egyptian society of cardio- thoracic surgery board...

Egyptian Society of Cardio- Thoracic Surgery Board of Directors

PresidentAhmed Labib , MD

Vice PresidentMohamed El Battowy, MD

Ahmed Abdel Aziz , MD

Elhusseiny Gamil , MD

General SecretaryMohamed Emara , MD

Ahmed Saleh , MD

Osama Mohamed , MD

TreasurerHisham Abdel Rahman , MD

Abdel Megid Mohamed , MD

Khaled Saad Eldin , MD

Mohamed Helmy , MD

Editor in chief jegyptsctsM. Abdelraoof , MD

Aly Hasan , MD

Hossam El Shahowy , MD

Wahid Osman , MD

Number (3-4)Volume 18 Jul - Dec 2010

Egyptian Societyof

Cardio- Thoracic SurgeryJournal Board

EDITOR-IN-CHIEFYasser M. W. Hegazy MD, FRCS

PAST EDITORSHassouna M. El-sabea, FRCS (1995-1996)

Mohamed S. El-Fiky, MD (1997-2004)Ezzeldin A Mostafa, MD (2004-2009)

CO-EDITORAhmed M Deebis, MD

Ahmed M Hassouna, MDAhmed El Kerdani, MD

ASSOCIATE (SECTION) EDITORSAhmed El Nouri, MD

Ashraf El Bassiony, FRCSMamdouh Sharawi, MD

Mohamed Eissa, MDSamir A. Hassan, MDSamir A. Keshk, MD

ETHICS EDITORM. Anwar Balbaa, MD

Submit Manuscripts: Editotial office330 El Sudan Street, Embaba , Egypt

Email : [email protected]. 3303 8054 - Mob. 0102327650

A4 The Journal of Egyptian Society Cardiothoracic Surgery ● Jul - Dec 2010

Abdel Fattah A. Abid ,Tunis . TunisiaAdel El Banna MD Cairo, EgyptAmal Ayoub, Cairo, Egypt Ahmed M. Amin Csiro, RgyptAhmed M. Ali, Banha, EgyptAhmed labib MD, Menofia. EgyptAhmed R. Nasr, Cairo, EgyptA. Samir El-Kosheiry , Cairo, EgyptAliS. Maklad, Cairo, EgyptAyman A. Soieb Cairo, EgyptAlradi kamal, Zagazig, EgyptAmro Bastawissy MD Cairo,EgyptBabulal Sethia, London, EnglandBertrand M. Goudot, Paris, FranceB M Fabri , Liverpool , EnglandBryn T Williams, Weybridge, EnglandDaniel G. Guilmet, Paris, FranceDavid J. Wheatley, Glasgow, EnglandEl-Nouri Ahmed, Cairo , EgyptEl-Hussieiny Camil , Cairo , EgyptFawzi Hossam on bario Canda Fouad Z Abdalla , Cairo , EgyptGerard Block, Paris, FranceGamal O. Abou Senna , Cairo ,EgyptGraham E. Venn, London, EnglandHamed Akshar MD Tanta EgyptHasan Alzahrani, Mekka, Saudi ArabiaHussein A.Gaafar, Cairo, EgyptHamdy M. El-Sayed, Cairo , EgyptHamed M. Al Akshar , Tanta , EgyptHisham A. Shawki, Cairo ,EgyptIhab Abdelmonem MD Tanta EgyptIbrahim Kadcazi MD Alex. EgyptIsmail A. Sallam , Cairo , EgyptIbrahim Haggag, Cairo , EgyptJames J. Pollock, Glasow, England

Journal SecretaryAhmed Ali Kalife

Editorial ManagerM Essa MD

M Othman MS

Jean-Paul F. Bessou, Rouen, FranceJohn R, Pepper , London , EnglandLotfi Eissa, Cairo , EgyptMohamed Abdel Alim MD Cairo EgyptMohamed A. Hamed, Cairo , EgyptMohamed Abou El-Ezz, Cairo , EgyptMostafa Agha, Alexandria, EgyptMohamed Batawi MD Cairo EgyptMohamed Elamir Alex, EgyptMohamed F. Bassiouni , Cairo , EgyptMohamed Emara MD Cairo EgyptMarc de Leval , London , EnglandM El-Fakih , Riadh , Saudi ArabiaMamdouh Gamal , Einthoven, HollandM. Ezzeldin Abdel Raouf , Cairo EgyptMagdi Gomaa . Cairo , EgyptMohamed S El-Fiky, Cairo, EgyptMarco Pozzi, Liverpool, EnglandMortaga Negm MD Cairo EgyptM S Ammar, Tunis, TunisiaMaher Shoier, Cairo, EgyptMogazy A. Tantawy, Cairo, EgyptMedhat A. El-Gamal, Cairo , EgyptMorsi Amin MD Suez EgyptPierre Michel Roux, Metz, FranceRobert M. Soyer, Rouen, FranceSherif Abdel Hady , Cairo , Egypt Shaaban Abu Elelaa , Mansoura , EgyptSamieh A Amer , Cairo , EgyptSami S. Kabbani , Damascus , SyriaSteven Tsui , Cambridge , EnglandTarek Z. Shallaby Cairo , EgyptWadih R. Dimitri, Birmingham, EnglandWahid Osman , Cairo , EgyptWalaa Saber MD Cairo EgyptZohair Al-Halees, Riyadh, Saudi ArabiaZohni M. Farrag , London , England

