The Egyptian Cardiothoracic Surgeon (ECTS - E-Journal)
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Candida Auris Endocarditis: An Enigmatic Case from Diagnosis to Management
Full text linkBackground: The most common diagnosed cause of invasive candidiasis is Candida Albicans but according to literature a lot of confirmed cases of Candida Auris become emerging multidrug-resistant infections. In a Japanese patient in 2009, Candida Auris was first described. This fungus is attributed to many outbreaks in different countries. It is a highly resistant variant and one of the most violent emerging pathogens.
Case presentation: We present a case of endocarditis caused by Candida arius that resulted in a large vegetation on the mitral valve with severe mitral regurgitation.
Conclusion: Management of endocarditis by collaboration between surgical and non-surgical facilities may ensure a good outcome even in the case of rare violent infections
Timing of repair of ischemic ventricular septal rupture; results of early vs. late repair
Full text linkBackground: The optimal time to repair ischemic ventricular septal rupture (VSR) is debatable. We compared the outcomes, including operative mortality, between patients who underwent early vs. late VSR repair.
Methods: Twenty-eight patients presented with VSR were included in this study. Patients were grouped according to the timing of repair into two groups; the early repair group (n= 12) and the late repair group (n= 16). The primary endpoint was operative mortality.
Results: There was no difference in age, gender, and associated comorbidities between between early and late repair. Anteroapical VSR was the most common type in both groups. There was no difference in the number of bypass grafts in both groups. Ischemic (95 (88- 142.5) vs. 137 (120- 147.5) min; P= 0.028) and cardiopulmonary bypass times (123.5 (115.5- 177.5) vs. 172.5 (152.5- 185) min; P= 0.023) were significantly shorter in patients who had delayed repair. Nine patients (75%) had operative mortality in the early repair group versus three patients (18.75%) in the late repair group (P= 0.006). There were no differences in blood loss, stroke, wound infection, ICU, and ward stay among the surviving patients.
Conclusion: Delayed repair of ischemic ventricular septal rupture could be associated with lower mortality in properly selected patients. Additionally, the delayed repair could decrease the ischemic and cardiopulmonary bypass times
Right coronary artery severe stenosis as a predictor of new onset atrial fibrillation after coronary artery bypass surgery
Full text linkBackground: post-operative Atrial fibrillation (POAF) commonly occurs in patients undergoing cardiac surgeries including Coronary artery bypass grafting (CABG). Role of right coronary artery (RCA) stenosis in developing POAF after CABG is not settled yet.
Objective: This retrospective study aimed to assess severe RCA stenotic lesion (70% or more narrowing) as a predisposing factor for POAF, in patients undergoing on-pump CABG, whether the RCA was grafted or not.
Patients and methods: A total of 100 patients who underwent on-pump CABG in xxxx Hospitals and xxxx Hospitals between January 2022 and June 2022 were divided into two groups: Group (A) had severe right coronary artery disease, and Group (B) did not have severe right coronary artery disease. Following the operation, all patients were examined daily for electrocardiogram (ECG) alterations until they were discharged.
Results: The mean age of the included patients was 52.6 (± 3), and 55 % of them were females. The mean Left ventricular ejection fraction was 56 (± 5). Incidence of atrial fibrillation was significantly higher in patients with severe RCA stenosis compared to those without severe RCA stenosis; p= 0.001 (68% vs 34%) denoting positive correlation between significant RCA stenosis and POAF; r=0.340, p=0.001.
Conclusion: Severe RCA stenosis is one of the predictors of developing AF after CABG
Early outcomes of minimally invasive mitral and tricuspid valve surgery in obese patients
Full text linkBackground: Minimal invasive valve surgery is the new trend in cardiac surgery. Many obstacles are present to increase the number of cases operated on with minimally invasive surgery. Minimal invasive surgery is technically demanding in obese patients with uncertain outcomes. In this study, we compared minimal invasive mitral and tricuspid valve surgery (MIVS) in obese patients with high BMI (body mass index) to normal BMI.
Method: We included 240 cases who underwent MIVS. These cases were divided into two groups. Group I (n=120) included patients with BMI >30 Kg/m2, and Group II (n=120) had BMI ≤30 Kg/m2.
Result: There was no in-hospital mortality in both group. Postoperative wound infection was nonsignificantly higher in Group I (9 (7.5%) vs. 2 (1.67%); P= 0.059). Drainage (450± 112 vs. 240± 230 ml; P<0.001), mechanical ventilation time (13.4± 1.3 vs. 6.4± 6.8 h; P<0.001), and ICU stay (2± 0.4 vs. 3.5± 1.3 days, P<0.001) were significantly higher in Group I. New onset atrial fibrillation was significantly higher in obese patients (P= 0.029). There were no differences between both groups in other outcomes.
