The Egyptian Cardiothoracic Surgeon (ECTS - E-Journal)
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Median sternotomy in penetrating cardiac trauma , does it make a difference ?
Full text linkBackground: Studies comparing the outcomes of left lateral thoracotomy and median sternotomy in the management of penetrating cardiac trauma in the Egyptian setting are lacking, which motivated us to conduct the current study. This study aimed to compare the perioperative and short-term outcomes between median sternotomy and left anterior thoracotomy in the management of patients with penetrating cardiac injuries.
Methods: A total of 40 patients with penetrating cardiac trauma were included: 34 were males (85%), and 6 were females (15%). The mean age was 35.00 ± 10.83 years. Patients were allocated into two groups: Group A (n= 20) was managed with median sternotomy, and Group B (n= 20) was managed with left lateral thoracotomy. The study outcomes included operative time, intraoperative blood loss, postoperative pain score, duration of mechanical ventilation, length of ICU stay, postoperative complications and mortality.
Results: The right ventricle was the most common injury site (60% vs. 50%, p= 0.619 in Groups A and B, respectively). Left lateral thoracotomy was associated with longer operation times [3750 (1500 – 6000) vs. 185 (70 - 260) mins, p= 0.002]. Left lateral thoracotomy patients had longer ICU stays [5 (2 – 7) vs. 3 (2 – 5) days, p= 0.004] and hospital stays [7 (4 – 12) vs. 5 (4 – 7) days, p= 0.001]. There were no differences in wound infection, pericardial effusion, or mortality between the groups. The pain score was lower in the median sternotomy group postoperatively from day 2 to day 7.
Conclusion: Median sternotomy was associated with a significant decrease in operation time, blood loss, pain score, duration of ICU stay, and hospitalization period. The median sternotomy approach could be preferred over the thoracotomy approach in patients with penetrating cardiac injury
Prognostic Impact of Previous Percutaneous Coronary Intervention on the Outcome of Coronary Artery Bypass Grafting in Multivessel Disease Diabetic Patients
Full text linkBackground: Previous studies suggest that patients who receive percutaneous coronary intervention (PCI) are at a higher risk of undergoing coronary artery bypass grafting (CABG). This study aimed to investigate the risk of CABG in patients with a history of PCI.
Methods: One hundred diabetic patients who underwent CABG from October 2020 to February 2022 were enrolled and divided into two groups. Group I consisted of 50 patients with no prior PCI, while Group II comprised 50 patients with a history of PCI.
Results: The mean age was 57.4 ± 8.67 years for Group I and 59.72 ± 7.5 years for Group II (p= 0.155). The mean cardiopulmonary bypass time was 108.56 ± 34.53 minutes for Group I and 127.4 ± 35.93 minutes for Group II (p=0.009). The ischemic duration was 75.68 ± 19.94 minutes for Group I and 75.12± 23.02 minutes for Group II. The mean number of grafts was greater in Group I (3.5 (3 – 3.5) vs. 3 (2 – 4), p= 0.011). The mean ventilation time was 9 (5 – 13.75) hours for Group I and 10 (5 – 19) hours for Group II. The mean length of ICU stay was 1 (1–2) day for Group I and 2 (2–3) days for Group II (p<0.001). The length of hospital stay was 8 (7–9) days for Group I and 10 (9–11) days for Group II (p<0.001). There were statistically significant differences between the groups in terms of MACE (higher in the PCI group, p=0.046), improvement in wall motion abnormalities (higher in the non-PCI group, p=0.007), and postoperative normal ejection fraction (higher in the non-PCI group, p=0.032). There was no significant difference in hospital mortality between the two groups (0 vs 3), with a p value =0.07.
Conclusion: A previous PCI could increase post-CABG morbidity and MACEs. However, no significant difference in postoperative mortality rates was found between patients who underwent prior PCI and those who did not
Outcome of Pectus Carinatum Treatment with the FMF® Dynamic Compressor System
Full text linkBackground: The use of the FMF dynamic compressor system for managing pectus carinatum (PC) has recently gained popularity. However, its efficacy and factors affecting treatment success are under investigated. The objective was to evaluate the outcome of PC treatment using an FMF dynamic compressor system.
Methods: This retrospective cohort study included 56 patients aged 13–17 years diagnosed with PC and managed using compression braces. A custom-made brace was made and applied. Patients were instructed to wear the brace to the greatest extent possible for optimal outcomes. Subsequent visits were scheduled, first every 6-8 weeks and thereafter every 3-4 months, until chest correction was achieved. The study outcomes were treatment success and complications.