EDITORIAL BOARD

The Journal of Egyptian Society Cardiothoracic Surgery ● Volume 18, Number (3-4) A5

Journal of The Egyptian Society of Cardio-Thoracic Surgery

Volume 18

CONTENTS

Jul - Dec 2010 Number (3-4) ISSN 1110-578X

A7A11A12A14

Guidelines for authorsGondition for publication formGuidelines for reviewersEvents of interests

ANNOUCEMENT

EDITORIALFreedom

First President of the Society addressYasser Hegazy MD , FRCS

Professor Anwar Balbaa MD

CARDIOVASCULAR

Mitral Valve Repair By Leaflet Augmentation With An Autologous Pericardial Patch In Rheumatic Mitral Valve Diseases

New Technique For Surgical Management Of Right Sided Active Infective Endocarditis

4

13

Mohamed El- Anwar, MD Ahmed Deebis MD, Moustafa El-Newahey MD, Moustafa El-Newahey MD, Mohamed Essa MD,

Ibrahim M. YassinMD Osama S. Abd El-Moneim MD

BMI and outcome of cardiac surgery in Scottish population

40

Ahmed Abdelgawad MD,Alan Dawson MD,Lisa Lawman MD,Hussien Elshafei MD

Cardiac surgery in nonagenarian. Should we operate? Cardiac surgery in nonagenarian

47

Ahmed Rezk, MD,Mushabab Almurayah, MD,Adel Almasswary, MD,Ali Youssef, MD,Wagih.Ouda, MD

Chylothorax after surgery for congenital heart disease in children: a retrospective observational study

76

Alaa Basiouni S MD Sameh Ibrahim MD

One year follow-up of omental flap for management Of deep sternal wound infection

67

Ahmed N. Khallaf MD, Ashraf A. Esmat MD,Tarek Eltawel MD

Current results of primary repair of truncus arteriosus in early infancy

51

Alaa-Basiouni S. MD

Local experience in management of post CABG Pericardial Effussion

35

Derar AlShehab MD ,Moataz S.,MD,Mohamed Abd.Rahman MD,Ayman A.,MD

Plication of paralysed diaphragm after congenital cardiac surgeries

71

Mohamed Fouad Ismail,MD, A.B.Said Mahmoud MD

Early postoperative outcome of total arterial coronary revascularization versus conventional CABG

22

Ahmed Khallaf MD,Ashraf Esmat MD,Tarek Eltawel MD and Yahia Balbaa MD

1

2

Early results of Skeletonized versus Pedicled radial artery in revascularization of coronary patients

27

Ibrahim M.Yassin,MD,SalahS. Atta M.D,Mohamad Attiya, M.D

THORACIC

Effectiveness of BioGlue In The Treatment Of Alveolar Air Leak

84

Mahmoud Abd-Rabo, MD

Case report Anomalous right coronary artery ostium encountered during aortic valve replacement surgery

98

Y Hegazy, MD ,R Jeffrey , MD ,S Mac Angnus

Case report

Graft Patency After using intra-Luminal Shunts during Off-Pump Coronary artery Bypass Grafting

90

A M Bassiony FRCS MD,Y M Hegazy FRCS MD,M M Mostafa MD*,M AbdelAzeem MD*,E AlKaady MD**,A Ashmawy MS**.

Osteomyelitis Of The Ribs As A Missed Late Post Cabg Ischaemic Chest Wall Complication

60

Ashraf El-Sebaie Mohammed, M.D.*and Mustafa El-Saban, M.D**.

TT


� 16 - 20 February 2011 Mamallapuram, Tamil Nadu India [iCalendar] CT CON 2011 - 57th Annual Conference of the Indian Association of Cardiovascular & Thoracic Surgeons Raddison GRT Temple Bay CME available

For information, contact: Secretariat, Doctor S. Rajan The Madra Medical Missioin No. 4-A, Dr. J.J. Nafar Nogappair, Chennai 600 037, Tamil Nadu, India Phone : + 91 44 26565991-Fax: +91 44 2656859 / 26565947 Email: [email protected] Additional information: http://www.ctcon2011.com

� 24 - 26 February 2011 Lugano Switzerland [iCalendar] European Multidisciplinary Conference in Thoracic Oncology Palazzo dei Congressi

For information, contact: EMCTO Conference Secretariat c/o ESMO Via Luigi Taddei 4 CH-6962 Viganello-Lugano Switzerland Phone: +41 (0)91 973 19 25 - Fax: +41 (0)91 973 19 18 Email: [email protected] Additional information: http://www.emcto.org

