The Egyptian Cardiothoracic Surgeon (ECTS - E-Journal)
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Impact of gender on postoperative outcome after posterior chordal preservation during isolated mitral valve replacement: A retrospective propensity score matched study
Full text linkBackground: Female patients experience poorer clinical results after mitral valve surgery. Preserving the sub-valvular chordae may lead to lower morbidity and mortality after mitral valve replacement (MVR) for both genders. This study aimed to compare operative mortality and postoperative morbidity following preservation of posterior mitral leaflet during isolated mechanical MVR, between male and female patients.
Methods: This retrospective study involved adult patients of either gender who had primary isolated MVR. The primary end-point of outcome was a combination of negative postoperative results, including operative mortality and complications. The outcomes were compared based on gender before and after adjusting for preoperative factors related to gender using 1:1 propensity score matching.
Results: The initial sample consisted of 380 patients, mostly female (215/380; 56.57%) with an average age of 51.45±10.79 years. Female patients showed higher rates of previous congestive heart failure, NYHA class III/IV, low ejection fraction, pulmonary hypertension, and atrial fibrillation. After surgery, female patients experienced a significant increase in hospital stay (9.30±3.55 vs 8.95±3.27 days, P = 0.02), total postoperative complications (7% vs 2.4%, P = 0.04), and adverse outcome rates (7.9% vs 2.4%, P = 0.02), with no significant difference in hospital mortality (1.4% vs 0.6%, P = 0.63). In the matched group of 330 patients, there were no significant differences in postoperative results (P < 0.05). Female gender associated with significantly higher odds for the composite of adverse outcomes (OR: 3.45, 95%CI: 1.14 -10.47, P = 0.02), which was not seen in the matched group (OR: 2.05, 95%CI: 0.60-6.94, P = 0.24).
Conclusion: Female gender did not influence the rate of operative mortality after posterior chordal preservation during MVR, but female patients experienced higher rate of overall postoperative complications and longer duration of hospital stay than male patients. When adjusting for preoperative risk factors, female gender did not impact postoperative outcomes
Early Results of Coronary Artery Bypass Grafting Surgery with or without Coronary Endarterectomy
Full text linkBackground: Managing patients with diffuse coronary artery disease is challenging. The advantages of coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) compared to CABG alone are controversial. This study compared short-term outcomes, including ICU and hospital stays, arrhythmias, postoperative myocardial infarction, renal impairment, and hospital mortality, between patients who underwent CABG without and with CE.
Methods: This randomized controlled study included 100 patients who underwent CABG with or without CE. Participants were randomly allocated into two equal groups. Group I (n=50) included patients who underwent CABG alone, and Group II (n=50) included patients who underwent CABG combined with CE.
Results: The right coronary artery was the most common vessel affected by CE (44%), followed by the left anterior descending artery (42%). Low-output syndrome and pleural effusion were more frequently observed in Group II; however, these differences did not reach statistical significance. There was no difference in postoperative complications or ejection fraction between the groups. The ICU stay was significantly longer in Group II (3.02±0.84 vs. 2.58±0.5 days; p=0.007). Additionally, patients in Group II had significantly longer hospital stays (14.48±1.87 vs. 11.98±1.35, p<0.001).
Conclusion: Compared with CABG alone, CABG with CE might not be associated with increased short-term mortality or morbidity. CABG with CE was associated with prolonged hospitalization, necessitating a careful assessment of the benefits versus an extended hospital stay when considering this adjunctive procedure
Custodiol versus Cold Blood Cardioloplegia in Minimally Invasive Aortic Valve Surgery: A Comparative Study
Full text linkBackground: Myocardial protection is a critical concern during aortic valve replacement. Custodiol cardioplegia and cold blood cardioplegia represent two primary strategies for myocardial preservation. This study sought to compare Custodiol and blood cardioplegia results for myocardial protection in aortic valve replacement.
Methods: This prospective study included 200 patients who were evenly divided into two groups based on the cardioplegia solution used: the Custodiol group (Group A) and the cold blood cardioplegia group (Group B). The study evaluated postoperative mechanical ventilation duration, ICU and overall hospital stay lengths, and echocardiographic findings at three and six months postoperatively.