Results: 46 (82.14%) had successful treatment. The pressure at initial correction was significantly lower in the successfully treated group than in the unsuccessfully treated group (6.8 ± 3 vs. 9.4 ± 3.84 psi, p=0.022). The successfully treated group had a significantly greater initial pressure of treatment than the unsuccessfully treated group (4.3 ± 1.19 vs. 2.9 ± 1.07 psi, p=0.001). The mean time to correction in the successfully treated group was 4.02 ± 1.72 months. Regarding self-assessment of the chest in the successfully treated patients, there was significant improvement after 6 (5.4 ± 1.47) and 12 months (5.5 ± 1.7) compared to the baseline assessment (2.2 ± 1.22) (p<0.001 for both), with no significant difference between the assessments after 6 and 12 months (p=0.743). Age (β: 0.132; p=0.01), the pressure of initial correction (PIC) (β: -0.214; p= 0.024), and high PIC (β: 2.092; p= 0.001) were significant risk factors for correction time.
Conclusions: A chest wall brace for treating PC with a compressive mechanism to correct this chest wall deformity might be a viable option in children and young adolescents with a high success rate
Penetrating chest trauma: A prospective study of prognostic factors for worse outcome after emergency surgery
Full text linkBackground: Even though chest penetrating injuries are common as well as challenging to treat, most of the time they can be dealt without surgery. This study aimed to evaluate contemporary outcome following emergent surgical interventions for penetrating chest trauma and possible factors associated with poor prognosis.
Methods: This prospective study included 100 cases admitted to benha university hospital with either Stab Wound or Gunshot wound to the chest, with systolic blood pressure ≤90 mmHg and who underwent through Thoracotomy or sternotomy within duration of one hour of arrival.
Results: This study included 81 patients (77 stabbings, 4 gunshots) underwent a thoracotomy and 19 underwent median sternotomy within 60 minutes after the penetrating trauma, the mean period of surgery was 3 ±0.9, There were 94 male and 6 female cases and their mean age was 25 ±10.14 years, the mean Intensive care unit stay was 2 ±0.83 days in addition mean hospital stay was 6 ±1.06 days, the individuals who died had trauma at mid-clavicular line of the chest (100%) compared to survivors (5.5%), lesser systolic blood pressure on presentation in the emergency room (71 ±11 mmHg) equated with those who survived (90 ±9 mmHg, P<0.001) and lower hemoglobin level (6.4 ±0.5) compared with those who survived (8.4 ±1, P<0.001). As a whole, the mortality rate was 9% (n=9). individuals' Death Rates with stab wounds was 5/96 (5.2%) compared with 4/4 (100%) for patients with gunshot wounds. Right ventricular injury (P=0.03) was associated with mortality.
Conclusion: Early referral, within one hour, to emergency surgery results in acceptable postoperative mortality in patients with penetrating chest trauma. Anterior location of injury, initial hemodynamic instability, and gunshot wounds associated with poor prognosis
Rapid Pleurodesis: Single Agent Single Session Vs. Multiple Sessions Using Multiple Agents in the Treatment of Recurrent Malignant Pleural Effusion
Full text linkBackground: One prevalent, upsetting side effect of several oncological conditions is malignant pleural effusion. Pleurodesis is one of the most effective ways to reduce symptoms, stop recurrence, and enhance quality of life. This prospective study aimed at evaluating the performance of three rapid pleurodesis procedures and determine which modality achieved the most positive results, the fewest problems, and the most cost-efficiency.
Methods: This study included 91 patients with recurrent and rapidly collecting malignant pleural effusion. They were distributed into three groups: Group A (single session, single agent), Group B (single session, combined agents), and Group C (multiple sessions, multiple agents) pleurodesis through a catheter which was closed for 2 hours and then opened to drain. The catheter was then removed, and the patient was discharged to continue outpatient follow-up.
Results: Group A included 28 patients, Group B included 29 patients, and Group C included 34 patients. The most common primary malignancy was breast cancer in Group A (46.4 %), and lung cancer in Group B (48.3%) and Group C (47.1 %). Frequently encountered complications following pleurodesis were fever (7.1%, 10.3% and 11.8 % for group A, B and C respectively); and dyspnea (7.1 % in Group A), (13.8% in Group B), and (8.8% in Group C). Hospital stay was longer in the third group with (p<0.001) without significant difference in the outpatient follow-up for lung inflation and recurrence as in one week was (3.6 % in Group A), (0 % in Group B and Group C), in one month was (10.7 % in Group A), (6.9 % in Group B), and (2.9 % in Group C), in 3 months was (14.3 % in Group A), (17.2 in Group B), and (11.8% in Group C).