� 10 - 13 March 2011 Newport Beach, CA United States [iCalendar] 31st Annual Cardiothoracic Surgery Symposium (CREF) The Newport Beach Marriott Hotel and Marina

Abstract submission deadline: 1 February 2011 For information, contact: Susan Westwood, Program Coordinator 31st Annual Cardiothoracic Surgery Symposium (CREF) 793-A E. Foothill Boulevard, #119 San Luis Obispo, CA 93405 Phone: 1 805 541-3118 Fax: 1 716 809-4082 Email: [email protected] Additional information: http://www.amainc.com/cref_cardiothoracic.html

� 11 - 12 March 2011 Palma de Majorca Spain [iCalendar EACTS Course “Right ventricular outflow tract management from neonates to adults: an interdisciplinary view”

For information, contact: EACTS Executive Secretariat 3 Park Street, Windsor, Berkshire SL4 1LU, UK Phone: +44 1753 832166 Fax: 44 1753 620407 Email: [email protected]

� 11 - 12 March 2011 Marbella Spain [iCalendar] Marbella Aortic Symposium - Disasters In Open and Endovascular Aortic Procedurees, Learning from Complicatoins - (Cardiovascular Surgery Department, Carlos Haya University Hospital. Málaga) Fuerte Marbella CME available

For information, contact: Technnical Secretariat Viajes Villarreal, Málaga, Spain Phone: +34 952 44 55 86 Fax: +34 952 56 46 32 Email: [email protected] or [email protected] Additional information: http://www.MAS2011.COM

� 13 - 18 March 2011 Snowmass Village, CO United States [iCalendar] Interventional Cardiology 2011: 26th Annual International Symposium The Silvertree Hotel CME available Abstract submission deadline: 28 January 2011

For information, contact: Promedica International CME 2333 State Street, Suite 203 Carlsbad, California 92008 Phone: 1 760 720-2263 - Fax: 1 760 720-6263 Email: [email protected] Additional information: http://promedicacme.com/

� 16 - 18 March 2011 TBA [iCalendar] EACTS Course “Open and endovascular aortic therapy”

For information, contact: EACTS Executive Secretariat 3 Park Street, Windsor, Berkshire SL4 1LU, UK Phone: +44 1753 832166 - Fax: +44 1753 620407 Email: [email protected] Additional information: http://www.eacts.org

� 20-22 March 2011 London United Kingdom [iCalendar] SCTS Annual Meeting and Cardiothoracic Forum Excel London Abstract submission deadline: 5 November 2010

For information, contact: Isabelle Ferner 35-43 Lincoln’s Inn Fields London WC2A 3PE Phone: +44 (0)20 7869 6893 - Fax: +44 (0)20 7869 6890 Email: [email protected] or [email protected] Additional information: http://www.scts.org

� 24 - 26 March 2011 Houston, TX United States [iCalendar] Houston Aortic Symposium: Frontiers in Cardiovascular Diseases, The Fourth in the Series The Westin Oaks Hotel CME available

For information, contact: Jennifer Terchek Phone: 1 760 720-2263 Fax: 1 760 720-6263 Email: [email protected] Additional information: http://www.promedicacme.com/

� 31 March - 1 April 2011 Brisbane, Queensland Australia [iCalendar] Asia Pacific Heart Valve Forum - Beyond the Basics Sofitel Hotel

For information, contact: Taylored Images - Gosia Wisniewska PO Box 247, Ashgrove QLD 4060 Phone: +61 7 3366 2205 Fax: +61 7 3366 5170 Email: [email protected] or [email protected]

Events of Interest


� 13 - 16 April 2011 San Diego, CA United States [iCalendar] International Society for Heart and Lung Transplantation 31th Anniversary Meeting and Scientific Sessions Hilton San Diego.

For information, contact: The International Society for Heart and Lung Transplantation 14673 Midway Road Suite 200 Addison, Texas 75001 Phone: 1 972 490-9495 Fax: 1 972 490-9499 Email: [email protected] Additional information: http://www.ishlt.org/

� 14 - 16 April 2011 Zurich Switzerland [iCalendar] 50th Anniversary Zurich Symposium To Be Announced At A Later Date

For information, contact: Email: 50YearsHeartsurgery [email protected]

� 27 - 29 April 2011 Alexandria Egypt [iCalendar] 18th Annual Conference of the Egyptian Society of Cardiothoracic Surgery Helnan Palestine Hotel

For information, contact: Official Conference Organizer: Manar Travel Corner Rd. 7 & 82, Maadi Cario, Egypt Phone: (+202) 23594 110 /23590/23585 Fax: (+202) 23780 458 Email: [email protected] Additional information: http://escts2011.com

� 28 - 30 April 2011 Varese Italy [iCalendar] XII congress Società Italiana di Chirurgia nell’ Ospedalità Privata (SICOP) ATA Hotels

