The Egyptian Cardiothoracic Surgeon (ECTS - E-Journal)
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Early Outcomes of Coronary Artery Bypass Grafting in Patients with Preoperative Renal Dysfunction
Full text linkBackground: Chronic kidney disease combined with coronary artery disease is a growing public health issue. Preoperative renal dysfunction is one of the major risk factors for perioperative morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG). This study aimed to analyze the early clinical outcomes of CABG in patients with preoperative renal impairment.
Methods: The study was conducted from July 2017 to July 2019. We included 100 patients who underwent CABG. Group A (n= 50) included patients with preoperative renal impairment and group B (n= 50) had patients with normal renal functions.
Results: The mean age was 63.3±9.1 years in Group A and 57.1±8.5 years in Group B (P<0.001). There were 35 males in Group A and 47 in Group B (P<0.001). Blood transfusion was more in Group A (47 (94%) vs. 32 (64%) patients; P=0.001). There was no difference in mortality between both groups.
Conclusion: Preoperative renal impairment in patients undergoing CABG is more common in elder females. Patients undergoing CABG with preoperative renal impairment could have a higher risk for blood transfusion
Groin Complications After Femoral Artery Cannulation in Minimally Invasive Cardiac Surgery
Full text linkBackground: Femoral cannulation is commonly used during minimally invasive cardiac surgery. We evaluated the occurrence of postoperative groin complications after femoral cannulation in minimally invasive cardiac surgery.
Methods: This retrospective study included 140 patients who had minimally invasive surgery with femoral cannulation. One hundred twelve patients (80%) had mitral valve surgery, 24 patients (17.1%) had atrial septal defect repair, and four patients (2.9%) had myxoma excision. Their mean age was 41.47± 11.71 years, and 60% were females (n= 84).
Results: Groin complications occurred in 14 patients (10%); seroma developed in 11 patients (7.9%), two had femoral artery hematoma (1.4%), and 1 (0.7%) patient had femoral arterial dissection, which was primarily repaired. There were no differences in the preoperative data between patients with and without groin complications. Patients with groin complications had non-significantly longer cardiopulmonary bypass time (155± 43.6 vs. 129.8± 35.7 min, P= 0.2) and longer hospital stay (13±3.8 vs. 11.6±4.3 days, P= 0.2)
Conclusions: Groin complications are relatively uncommon in minimally invasive procedures and are usually simple to manage
The Sonographic Measurement of the Inferior Vena Cava Diameter versus the Central Venous Pressure in Assessing Fluid Responsiveness in Patients after Coronary Artery Bypass Graft Surgery
Full text linkBackground: Fluid status assessment and management post coronary artery bypass grafting (CABG) is a clinical challenge. The study aimed to establish whether central venous pressure (CVP) and ultrasound measures of respiratory variability of inferior vena cava (IVC) diameter might predict fluid responsiveness in mechanically ventilated patients after CABG.
Methods: This comparative study included 200 consecutive adult patients who underwent elective CABG. We recorded the following parameters: heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), central venous pressure (CVP), inferior vena cava maximum (IVCmax), and minimum (IVCmin) diameters, left ventricular ejection fraction (LVEF), and velocity-time integral in the left ventricular outflow tract (VTI-LVOT).
Results: The age of the patients ranged from 45 to 71 years, and 147 were males (73.5%). Patients were grouped into fluid responders (n= 135), defined as stroke volume variation (SVV) of 15% or greater following fluid bolus administration, and fluid non-responders (n= 65), defined SVV of less than 15% following fluid bolus administration. There was no statistically significant difference between the groups regarding their CVP, maximum and minimum IVC diameters, inferior vena cava distensibility index (IVC-DI), and other markers of fluid responsiveness (p-value 0.47, 0.34, 0.59, and 0.64, respectively). There was a significant difference in SVV between fluid responders (18.33±2.767) and non-responders (10.95±1.940) (p-value <0.001).
Conclusion: Neither CVP nor sonographic measures of IVC diameter respiratory variability provided an accurate method to distinguish between fluid responders and non-responders in the early postoperative period after CABG
Coronary artery bypass grafting in non-dialysis dependent chronic renal disease
Full text linkBackground: Renal impairment is associated with increased morbidity and mortality after coronary artery bypass grafting (CABG). Therefore, we aimed to study the risk factors of increased morbidity and mortality after CABG in patients with non-dialysis-dependent mild-to-moderate chronic kidney disease.