Results: Compared with Group B, Group A had significantly shorter ventilation times (min-max: 6-9 vs. 9-15 hours), ICU stays (3-3 vs. 4-5 days), and hospital stays (7-9 vs. 10-20 days) (p<0.001 for all). Group A exhibited shorter cardiopulmonary bypass times (179 ± 9 minutes vs. 216 ± 14 minutes, p<0.001) and cross-clamp times (137 ± 8 minutes vs. 176 ± 18 minutes, p<0.001). Postoperative atrial fibrillation was more common in Group A (66% vs. 20%, p<0.001), while ventricular tachycardia and nodal rhythm post-defibrillation were greater in Group B. Mortality was lower in Group A (2% vs. 9%, p=0.03). However, at three and six months postoperatively, echocardiographic findings were significantly different in terms of left atrial diameter and left ventricular end-systolic diameter between Group A and Group B (p<0.001).
Conclusion: Custodiol cardioplegia could be associated with superior postoperative outcomes, including shorter ventilation times, ICU and hospital stays, and lower mortality rates, compared to cold blood cardioplegia in minimally invasive aortic valve replacement surgery
Keeping the mitral smile: is it durable? A comparative study of mid-term outcomes of mitral valve repair and mechanical mitral valve replacement in rheumatic heart patients
Full text linkBackground: Rheumatic heart disease is a significant cause of morbidity and mortality in endemic countries. Traditionally, mechanical valve replacement has been the preferred surgical approach for treating rheumatic mitral valve disease due to its favorable short-term outcomes and low incidence of postoperative complications. However, its midterm results are suboptimal due to increased risks of thrombosis and bleeding. This study compared the midterm outcomes of mitral valve surgeries, repair versus replacement, in rheumatic patients.
Methods: A comparative retrospective clinical study was conducted from January 2016 to December 2018. The study included 203 patients who underwent mitral valve surgery for rheumatic heart disease. The patients were divided into two groups: Group A (n=107) had mitral valve repair, and Group B (n=96) had mitral valve replacement.
Results: In Group A, the mean age was 45.5 ± 5.2 years, and 49% of the patients were male. While in Group B, the mean age was 46.2 ± 5.35 years, and 54.75% of the patients were males. The two groups had no significant difference regarding cardiac dimensions or function preoperatively. In Group A, the mean cardiopulmonary bypass time was 89 ± 9 minutes, and the mean cross-clamp time was 81 ± 7 minutes; in Group B, the mean cardiopulmonary bypass time was 77±12 min, and the mean cross-clamp time was 81 ± 7 min. The two groups had highly significant differences concerning cardiopulmonary bypass and cross-clamp times (p<0.001). Survival at 5 years was 98.5% for Group A vs. 93.15% for Group B (0.09). The reoperation rate was 9.0% in Group A vs. 4% in Group B (p= 0.261). The thromboembolism incidence was 0.47% in Group A vs. 7.3% in Group B (p= 0.03), and the bleeding-related complications were 0.94% in Group A vs. 7.3% in Group B (p= 0.03).
Conclusion: The outcomes of mitral valve repair could be comparable to replacement in patients with rheumatic heart disease. Mitral valve replacement were associated with higher bleeding and thromboembolic complications compared to mitral valve repair
Clinical Outcomes of the Use of Custodiol versus Warm Blood Cardioplegia during Coronary Artery Bypass Grafting in Patients with Significant Left Main Coronary Artery Disease
Full text linkBackground: Patients who undergo coronary artery bypass graft (CABG) surgery, particularly those with significant left main coronary artery disease (LMCAD), require optimal myocardial protection. The selection between Custodiol and warm blood cardioplegia remains critical in enhancing surgical outcomes and improving postoperative quality of life. This study sought to compare Custodiol and warm blood cardioplegia regarding myocardial protection during CABG surgery.
Methods: This randomized controlled clinical trial was carried out on 100 patients with significant LMCAD. Patients underwent CABG surgery using either Custodiol (Group I, n= 50) or intermittent antegrade warm blood cardioplegia (Group II, n= 50). In Group I, 13 patients were female (26%); in Group II, 15 were female (30%).
Results: Both groups had comparable preoperative demographics. Use of hemofilter [8 (16%) vs. 1 (2%), p= 0.004], DC shock [ 6 (12%) vs. 1 (2%), p= 0.037] were more common in Group I. Arrhythmia occurred more frequently in Group I intraoperatively [ 9 (18%) vs. 2 (4%), p= 0.009]. No early mortality was observed in either group. Postoperative data revealed no significant differences between the groups in vital parameters, complications, echocardiographic data, or mortality.
Conclusion: Both Custodiol and warm blood cardioplegia demonstrated comparable efficacy and safety profiles for myocardial preservation during CABG surgery in patients with significant LMCAD. Custodiol could be an effective alternative to blood cardioplegia in patients with LMCAD
Have Water Seal Drainage Systems Come to an End?