For information, contact: Organising Secretariat, Balestra Congressi P.za Roberto Malatesta, 16 00176 Roma (Italia) Phone: +39.06.2148068 - Fax: +39.06.62277364 Email: [email protected] or segreteriascientifica XIICongressoSICOP.it Additional information: http://www.xiicongressosicop.it

� 4-5 May 2011 New York, NY United States [iCalendar] ACTS 20011 - Advanced Cardiac Techniques in Surgery, The Eighth in the Series The Equitable Center & The Sheraton New York Hotel and Towers CME available

For information, contact: Promedica International CME Phone: 1 760 720-2263 Email: [email protected] Additional information: http://www.promedicacme.com/

� 7 - 11 May 2011 Philadelphia, PA United States [iCalendar] 91st Annual Meeting - American Association for Thoracic Surgery Pennsylvania Convention Center CME available

For information, contact: 900 Cummings Center Suite 221-U Beverly, MA 01915 Phone: 1 978 927-8330 Additional information: http://www.aats.org/annualmeeting

� 26 - 29 May 2011 Phuket Thailand [iCalendar] The First Conjoint Meeting of ATCSA and ASCVTS Hilton Phukiet Arcadia Resort & Spa Abstract submission deadline: 28 February 2011

For information, contact: Secretarial Office ProCOngress (Thailand) Co., Ltd. 4/383 Moo 6, Soi Nakniwas 37 Road Ladprao, Bangkok 10230 Thailand Phone: 662 956 1580 - Fax: 662 932 4454 Email: [email protected] or [email protected] Additional information: http://www.ascvts-atcsa2011.org

� 26 - 28 May 2011 Berlin, Germany [iCalendar] 19. Jahrestagung der Deutschen Interdisziplinären Gesellschaft für Außerklinische e.V., vormals Arbeitsgemeinschaft für Heimbeatmung und Respiratorentwöhnung e.V., und 6. Beatmungssymposium der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin Berliner Congress Center Abstract submission deadline: 11 February 2011

For information, contact: Veranstalter und Kongress-Organisation Karlsruher Str. 3 89108 Freiburg Phone: 0761 696 99 0 - Fax: 0761 696 99 11 Email: [email protected] Additional information: http://www.beatmungskongress2011.de

� 5 - 8 June 2011 Marseille France [iCalendar] 19th European Conference on General Thoracic Surgery Parc Chanot Conference Center, Marseille .

For information, contact: Mondial Congress and Events Mondial GmbH & Co. KG Operngasse 20b 1040 Vienna, Austria Phone: + 43 1 58804-0 - Fax: + 43 1 58804-185 Email: [email protected]

� 10 - 11 June 2011 Washington, DC United States [iCalendar] ASAIO’s 57th Annual Conference Hilton Washington CME available Abstract submission deadline: 19 January 2011

� For information, contact: ASAIO Inc 7700 Congress Avenue, Suite 3107 Boca Raton, Florida 33487-1356 Phone: 1 561 999-8969 Fax: 1 561 999-8972 Email: [email protected]


Editorial

FreedomDear Readers and Colleagues I feel proud to announce that our new Board of the ESCTS has been elected and in

charge effectively under the lead of the distinguished Professor Ahmed Labib. They have important tasks to achieve . We wish them all the best and we are ready to support their Cause and effort whenever needed.

Professor Abdel Raouf has been as well elected as the coming Editor-In-Chief for the JESCTS it’s a very tiring responsibility that I am sure he will fulfil efficiently and with great success.

For myself it was really a joy and happiness serving you as Co-Editor then Editor –In-Chief for six successive years all together. I hope that I rose to your expectations and was able to perform my tasks and Jobs properly.Whatever the obstacles and the problems we faced we tried to solve them to our best.

‘’For they may take our lives, but they will never take our freedom’’William Wallace of Scotland

You can capture a man’s body but never his heart his soul or his freedom. We have been fighting all the way to liberate our will and our future but remains our true mission which is to liberate the young generations from the soul captivity which defeats the heart , the imagination and the creativity ; no worse than a man with an amputated soul.

My dear colleagues don’t fear the future don’t fear other people what will happen will happen its God’s Will so free yourself from the imaginary chains of your fellow men who think that they have been granted power to rule and not to serve. Believe in your abilities in your courage you are the power that drive the nation forwards you are the hope ; break

the chains of fear of ignorance of defeat ,set yourself free leave the cage ;the door is open. Dear colleagues free yourself and fly.

When coming to cross roads in life, always the right path is crystal clear !! ( Like Alpatcino says in one of his films ) it’s a path made of principles integrity and courage path that leads to the right goal, path of the people blessed by Almighty God path that leads to the truth and value of this life and the life after;

God lead us to this path ; Amen.Dear Colleagues and Readers its time for us to leave you ; the sea is open for new captain and crew to sail ,we pray for them to reach brighter horizon and better shores .

It was an Honour and will remain throughout my life to serve you ; may the Almighty God accept our deeds in good intention ; bless and guide us to the right path all the time .