Methods: This prospective study included 50 patients with non-dialysis-dependent renal impairment (renal disease stage II or III) with off-pump (n= 25) or on-pump (n= 25) CABG. Postoperative outcomes and creatinine levels were compared between both groups.
Results: The mean age of all patients was 48.4±12.3 years, and females presented 54% (n= 27). There were no differences in postoperative myocardial infarction (P= 0.923), atrial fibrillation (P= 0.776), blood transfusion (P=0.794), and ICU (P=0.772) and hospital stay (P= 0.698) between groups. Mechanical ventilation was longer in patients with on-pump CABG (16.4 ± 10.9 vs. 6.1 ± 3.2 hours; P˂0.001). Creatinine levels were significantly lower in patients who had off-pump CABG (P˂0.001). The cumulative mortality hazard increases to 56.7% in patients with preoperative creatinine levels above 2 mg/dl.
Conclusion: High preoperative creatinine levels could increase mortality in patients undergoing CABG. Off-pump CABG could be a better approach in patients with mild to moderate renal dysfunction
The effect of subcutaneous drain insertion after median sternotomy on surgical site infection in obese patients
Full text linkBackground: Sternal wound infection after cardiac surgery is associated with high morbidity and mortality. This study aimed to assess the effect of subcutaneous wound drainage on surgical site infection in overweight patients undergoing cardiac surgery via median sternotomy.
Methods: This prospective study was conducted on 100 obese patients undergoing sternotomy as a part of cardiac surgery from March 2021 to June 2022. The study included two groups. Group 1 (n= 45) had prophylactic subcutaneous drainage after surgery, and Group 2 (n= 55) did not have prophylactic subcutaneous drainage.
Results: Hospital stay (7.8±1.9 vs. 8.65±1.38 days; P= 0.013) were higher in patients without drains. Deep sternal wound infection [2 (4.44%) vs. 9 (16.4%); P= 0.105], superficial wound infection [2 (4.44%) vs. 7 (12.7%); P= 0.18] and debridement with secondary suture [1 (2.2%) vs. 6 (10.9%); P= 0.125] were non-significantly lower in patients with subcutaneous drains.
Conclusion: Obese cases who received prophylactic subcutaneous wound drainage after sternotomy wound closure could have a lower incidence of wound complications. A larger randomized trial is recommended
Short Term Outcome of Plasma Pleurodesis in Post Pulmonary Resections Persistent Air Leak
Full text linkBackground: Air leak is the most common morbidity after pulmonary resection surgery. It may result in prolonged duration with chest tubes with their annoying chest pain, prolonged hospital stay time with increased financial costs, pneumonia, empyema, and patient dissatisfaction. Our objective was to evaluate the efficacy of plasma pleurodesis for stoppage of air leak after lung resection, in comparison to conservative measures.
Methods: This prospective single-blinded randomized study included 60 patients randomly divided into two groups:
Group A: included 30 patients who received intrapleural fresh frozen plasma. One bag of FFP, contains 250 ml of plasma, matched for the ABO group was installed through the apical chest tube into the pleural cavity.
Group B: a control group of 30 patients who did not receive any sclerosing agent. They were managed with under-water seal and observation.
Results: This study showed that the stoppage of air leak in group A was faster “which stopped in 9-10 days” in comparison to control group B “24-25 days”, (P-value <0.001). There was a significant difference between groups A and B regarding the hospital stay, which was in 9-10 days in group A in comparison to group B “26-28 days (P-value <0.001).
Conclusion: Intrapleural fresh frozen plasma appears to be a valuable option to stop persistent air leaks post pulmonary resections. It’s a cheap, available, and safe agent. It reduced hospital stay, costs and morbidities
Impact of Levosimendan on High Sensitivity Cardiac Troponin-T after Valvular Heart Surgery: A Randomized Clinical Trial
Full text linkBackground: Various measures have been used for maintaining adequate cardiac output after valvular heart surgery. The study aimed to evaluate the impact of levosimendan on high-sensitivity cardiac troponin-T after valvular heart surgery.
Methods: This prospective randomized clinical trial included 400 patients. All patients above 18 years who underwent elective cardiac valvular surgery were randomly classified into two equal groups. Group A (n= 200) included patients who received levosimendan during weaning from cardiopulmonary bypass, and Group B (n= 200) included patients who did not receive levosimendan.