Conclusion: Rapid pleurodesis – either with a single agent in a single session, a combined agent in a single session, or multiple sessions using multiple agents – is an effective treatment to avoid the recurrence of malignant pleural effusion with minimal side effects. Since the first protocol is equally successful and requires only a short hospital stay at a moderate cost, we recommend it
Comparing the Efficacy of Custodiol and Cold Blood Cardioplegia in Myocardial Preservation
Full text linkBackground: Strategies for myocardial protection vary among surgeons, and data on the optimal cardioplegia solution are insufficient. The perfect cardioplegia solution for myocardial protection during cardiac surgery is still controversial. This study aimed to compare the efficacy of custodiol and cold blood cardioplegia in preserving the myocardium.
Methods: In this comparative prospective study, the patients were split into two groups of 60 patients each. Group A received Custodiol HTK solution, whereas Group B received cold blood cardioplegia. Preoperative laboratory investigations, operative data, postoperative ICU stays, and complications were compared between groups.
Results: The number of cardioplegia doses was significantly greater in Group B (1.05 ± 0.22, vs. 1.90 ± 0.82; p<0.001). There were no significant differences between the cardioplegia groups regarding hospital stay (p= 0.246), intensive care unit stay (p= 0.144), mortality (p= 0.769), low cardiac output (p>0.99), postoperative myocardial infarction (p= 0.432), intra-aortic balloon pump insertion (p= 0.224), reoperation (p>0.99), duration of mechanical ventilation (p= 0.389), pulmonary complications (p= 0.432), stroke (p>0.99), or the need for renal dialysis (p= 0.559).
Conclusions: Custodiol cardioplegia could be advantageous in cardiac surgeries when a longer duration is expected. However, this study did not report differences in postoperative outcomes between patients with custodiol or cold blood cardioplegia
Negative pressure wound therapy versus conventional therapy for the treatment of post-coronary artery bypass graft mediastinitis
Full text linkBackground: Various treatments, such as negative pressure wound therapy or traditional therapy, can be employed to manage postoperative mediastinitis. The superiority of one approach over the other is still a subject of discussion. Our purpose was to compare the results of negative pressure wound therapy and conventional therapy for treating postcoronary artery bypass graft mediastinitis.
Methods: This study included 50 individuals with mediastinitis after coronary artery bypass grafting. Patients were divided into Groups A and B according to whether the wound was treated with negative pressure wound therapy (n= 25) or conventional therapy (n= 25), respectively.
Results: The studied groups were comparable concerning age (P = 0.5), sex (P = 0.395), and body mass index (P = 0.556). No significant differences were detected among the studied groups concerning diabetes mellitus (P = 0.733), chronic obstructive pulmonary disease (P = 0.564), previous myocardial infarction (P = 0.370), isolated or combined surgery (P = 0.508), left main stenosis (P = 0.569), or emergency surgery (P = 0.508). Group A exhibited a significantly shorter hospital stay (26 ±4 days) than Group B (37 ±6) (P < 0.001). In contrast, no significant differences were observed among the studied groups concerning ventilation hours (P = 0.913) or ICU stay (P = 0.524). Group A demonstrated significantly lower reinfection than Group B (24% vs. 52%, respectively; P = 0.041). No significant differences were noted concerning reoperation for bleeding (P = 1.0) or mortality (P = 0.1). Group A demonstrated a significantly lower mean cost than Group B (110±23 vs. 140 ±37, respectively; P = <0.001).
Conclusion: Negative pressure wound therapy for postcoronary artery bypass graft mediastinitis could be more effective than the conventional treatment methods
Impact of Modified Del Nido Versus Traditional Cold Cardioplegia on Myocardial Protection in Cardiac Patients with a Low Ejection Fraction
Full text linkBackground: The optimal cardioplegia solution in patients undergoing complex cardiac surgery is debatable. This study aimed to compare the efficacy of modified Del Nido cardioplegia to that of conventional cold cardioplegia in patients undergoing cardiac surgery with low ejection fraction.
Methods: Participants were randomly divided into two groups: Group I had modified Del Nido cardioplegia (n=23), while Group II had standard blood cardioplegia (n=23).