May God Bless you ALL

Yasser M W HegazyEditor in Chief

Journal of the Egyptian Society of Cardio-Thoracic Surgery

2 The Journal of Egyptian Society Cardiothoracic Surgery ● Jul - dec 2010

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First President of the Society addressProfessor Anwar Balbaa MDElhics Editor Jornal of the Egyption Societyof Cardio_Thoracic Surgery

Mr Chairman I would like to start by expressing my thanks to you and to the organizing committee for giving me the honor and pleasure of addressing this distinguished gathering of eminent guests , colleagues and students whether medical or surgical, who , over the years are giving not only their efforts but also their souls to their patients in order to save them or improve their quality of life . George Sava wrote in his biography: They come by appointment ….After qualifying as lecturer in general surgery ( Cairo University), I chose to specialize in Cardiothoracic surgery. I can never forget one of my professors asking me who is the specialist? He said the specialist is the man who tries to know more and more about less and less, until he comes to know everything about nothing I started my career in the UK where I began by studying chest medicine and cardiology for six months, followed by training as registrar in cardiothoracic surgery. Then I traveled to the USA for experimental surgery training where I was privileged by attending rounds with Pall Wood – Lord Brock – H Shumacker – Dwight Harken and Cameron Haight.

When I came back to Cairo, we were only six qualified surgeons . The next Phase of open heart surgery followed but was rather difficult to realize owing to the budgeting deficiencies which were similar in all three main centers at that time. The trio of Professors; Hamdy El Sayed,

the late Prof. Hassouna Sabee and myself agreed to apply the policy of in-situ training:, that is to invite expert teams, headed by friendly attitude and in born love to teach The local teams . This always included Senior surgeons anesthetists, perfusionists, intensivists and even operating room nurses, to be able to upgrade the performance in total , year after year .

Examples of the excellent pioneers who gave us extreme heartly assistance included:• Prof.Michaud ( France)• Prof Chessignole (France)• Prof Dubost (France)• Prof Allrecthtson ( Denmark)• Prof Frigiola ( Italy )• Prof Yacoub (UK)• Prof Ross (UK)• Prof Neveux (France)• Prof Logeais (France)• Prof Bloc (France)

The outcome of this policy was shown clearly by the increasing number of Cardiothoracic surgical specialists, increasing number of new centers established, and remarkably good and excellent results obtained in acquired and congenital heart surgery. Some of our Egyptian cardiac surgeons are working now in Europe and different Arab countries.

The Journal of Egyptian Society Cardiothoracic Surgery ● Volume 18, Number (3-4) 3

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Only in the years following the October 1973 victory , our national resources permitted to finance this progress and its expansion by adding more university centers all over Egypt .

The work load is great in our country where rheumatic heart disease is still common with progressively increasing ischemic heart disease and increasing facilities for early diagnoses of congenital heart disease ;The number of cases per year probably exceeds 17,500. This number was 16,00 in 2008.

LEARNING CURVEThroughout my life , I always felt uncomfortable

about this term. It is the legitimate right of every surgeon to train and improve. It is also the legitimate right of the patient to go through his treatment, whether medical or surgical as safely as possible ,as enough is what he is losing by his illness or injury . It is quite natural that treatment by a senior experienced surgeons is safer and with lesser problems due to their wisdom and better experience .

Even this statement is not absolute. “Edward Churchil” of Boston wrote” some surgeons spend their lives doing the same mistakes, time and time again and they call this “Experience” and they even write textbooks about it!”

How could this residency training problem be solved?

I think there is one formula to do it ;The trainee should be given the chance to assist

his trainer regularly in decision making and in surgical techniques added to very serious reading and studying the candidate is evaluated at frequent intervals.

When he proves to be reliable, he is allowed to operate with his teacher assisting him several times. In due time, he is permitted to operate alone and his teacher would be available in the next room. as a safe surgeon is our aim.

In our university law, when a qualified surgeon with doctor degree is appointed as lecturer in the university he is not permitted to start his private practice before 3 years.

As juniors, we were grumbling about it However, we realized later that this was very sane and logic. In the university hospital he will be working under reassurance that he can get help in opinion and even surgical support in minutes

Even when I operate, I always ensure the patient safety by having a trained assistant who can complete the operation if an emergency develops or i drop dead. We owe this to our patients. I always look at the patient, according to his age as my father, brother, wife or child ; would I like to leave his fate for chance or luck?

I use a phrase to tell my trainee at the start of his residency: “if your learning curve will result in a grave yard full of victims of your training, then our profession has no need for your services.”

Allow me to tell a little story about a colleague who, during our residency suffered a stone kidney; he was a close relative of a famous urologist. When we decided to visit him after the operation we were shocked to know that he chose a professor of general surgery to operate upon him. I asked him why? He replied My relative is an international figure and a very quick surgeon, I would love to watch him operating , but when I am on the table I would like a surgeon who counts the RBCs.

The mortality and morbidity conferences are mandatory in a training scheme I believe that in this way we can avoid the dangers of the learning curve.