Conclusion: Minimally invasive surgery in obese patients had satisfactory outcomes compared to those with normal BMI. Obesity should not be considered a contraindication for minimally invasive surgery
The Use of lactate as a marker of occult hypoperfusion and outcome following adult cardiac surgery
No full textBackground: Hyperlactaemia (HL) is a hypoperfusion marker associated with increased mortality. We aimed to determine whether postoperative serial arterial lactate (AL) measurements after cardiac surgery could predict mortality, atrial fibrillation, wound infection, prolonged ventilation, ICU stay duration, and renal failure.
Methods: Between September 2020 and November 2022, this prospective cohort study was conducted on 100 patients who were split into two groups: Group 1 (n= 17) had low lactate levels, and Group 2 (n= 83) had high lactate levels equivalent to or greater than 4 mmol/L.
Results: Body mass index (BMI) (26± 2.6 vs. 23.2 ±1.4, P 0.001), diabetes mellitus (59% vs. 29.4%, P = 0.026), and smoking (57.8% vs. 17.6%, P = 0.003) were all significantly higher in Group 2. Group 2 had a significantly longer cross-clamp time (77 22 vs. 64 26; P = 0.043). Atrial fibrillation (39.8% vs. 0%, P = 0.001), ventilation time (24 (8- 150) vs. 8 (6- 12) hours, P = 0.001), renal dysfunction (26.5% vs. 0%, P = 0.016), length of ICU stay (4 (1- 10) vs. 2 (2- 3) days, P = 0.001), and mortality (28.9% vs. 0%, P = 0.04) were all significantly higher in Group 2. Peak intraoperative lactate showed moderate significant positive correlations with BMI (r = 0.349, p < 0.001), cross-clamp (r = 0.483, P < 0.001), cardiopulmonary bypass time (r = 0.426, P < 0.001), and length of ICU stay (r = 0.468, P < 0.001).
Conclusion: Hyperlactatemia could be associated with higher postoperative morbidity and mortality. Hyperlactemia and its causes should be treated once diagnosed to improve the outcomes
Multiple arterial grafts for total arterial coronary artery bypass grafting vs. the conventional approach
Full text linkBackground: Conduit choice for coronary artery bypass grafting (CABG) is a hot topic. The objectives of this study were to characterize the patients who received multiple arterial grafts vs. vein grafts; additionally, we compared the outcomes in those patients.
Methods: This retrospective study included 195 consecutive patients who underwent CABG. We grouped the patients into three groups according to the conduits used with the left internal mammary artery (LIMA). Group I had saphenous vein grafts (SVG) (n= 31), Group II had radial artery grafts (RA) (n= 86), and Group III had the bilateral internal mammary artery (BIMA) plus RA (n= 78).
Results: The patients with multiple arterial grafts were significantly younger (64.87±8.2 vs. 68.42±9.03 vs. 61.76±8.6 years, in the SVG, LIMA_RA, and BIMA+RA groups, respectively, P<0.001). Off-pump surgery was significantly more prevalent in patients with LIMA+RA (P= 0.01). Postoperative drainage was significantly higher in patients with BIMA+ RA compared to LIMA+RA (P= 0.006), with no significant difference between BIMA+ RA and LIMA+SVG (P= 0.081). Sternal wound infection was non-significantly higher with multiple arterial grafts (P=0.09). There was no difference in other hospital outcomes among groups. The median follow-up was 59 (47-66) months. The composite endpoint of recurrent angina, myocardial infarction, coronary revascularization, and heart failure occurred in 17 patients [4 (12.9%) vs. 8 (9.30%) vs. 5 (6.41%), in the vein graft, one arterial and two arterial grafts groups, respectively] (P=0.484). Mortality occurred in 7 patients, [1 (3.23%) vs. 4 (4.65%) vs. 2 (2.56%), in the vein graft, one arterial, and two arterial grafts groups, respectively] (P= 0.834).
Conclusions: Total arterial revascularization with multiple arterial grafts could increase postoperative drainage and sternal wound infection, with no difference in the short and long-term outcomes compared to single arterial and vein grafts. The choice of the conduit for coronary artery bypass grafting should be tailored according to the patient's characteristics
The impact of increased body mass index on the outcomes after valve replacement
Full text linkBackground: The association between obesity and the outcomes of surgery is controversial. This study aimed to assess the effect of body mass index (BMI) on early and late morbidity and mortality after valve replacement surgery.
Methods: The study was conducted on 100 valve replacement patients from 2020 to 2022. The patients were divided according to BMI into two groups: patients with morbid obesity (BMI ≥ 35) (Group A: n = 50) and patients who had BMI< 35 (Group B.; n = 50).
Results: Hospital (9.43 ± 5.93 vs. 7.25 ± 4.05 days, P= 0.034), ICU length of stay (7.32 ± 5.67 vs. 4.52 ± 3.24 days, P= 0.003), and duration of mechanical ventilation (3.58 ± 2.54 vs. 2.342 ± 2.05 days, P= 0.008) were significantly higher in Group A. There was no significant difference in postoperative mortality between both groups (P= 0.678). There was no significant difference in morbidity and mortality after a 3-month follow-up. Hemoglobin was significantly lower in Group A (P =0.034), with no difference in postoperative laboratory investigations.