Full text linkBackground: We hypothesized that underwater seal drains are not mandatory after thoracic procedure when the visceral pleura remains intact. A small size drain with low auto-suction system (e.g., Hemovac) may be sufficient if no evidence of air leak.
Methods: This is an observational study on using low auto-suction drain as a solo pleural drain after thoracic procedures in which visceral pleura remained intact at the end of surgery. After completion of the procedure on the selected Cohort of patients, 10F Hemovac drain was inserted and fixed using 4/0 silk suture. Small collection bag, 250cc, was connected. To ensure tight wound closure around the small caliber drain, a tunneled insertion techniques using valve mechanism for at least one intercostal space was used. Finally, by the end of the procedure, Seal/Suction test should be utilized to test for the presence of air leak either from around the drain site or disintegrated visceral pleural surface. The primary outcomes were to detect the feasibility of low-suction drain after selected thoracic procedures. The secondary outcomes were to monitor the incidence of postoperative complications related to drainage system in the short term.
Results: the low-suction drain was used in 125 patients ranging between 4-86 years old. The drain was removed by the end of postoperative day 1 in 76%. Only 8 patients (6.4%) required drainage longer than 48 hours. Small apical air space (< 2cm) was detected on the immediate postoperative chest X-ray in only 8 patients (6.4%). Minimal pleural fluid was seen on the follow-up x-ray at one week in the outpatient clinic in 16 patients (%12.8). None of the patients required insertion of a chest drain or thoracocentesis. No complication related to using the Hemovac drain was reported.
Conclusion: Our observations suggest that low vacuum drainage systems are a feasible alternative to water-seal drainage systems in the remarkable number of thoracic procedures. This safe and practical drainage system could pave the way towards drainless surgery which is a culminating level for thoracic surgeons
Outcomes of tricuspid valve repair versus replacement for the surgical treatment of infective endocarditis
Full text linkBackground: The surgical management of right-sided infective endocarditis (IE) is challenging, and the superiority of tricuspid valvuloplasty (TVP) or tricuspid valve replacement (TVR) is not well established. Our study aimed to compare the clinical outcomes of TVP and TVR for right-sided IE.
Methods: All patients aged ≥18 years with isolated right-sided IE who underwent surgical treatment between 2015 and 2022 were retrospectively studied. The enrolled patients were diagnosed according to the modified Duke criteria and had tricuspid valve vegetation. The primary outcome was 6-month mortality, and the secondary outcomes included recurrence of IE, recurrence of tricuspid regurgitation (TR), need for reoperation, new need for dialysis, need for a permanent pacemaker, cerebrovascular stroke, and duration of ICU stay.
Results: 109 adult patients with isolated tricuspid valve infective endocarditis underwent surgical treatment. Sixty (55%) patients had TVP, and 49 (45%) had TVR. The patients who underwent TVR were significantly younger [54 (48-56) vs. 47 (39-52) years, p<0.001] and had greater frequencies of staphylococcal and fungal infections than the patients who underwent TVP. Compared with the TVP group, the TVR group had significantly longer cardiopulmonary bypass [79 (76-87) vs. 98 (95-108) min, p<0.001) and aortic cross-clamping times [51 (45-56) vs. 75 (72-80) min, p<0.001]. Patients with TVP had lower rates of recurrent IE (8.3% vs. 32.7%, p=0.02), recurrent TR (11.7% vs. 32.7%, p=0.023), reoperation (11.7% vs. 32.7%, p=0.023) and 6-month mortality (3.33% vs. 14.29%, p=0.06) than did those in the TVR group. There were no significant differences in blood loss, reopening for bleeding, new need for dialysis, cerebrovascular stroke or ICU stay between the two groups.
Conclusions: Compared with tricuspid valve replacement, tricuspid valve repair might be associated with lower rates of recurrent IE and reoperation. Although statistically insignificant, tricuspid valve replacement was associated with a greater mortality rate than TV repair. TVP could be the recommended treatment for patients with right-sided IE
Emergency small- vs large-tube thoracostomy in chest trauma patients
Full text linkBackground: Therapeutic drainage is used to treat pleural disorders such as pneumothorax, hemothorax, empyema, chylothorax, and malignant effusions. This study aimed to conduct a comparative analysis of small (24-26 Fr) versus large (30-32 Fr) tube thoracostomy in terms of the efficacy of drainage due to concerns about obstruction (in the case of hemothorax) or inadequate drainage (in the case of hemothorax, pneumothorax, or hemopneumothorax), pain score, repositioning, and the need for thoracotomy.