I was happy to find that applying these principles gave a wonderful fruit. Prof Y.Aung of Liverpool UK published a 5 year study of early and late results of 5700 CABG surgery cases, he found that there was no difference between the cases operated upon by the consultants and the trainees …

A LOOK INTO THE FUTUREI am addressing essentially my junior colleagues let

me remind you of certain facts.• Cardiothoracic surgery was the first to introduce the

concept of intensive care• Cardiothoracic surgery introduced endoscopy in

medicine • Prof. Loop wrote “there is no technical field -today-

ahead of cardiothoracic and cardiovascular surgery. In no other surgical field is science moving so fast

Let me also remind you that your experience and know how has tremendously increased by having to deal with bad cases and redo patients. The result is minimizing mortality and morbidity and better ability to face future challenges.


Cardiovascular

Mitral Valve Repair By Leaflet Augmentation With An Autologous Pericardial Patch In Rheumatic Mitral Valve Diseases.

Mohamed El- Anwar, MDAhmed Deebis MD,Moustafa El-Newahey MD,Moustafa El-Newahey MD,Mohamed Essa MD,

Addrees reprint request to :

Dr/ Mohamed El- Anwar.

Department of cardiothoracic

surgery –

Zagazig University- Zagazig- Egypt.

Mobile: 0126673568

E-mail: [email protected]

Codex : 04/130/1010

Objective: Severity of tissue retraction involving both leaflets is main pitfall for valve repair in rheumatic mitral valve disease. Our aim was to evaluate operative and short-term outcome of mitral valve repair by augmentation of leaflets with autologous pericardium in rheumatic mitral valve disease.methods: Thirty patients underwent mitral valve repair for rheumatic mitral valve disease with augmentation of leaflet beside other methods of repair and followed up during the period from March 2008 till June 2010. All patient data were collected and statistically analyzed.Results: All patients had severe mitral regurge (MR) (100%); four patients had combined moderate mitral stenosis (MS) (13.3%). Mean age of patients was 27.6 ± 11.1 years; they were 12 males and 18 females with male to female ratio of 2:3. Those patients had mean New York Heart Association (NYHA) class of 3.4 ± 0.6. Operatively, 27 patients (90%) had posterior leaflet augmentation and 3 patients (10%) had anterior leaflet augmentation. All patients (100%) have flexible annuloplasty ring, 4 patients (13.3%) had open commissurotomy and 4 patients (13.3%) have artificial chordae. Tricuspid annuloplasty was done by Devega repair for 5 patients (16.6%). Mean aortic clamp time and cardiopulmonary bypass time were 47.37 ± 8.3 minutes and 68.8 ± 11 minutes respectively. Only one case has early mortality at second day postoperatively due to low cardiac output state with no early morbidity in our study. After one year follow-up, there were 26 patients in NYHA class I (89.8%), 2 patients is NYHA class II (6.8%) and one patient is NYHA class III (3.4%) and this was statistically very highly significant (p <0.001) when compared with the preoperative data. Also, after one year, there were no MR in 22 patients (76.8%), mild MR in 4 patients (13.7%), moderate MR in one patient (3.4%), moderate MR and moderate MS in one patient (3.4%) and severe MR and severe MS in one patient (3.4%) and this was statistically very highly significant (p <0.001) when compared with the preoperative data. There were only one case (3.3%) reoperated after one year due to progression of rheumatic activity and two cases (6.6%) had moderate MR and moderate MS and follow-up was advised.Conclusion: Augmentation of leaflet (anterior or posterior) in repair of rheumatic mitral valve disease can get rid off short retracted leaflet and has excellent early results.

Cardiovascular


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The effect of rheumatic disease on mitral valve is usually multifactorial. The most frequent mechanism is leaflet retraction. Posterior leaflet retraction occurs in almost 60% of cases but anterior leaflet retraction

is less common (1). The main cause of leaflet retraction is progressive fibrosis of leaflet and subvalvular apparatus (2).

Safety and long-term durability of mitral valve reconstruction are well established as preserve left ventricular function and avoid valve-related complication as valve dysfunction, thromboembolism and anticoagulant-related bleeding (3).

Leaflet augmentation with autologous pericardial patch briefly fixed in 0.6% gluteraldehyde solution gets rid of fibrosis and retraction of leaflets in rheumatic mitral valve disease (4). The use of autologous pericardial patch briefly fixed with gluteraladehyde in mitral valve repair offer durable results with no calcification or retraction. It has been applied successfully for anterior and posterior leaflet augmentation in cases of rheumatic mitral valve disease. Repair of rheumatic mitral valve disease with patch augmentation is to lengthen the severely shortened and retracted leaflets to reestablish coaptation; it is done beside other method of repair as annuloplasty with ring, artificial chordae, chordae transfer and commissurotomy (5).

