosis was also lower (5% vs. 20%, p=0.151), and the need for reoperation was lower in the NPWT group (5% vs. 20%, p=0.151). The average length of hospital stay was significantly shorter in the NPWT group (20 ± 3 days) than in the conventional group (36 ± 6 days) (p<0.001).
Conclusion: Negative pressure wound therapy is more effective than conventional treatment in managing deep sternal wound infections following cardiac surgery. NPWT significantly reduces infection rates, accelerates recovery, and minimizes complications, leading to shorter hospital stays. This study supports the use of NPWT as a preferable treatment option for DSWI
Comparative Analysis of the Pleural Vent versus the Intercostal Tube for Managing Spontaneous Pneumothorax
Full text linkBackground: Evidence supporting using pleural venting over traditional intercostal chest drains for managing spontaneous pneumothorax is limited. Therefore, this study aimed to compare using pleural vents and intercostal tubes in managing spontaneous pneumothorax.
Methods: In this randomized clinical trial, 61 patients with spontaneous pneumothorax were randomly assigned to two groups. Group I included patients initially managed via intercostal chest tubes (n= 31), and Group II included patients with a pleural vent as the initial management (n= 30). The study outcomes were pain score; the need for nonsteroidal anti-inflammatory medications (NSAIDs) or narcotics; wound infections; pleural effusion; the duration of treatment; the need for surgery; and patient satisfaction and recurrence of pneumothorax at 1, 3, and 6 months after discharge.
Results: The baseline data were comparable between the groups, with no differences in the laterality or size of the pneumothorax. The requirements for NSAIDs (77% vs. 13%, p<0.001) and narcotics (42% vs. 0%, p<0.001) were more frequent in Group I. The duration of treatment was longer in Group 1 (3.71± 0.78 vs. 3.03± 0.61 days; p<0.001). Surgery was required more frequently in Group I (61% vs. 0%, p<0.001). Recurrence after three months was more common in Group I (11 (35.48%) vs. 1 (3.33%); p= 0.003). There was no difference in posttreatment pleural effusion between the groups, whereas wound infection was more common in Group I.
Conclusions: Pleural vents for managing spontaneous pneumothorax offer significant advantages over traditional intercostal chest tube placement. Patients managed with pleural vents experienced markedly lower pain levels, reduced reliance on NSAIDs and narcotics, and shorter treatment durations. Additionally, the need for surgical intervention and recurrence rates were substantially lower in the pleural vent group
Incidence, Predictors, and Prognostic Impact of New-onset Atrial Fibrillation After Isolated Primary Coronary Artery Bypass Grafting
Full text linkBackground: New-onset atrial fibrillation (NOAF) after coronary artery bypass grafting (CABG) is associated with considerable morbidity and mortality. The objectives of this study were to estimate the incidence and predictors of NOAF after isolated primary CABG and evaluate its prognostic impact on the hospital outcomes of surgery.
Methods: This study included 154 consecutive patients who underwent isolated primary CABG between October 2021 and February 2022. Patients were divided into two groups; Group 1 included patients with NOAF, and Group 2 had patients without NOAF.
Results: NOAF occurred in 29 patients (18.8%). NOAF patients were significantly older (52.13± 6.30 vs. 55.45± 7.47 years; p =0.028), with more prevalence of diabetes mellitus but did not reach a significant level (62.1% vs. 44.8%; p = 0.094) and had a greater preoperative white blood cells count (WBCs) (8.87± 2.95 vs. 8.0± 2.17 /mm3; p = 0.071). Preoperative creatinine clearance (137.58± 53.94 vs. 114.94± 39.18 ml/min; p = 0.04), postoperative ischemic ECG changes (55.2% vs. 30%; p = 0.004), perioperative myocardial infarction (31% vs. 15.2%; p= 0.046), postoperative CK-MB (84.83± 81.26 vs. 64.76±46.58 units; p= 0.077), hemodynamic instability (72.4% vs. 41.6%; p= 0.003), and postoperative significant ECG changes (34.5% vs. 17.6%; p= 0.044) were greater in patients with NOAF. Age, preoperative creatinine clearance, preoperative WBC, and DM were associated with NOAF in the univariable analysis. None were found to be predictors of NOAF in the multivariable analysis.
Conclusions: NOAF after isolated primary CABG is common. Advanced age, renal function, hemodynamic instability, and perioperative myocardial infarction might be associated with NOA