Methods: This randomized prospective study included 112 chest trauma patients who experienced significant hemothorax, pneumothorax, or a combination of these conditions in a trauma unit (reception, inpatient, or ICU) between December 2021 and December 2022. Patients were randomly divided into two groups. Group I included 56 patients who underwent small (24–26 Fr) tube thoracostomy and 56 patients in Group II, in which a large (30-32 Fr) tube thoracostomy was performed.
We investigated the differences between the two groups in terms of pain score, complication rate, duration of tube insertion, and need for another chest tube or thoracotomy.
Results: There was no statistically significant difference between the two groups concerning the mode of trauma, chest trauma, or effect of trauma (p= 0.781, 0.622, >0.99, and >0.99, respectively). The two groups had a highly statistically significant difference regarding the pain score (p<0.001). There was no statistically significant difference between the two groups regarding the duration of tube insertion (P<0.001). There were no statistically significant differences between the two groups regarding outcomes (drainage efficacy, tube repositioning, tube replacement, or the need for thoracotomy) (p= 0.315, 0.344, and 0.814, respectively).
Conclusion: Increasing the tube size might not affect the efficacy of drainage, the duration of tube insertion, the need for another tube, or the need for thoracotomy. Small (24-26 Fr) tube thoracostomies could also have favorable pain score outcomes
Chordae Tendineae Sparing during Mitral Valve Replacement: A Comparative Study
Full text linkBackground: Mitral valve replacement (MVR) with chordal sparing could improve ventricular function in patients with mitral regurgitation. This study aimed to compare the outcomes of prosthetic MVR with and without chordae tendineae sparing.
Methods: This prospective, single-blinded, randomized study was executed on 60 patients undergoing prosthetic MVR with or without chordae tendineae sparing. Patients were divided into two equal groups: Group A (n= 30) included patients who underwent MVR with complete chordae tendineae sparing, and Group B (n= 30) included patients who underwent mitral valve replacement without chordae tendineae sparing.
Results: Patients who underwent chordae tendineae sparing demonstrated significantly lower total bypass time (median = 67 vs. 110 min, P < 0.001), total cross-clamp time (median = 40 vs. 80 min, P < 0.001), inotropic support (30% vs. 96.7%, P < 0.001), and arrhythmia (6.7% vs. 86.7%, P < 0.001) than those who did not undergo chordal sparing. Additionally, patients who underwent sparing demonstrated a significantly lower 6-month left ventricle end-systolic diameter (3 ±0.8 vs. 3.9 ±0.5 cm, P < 0.001), 6-month left ventricle end-diastolic diameter (4.4 ±0.7 vs. 5.3 ±0.5 cm, P < 0.001), 3-month left atrium diameter (4.5 ±0.8 vs. 5.1 ±0.6 cm, P < 0.001), and 6-month left atrium diameter (4.3 ±0.8 vs. 5.4 ±0.6 cm, P < 0.001).
Conclusion: This technique of MVR might enhance cardiac function and structural parameters and lower the end-diastolic and systolic diameters and the end-systolic and diastolic volumes up to the sixth month of follow-up
Comparison Between Effects of Amiodarone vs. Nebivolol in Treating Atrial Fibrillation Following Coronary Artery Bypass Grafting
Full text linkBackground: Atrial fibrillation (AF) is the most prevalent type of arrhythmia following cardiac surgery. Several agents are used for managing postoperative AF, but their efficacy is controversial. This study evaluated the effectiveness of amiodarone versus nebivolol in treating postoperative AF.
Methods: This randomized trial was conducted from November 2022 to November 2023 and involved 100 patients who developed postoperative AF after coronary artery bypass grafting. Patients were divided into two groups: Group A (n=50) received amiodarone, and Group B (n=50) received nebivolol.
Results: Compared with Group B, Group A had a significantly longer aortic clamp time [60.9 ± 11.27 vs. 55.6 ± 10.18 min; p value= 0.051]. Moreover, the total cardiopulmonary bypass time did not significantly differ between the two groups [89.62 ± 19.76 vs. 92.44 ± 17.74 min; p value= 0.455]. Compared with Group B, sinus rhythm control in Group A was notably better at 6 hours (16% vs. 2%), 12 hours (44% vs. 12%), 24 hours (62% vs. 16%), 48 hours (83.3% vs. 17%), and 72 hours (100% vs. 25.5%) postintervention (p < 0.001). However, no significant difference was observed in the effect of either drug on the rate control at these intervals. Moreover, the morbidity and mortality rates were not significantly different between the two groups.
Conclusion: Amiodarone might be superior to nebivolol in the treatment of postoperative AF following coronary artery bypass grafting. Amiodarone could be the treatment of choice for postoperative AF after CABG