Anterior leaflet augmentation technique is applied if degree of anterior leaflet retraction did not safely allow downsizing of annuloplasty ring by two sizes (risk of stenosis) (6). Also, it provides better results than prosthetic annuloplasty alone or another method of repair alone (5). Posterior leaflet extension with autologous pericardial patch allows the posterior leaflet to bulge and moves anteriorly during systole towards the anterior leaflet to coapt with it (5).

The aim of the work was to evaluate operative and short term outcome of mitral valve repair by augmentation of leaflets with autologous pericardium in rheumatic mitral valve disease.

METHODS :Thirty patients with severe rheumatic mitral regurge

(MR) operated electively by mitral valve repair with leaflet augmentation beside other methods of repair and followed-up during the period from March 2008 till June 2010 in Cardiothoracic Surgery Department, Faculty of Medicine, Zagazig University.

Our inclusion criteria were: (1) pure rheumatic MR or predominantly MR, (2) valve suitable for repair by augmentation detected by preoperative transthoracic echocardiography and intraoperative transoesophageal echocardiography (TEE) before bypass, (3) age of patient ranges from 16 years to 45 years, (4) EF ≥ 50%, (5) pulmonary artery pressure is ≤ 30 mmHg, (6) no other valve lesions except functional TR and (7) no associated coronary artery disease.

Our exclusion criteria were: (1) patients with MR due to other causes and (2) patients with mixed rheumatic mitral valve disease with mild MR.

Each patient was examined by 2-D, M-mode and color Doppler echocardiography within one month before surgery. Multiple views were obtained with standard 2-D imaging techniques. These views include parasternal long axis, parasternal short axis and apical views. These views are used to assess mitral valve leaflets as regard pliability, prolapse, thickness and retraction, mitral valve area measurement, sub-valvular apparatus for chordae elongation, shortening or rupture and for fusion of papillary muscles, calcification of annulus and commissural fusion. With standard M-mode recording, we measured the chamber sizes, ventricular thickness. Doppler echocardiography was used to determine the presence and severity of MR.

After induction of general anesthesia before the start of the operation, a transoesophageal echocardiography probe was placed using a Vivid-3 machine. The main goal of prebypass TEE examination was generally to give the surgeon important information regarding morphology of the mitral valve, as degree of annulus dilatation, condition of leaflet and subvulvular apparatus.

Surgical Technique: In all patients, standard midline sternotomy was done. Autologous piece of pericardium was freed from any pleural or mediastinal adhesion and harvested. Piece of pericardium was carefully unfolded on sponge and dipped into a bath of 0.06% gluteraldehyde solution for 5 minute period. It was then rinsed in saline bath in separate bowel for additional 30 minutes.

Standard cardiopulmonary bypass (CPB) used by membranous oxygenator and aortic and bicaval cannulation. Myocardial protection was done in all patients with Tepid whole blood antegrade cardioplegia. Standard left atriotomy was made parallel to interatrial

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groove and extended and wrapped superiorly and inferiorly and self-retaining retractors were placed.

After proper exposure of the mitral valve, the whole valve apparatus was symmetrically assessed and evaluated to decide which operative reparative procedure will be suitable. First, the atrium is examined to determine whether a jet lesion is present, which would indicate a prolapse of the opposing leaflet. Then, the appendage is examined for thrombus. The annulus is evaluated for annular dilatation.

The leaflet tissue is then mobilized with a two never hook retractor to assess leaflet pliability and to check for leaflet prolapse or restricted leaflet motion. Leaflet prolapse is considered when the free edge of one leaflet overrides the plane of the orifice when the edge is pulled towards the atrium with nerve hook. Restricted leaflet motion is present when a leaflet does not fully and/or easily opens. Precise measurement of leaflet prolapse may be obtained by the “reference point” method; exerting traction with a nerve hook on different points of the free edge of the leaflets makes it possible to find a non-prolapsed area, usually on mural leaflet adjacent to anterior commissure.

In segmental valve analysis, the valvular apparatus is separated into eight segments; the three scallops of the posterior leaflet are identified as P1 (anterior scallop), P2 (middle scallop), and P3 (posterior scallop). The three corresponding segments of the anterior leaflet are termed A1 (anterior part), A2 (middle part), and A3 (posterior part). The remaining two segments are the Anterior Commissure (AC) and the Posterior Commissure (PC). These eight segments are analyzed comparatively using P2 as the reference point leaflet pliability is also explored at each segment.

This segmental valve analysis provides precise information, which serves as guideline to valve reconstruction. Thus, evaluation of pliability of anterior and posterior leaflet will be done. If leaflet fibrosis is extensive, then repair is likely to fail or to end up with significant mitral stenosis.