Conclusions: Morbid obesity was not associated with increased mortality after valve replacement surgery; however, it could increase the duration of ventilation, ICU, and hospital stay
Redo mitral valve replacement for initially rheumatic heart disease: In-hospital outcomes and operative risk prediction
Full text linkBackground: Redo mitral valve replacement (redo-MVR) remains a challenge despite advances in surgical techniques. Little is known about the outcomes of redo-MVR in patients with rheumatic heart disease. We aimed To evaluate the in-hospital outcomes and associated risk factors for mortality and morbidity after re-operative mitral valve replacement in patients with initial rheumatic heart disease.
Methods: This retrospective cohort study included 214 patients, 96 males (44.9%) and 118 females (55.1%), who underwent redo-MVR between January 2015 and December 2020. The mean age was 41.87±11.7 years. European Heart Surgery Risk Assessment System II (EuroSCORE II), Age, Creatinine, Ejection Fraction (ACEF) scores were used for risk stratification. The primary endpoints were in-hospital mortality, major morbidity (renal failure, prolonged ventilation, stroke, reoperation, or deep sternal wound infection), and the composite outcome of mortality and/or morbidity).
Results: Major morbidities occurred in 31.8% of patients, and the in-hospital mortality rate was 19.6%. Predictors of mortality were New York Heart Association class (NYHA) III/IV (OR: 5.4; p˂ 0.001), cardiogenic shock (OR: 13.74, p˂0.001), low left ventricular ejection fraction (LVEF) (OR: 4.36; p= 0.01), and perioperative intra-aortic balloon pump (OR: 6.79; p= 0.01). The significant predictors of mortality and/or major morbidity were NYHA III/IV (OR: 2.39; p˂0.001), low LVEF (OR: 4.44; p= 0.001), active endocarditis (OR: 2.4; p=0.04), and perioperative IABP (OR: 3.88; p= 0.045). EuroSCORE II had better accuracy than the ACEF score to predict adverse outcomes (AUC: 0.70 [95% CI: 0.63-0.78] versus 0.58 [95% CI: 0.50-0.66], p= 0.01) .
Conclusion: Advanced NYHA class and low LVEF could be associated with poor outcomes after redo-MVR in patients with primary surgery for rheumatic mitral valve disease. EuroSCORE II is a helpful tool for risk stratification during redo-MVR
Intensive care unit psychosis after cardiac surgery
Full text linkBackground: Postoperative psychosis after cardiac surgery is associated with increased morbidity, length of hospital stay, and mortality. We aimed to assess the risk factors and outcomes of postoperative psychosis after cardiac surgery. Methods: This research is a retrospective observational case-control study that included 100 patients divided into two groups. Group 1 included 50 patients with postoperative psychosis, and Group 2 included 50 patients with no postoperative psychosis. Data were collected from the Cardiac Surgery Department database from October 2020 to April 2021.
Results: The mean age was 67.94 ± 11.69 years in patients with psychosis and 68.98 ± 10.19 years in the control (P= 0.636). Males patients presented 66% (n= 33) in patients with psychosis versus 70% (n= 35) in the control group. Cardiopulmonary bypass (144.9 ± 35.61 vs. 109.1 ± 17.19 min, P˂0.001) and ischemic times (61.96 ± 15.93 vs. 50.52 ± 9.62 min, P˂0.001) were significantly longer in patients with psychosis. The mean arterial pressure (MAP) (61.93± 13.44 vs. 80.78 ± 5.91 mmHg, P˂0.001) and oxygen saturation (79.82 ± 8.81 vs. 90.12 ± 4.91%; P˂0.001) were significantly lower in patients with psychosis. Central venous pressure was 11.76± 2.33 in patients with psychosis versus 3.58± 1.70 mmHg in the control group (P˂0.001). ICU was significantly longer in patients with psychosis (4.82 ±2.14 vs. 1.62 ± 0.55 days; P˂0.001), while there was no difference in the hospital stay. By multivariable analysis, lower MAP was an independent predictor of postoperative psychosis (OR: 0.930 (95% CI: 0.737–0.999), P= 0.045).
Conclusion: Low mean arterial pressure could predict postoperative psychosis. Proper blood pressure control could decrease the incidence of psychosis after cardiac surgery
Right internal mammary artery for the management of anomalous right coronary artery from the left sinus of Valsalva; a case report
Full text linkBackground: Anomalous origin of the right coronary artery from the left sinus of Valsalva (ARCA) is a rare anomaly. Surgery is recommended in symptomatic patients, while the optimal surgical approach is controversial.
Case presentation: We present a case of an ARCA in a 56-year-old male who was managed with coronary artery bypass grafting using the right internal mammary artery and ligation of the proximal right coronary artery. The patient remained asymptomatic after 1 year of follow-up.
Conclusions: ARCA can be managed using the right internal mammary artery with ligation of the proximal right coronary artery to prevent the competitive flow