Results: Cardiopulmonary bypass, cross-clamp, reperfusion times, and use of inotropes were insignificant between groups. Troponin levels on days 0, 1, and 2 showed a significant decrease in Group A (P˂0.001). Postoperative ejection fraction was significantly higher in Group A (66.10 ± 4.41 vs. 46.60 ± 3.98; P˂0.001). Duration of mechanical ventilation (4.70± 1.16 vs. 10.70± 0.82; P˂ 0.001), intensive care (1.90 ± 0.57 vs. 5.90 ± 1.29; P˂0.001), and hospital stay (6.90 ± 1.91 vs. 13.40 ± 3.10; P˂0.001) were significantly lower in Group A.
Conclusions: Levosimendan could have cardioprotective effects, resulting in a significant reduction of postoperative high sensitivity cardiac troponin-T release after valvular heart surgery. It could be associated with improved left ventricular ejection fraction, short duration of mechanical ventilation, ICU, and hospital stay
Reconstruction of a Diffusely Diseased Left Anterior Descending Coronary Artery with Left Internal Thoracic Artery Patch: One year follow up
Full text linkBackground: Management of patients with extensive coronary artery disease (CAD) is challenging. This study presents the results of extensive reconstruction of the left anterior descending (LAD) coronary artery using the left internal thoracic artery (LITA) patch in patients with extensive LAD disease.
Methods: This study was conducted between January 2017 and April 2020 and included 86 patients. Males presented 88% (n=76), and the mean age was 57.8±7.31 years. Patients underwent long (2- 4 cm, n= 51) or extensive (≥4 cm, n=. 35) segment reconstruction of the LAD using LITA graft. Associated comorbidities were diabetes mellitus (n= 68, 79%), hypertension (n=, 60, 69%), and chronic kidney disease (n= 5, 5.8%).
Results: The mean cardiopulmonary bypass and aortic cross-clamp times were 107 ±21.24 and 68±12.8 min, respectively. ICU stay ranged from 1 to 15 days and hospital stay from 6 to 30 days. Seven patients (8%) needed IABP, 3 (3.5%) had low cardiac output, 10 (11.5%) had pulmonary complications, 5 (5.8%) had mediastinitis, 7 (8%) had a stroke, and 5 (5.8%) had acute kidney injury. Mortality occurred in seven patients (8%), 4 (4.6%) had hospital mortality, and 3 (3.5%) had late mortality. During the 1-year follow-up, 7 (8%) patients had recurrent anginal pain. CT angiography showed patent LITA to LAD in 6 patients.
Conclusion: Extensive LITA patch reconstruction of the diffuse LAD disease could be a safe procedure with accepted early clinical outcomes
Video-Assisted Thoracoscopic Surgery versus Open Decortication in Chronic Pleural Empyema
Full text linkBackground: The role of video-assisted thoracoscopic surgery (VATS) for managing organized empyema is still limited. This study compared VATS versus open decortication in patients with chronic pleural empyema.
Methods: This randomized controlled trial included 58 patients with stage III empyema. Patients were divided into two groups. Group A (n= 30) included patients who had decortication through an open thoracotomy, and Group B (n= 28) included VATS decortication patients. Two patients in the VATS group were converted to the open approach and were excluded from the analysis.
Results: The mean age in Group A was 48.23 ± 8.44 years and 49.79 ± 7.85 years Group B (p= 0.47). There were 16 males (53.3%) in Group A and 15 (63.6%) in Group B (p= 0.99). The operative time was 336.0 ± 67.60 min in Group A and 291.07 ± 56.66 min in Group B (p= 0.01). There was no difference in intraoperative complications between groups. Postoperative hospital stay (p= 0.23) and ICU admission (p= 0.24) did not differ between groups. In Group A, the pain scale was 8 (6- 8), and it was 4 (2- 4) in Group B (p˂ 0.001). No difference was recorded in the postoperative complications between groups.
Conclusion: The outcomes of VATS in managing stage III empyema are comparable to the open approach. VATS has the advantage of lower postoperative pain. VATS could be an alternative to open decortication in patients with stage III pleural empyema
Operating a recurrent synovial sarcoma of the sternoclavicular joint: a case presentation
Full text linkBackground: Synovial sarcoma is one of the rarest soft tissue tumor with a high grade of malignancy. Primary synovial sarcoma of the chest wall is rare.
Presentation of case: A 65-year-old woman presented with history of left upper chest wall mass previously operated 9 months ago. The pathological report was a synovial sarcoma. Computed chest tomography was done and revealed a RT anterior infraclavicular mass with cystic a solid lesions measuring 8.5 *3.5*4 cm.
Conclusion: The synovial sarcoma is aggressive malignancy and we think from the story of this case that early radical surgery plus systemic chemotherapy provides better outcome