Results: There was no difference in baseline data between the study groups. Group I had 20% lower additional doses of Del Nido (p= 0.032) and had shorter periods of cardiopulmonary bypass (2.78 ± 0.69 vs 3.35 ± 0.72 h, p= 0.039) and aortic cross-clamp (2.1 ± 0.56 vs. 2.5 ± 0.8 h, p= 0.040) times. Group I’s need for inotropes decreased by 20% (p= 0.044). Postoperative data revealed that Group I had less time in the hospital (5.9 ± 2.9 vs. 7.7 ± 3.4 days, p= 0.037) and intensive care unit (26.3% less duration) and required less time to wean off the mechanical ventilator (18.2 ± 15.7 vs. 45.4 ± 22.7, p<0.001). There was no difference in mortality between the two groups.
Conclusion: In complex cardiac surgery patients with low ejection fraction, modified Del Nido cardioplegia may be as effective as traditional cardioplegia, with the added benefit of shorter cross-clamp and cardiopulmonary bypass times. Additionally, modified Del Nido cardioplegia may result in less inotropic support
Comparison of two surgical approaches for the treatment of atrial septal defects
Full text linkBackground: Cardiac surgery has adopted less invasive procedures in the last two decades, aiming to reduce surgical insult and achieve early patient recovery. The present study compared median sternotomy and minimally invasive techniques for managing atrial septal defects.
Methods: The current study is a prospective cohort comparative study that included 67 patients randomly divided into two groups. Group A included 34 patients with median sternotomy; their ages ranged from 2 to 40 years (mean± SD 36.12±7.3 years). Group B (n= 33) underwent minimally invasive surgery, and their ages ranged from 21 to 46 years (mean± SD 32.09±7.35).
Results: Minimally invasive patients had fewer blood transfusions (1.06±0.24 vs. 1.79±0.25 units, P<0.001), less pain on the second day (3.73±0.72 vs. 7.94±1.01, P<0.001) and fifth day (2.09±0.52 vs. 5.38±.49, P<0.001) of the operation, and a shorter duration of hospital stay (4.85±0.75 vs. 6.38±0.78 days, P<0.001) than median sternotomy patients. Wound infection was reported in three cases with minimally invasive surgery, while nine patients had wound infection with median sternotomy. However, both groups had no reported mortality after two months of follow-up.
Conclusion: Atrial septal defect closure with minimally invasive approaches could be safe with low morbidity, a fast recovery phase, and the ability to restore normal activities
Comparative study between minimally invasive and open esophagectomy for the treatment of esophageal cancer
Full text linkBackground: Complete resection of the esophageal tumor is the gold standard therapy. The optimal surgical approach for esophagectomy is still controversial. This study compared the short-term outcomes of minimally invasive (MIE) and open esophagectomy for treating esophageal cancer.
Methods: A prospective study was conducted on 70 consecutive patients who received esophagectomy for esophageal carcinoma between 2017 and 2019 at Henan Cancer Hospital, Zhengzhou, China. Fifty patients received MIE (Group A), and 20 received open esophagectomy (Group B). Among Group B, 17 patients had left thoracotomy, and three had three incision esophagectomy.
Results: The mean age in Group A was 61.48 ± 8.06 years, and 61.3 ± 7.52 years in Group B (p= 0.932). In Group A, most of the tumors were located in the middle thoracic area (56%), while in the open esophagectomy group, most of the tumors were located in the lower thoracic-esophagogastric junction area (50%) (p<0.001). The most common stage in Group A was (T3N0M0) and (T3N0M0) in Group B (p= 0.044). Neoadjuvant therapy was used in 48% of patients in Group A and 15% in Group B (p=0.08). The mean number of resected lymph nodes in Group A was 28.8 ± 7.8 lymph nodes versus 22.4 ± 7.7 in the open esophagectomy group (p=0.003). The mean operative bleeding amount was 80±34.6 ml and 185± 46.2 ml for groups A and B, respectively (p=0.001). The mean ICU stay for Group A was 0.5± 0.7 days versus 0.4± 0.6 days for Group B (p=0.4). The mean postoperative hospital stay for Group A was 8± 3 days, while in Group B, the mean postoperative hospital stay was 14± 3 days (p=0.001). Postoperative complications occurred in 2 patients (4%) in Group A and seven in Group B (p= 0.001). No tumor recurrence was detected radiologically among the two groups in the three months follow-up period.
Conclusion: Minimally invasive esophagectomy may be a feasible and safe procedure for patients with early-stage esophageal cancer or locally advanced neoplasms who have received neoadjuvant therapy