In cases of fibrotic retracted posterior leaflet, augmentation with autologous pericardium briefly fixed in 0.6% gluteraldehyde is done. The posterior leaflet is detached from the annulus starting at middle and then

extended towards the two commissures leaving about 2 ml of leaflet tissue beside the annulus. For better mobilization of leaflet 2nd and 3rd chordae if it may released whenever needed. Autologous pericardial patch which has previously prepared, it takes half circle shape; its length should correspond to intercommissural distance. The width was calculated from the width of the anterior leaflet with 1:3 ratio to avoid systolic anterior motion. Once appropriately sized, the patch was sewn into the defect of the posterior leaflet. The smooth surface of the pericardium is turned toward the atrium for valve repair (figure 1). By Prolene 5/0, take 3 stitches; one at each periphery of patch which will later taken at site commissure and 3rd stitch taken at curved part of patch which will taken at center of anterior part of detached posterior leaflet. Then, suture the patch to leaflet by two rows. We should keep height of at least 3 cm when tailoring the patch to remain enough tissue in place to allow pericardium to bulge more anteriorly during systole toward anterior leaflet. Then, annuloplasty ring size was determined by trigone-to-trigone distance of anterior leaflet and flexible annuloplasty ring (Cosgrofe-Edward flexible physioring) was inserted in all cases. Any residual leak between annulus and the patch will lead to severe haemolysis, so no leave too much space between annulus and the patch (figure 1).

Figure (1): Insertion of pericardial patch to augment posterior leaflet.

In cases of fibrotic and short retracted anterior leaflet that does not provide adequate coaptation and obligate us to insert small annuloplasty ring (risk of stenosis). So, anterior patch augmentation was done with autologous pericardial patch briefly fixed in 0.6% gluteraldehyde solution and this allows good size ring and better coaptation. By 2/0 ethibond suture, take transverse Mattress suture parallel to annulus for annuloplasty ring insertion before augmentation. Then, curvilinear incision was made in the base of anterior leaflet parallel to anterior


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annulus from posteromedial commissure to anterolateral commissure, leaving 1 to 2 ml of leaflet tissue at annulus. This caused the anterior leaflet to “fall” forwards and into the ventricle. The autologous patch which taken after sternotomy was fashioned to size of the ring that was selected to restore the zone of coaptation between anterior and posterior leaflets. The length of the patch is the length of the ring obturator and the width of the patch was cut to be at least as wide as the trigone to trigone distance. The shape of patch is semicircular which is sewn into the deficit of anterior leaflet with three running 5/0 prolene suture, two stitches at periphery of patch and both trigone and 3rd one at center of curve border of patch and center of curvilinear incision of anterior leaflet. Once the anterior leaflet is enlarged, the new dimensions of the anterior leaflet were measured using appropriate sizers and prosthetic ring annuloplasty was then achieved using a flexible annuloplasty ring (Cosgrofe-Edward flexible physioring) in all cases. We tried to oversizing of prosthetic ring one or 2 sizes to prevent significant residual mitral stenosis and prevent occurrence of systolic anterior motion of the mitral valve (SAM) after repair.

Artificial chordae by using Gortex sutures (4/0) was done in cases of rupture chordae or anterior leaflet prolapse after leaflet augmentation and before ring insertion. Commissural fusion was repaired by performing open commissurotomy along line of fusion of commissures till within 2 mm from the annulus starting from orifice; it was done prior to leaflet augmentation.

Through the mitral valve orifice, cold saline was injected by hand pressure via a bulb syringe to fill the left ventricle. We used this method in all patients of valve repair. The repair is accepted if no regurge at all (figure 2). Routine closure of left atriotomy using 2 prolene (3/0) sutures and then weaning from cardiopulmonary bypass will be performed.

Figure (2): Intraoperative test of valve competence after complete leaflet augmentation and insertion of the prosthetic ring.

Post-CPB TEE assessment was done in all patients for evaluating leaflet structure and motion, assessment of residual regurge, calculation of mitral valve gradient and area assessment of ventricular function and assessment of SAM. No more than mild (grade 1+) regurge was considered acceptable.

After full satisfaction of the result of mitral valve repair, decannulation is done. Then, haemostasis and routine closure of sternotomy were done after insertion of two mediastinal drains. The patient was transferred to the intensive care unit (ICU) and managed as the routine.

Follow-up: Postoperative follow-up was done for all patients in the form of clinical examination, chest X-ray, electrocardiography (ECG) and transthoracic echocardiography postoperatively at 3 months, 6 months and one year.

All operative and early and late postoperative data of all patients were collected and analyzed.

Statistical analysis:The Values of variables data were presented

using the arithmetic mean, the Standard Deviation (SD) and percentage (%). The preoperative data and the postoperative data were analyzed and compared. Comparisons between the preoperative data and the postoperative data were done by using Student t-test and Chi-square test (χ2) to determine the p-value and statistical significance of the variables being compared. Differences were considered statistically significant when P value was < 0.05. P value < 0.01 was considered to be statistically highly significant and P value < 0.001 was considered to be statistically very highly significant and P value > 0.05 was considered non significant. Software Package SPSS version 11.0 (SPSS, Inc, Chicago, Ill) was used to perform statistical analysis.

RESULTSPreoperative demographic, clinical, and

echocardiographic data of all operated patients are shown in Table 1. The mean age of patients were 27.6 ± 11.1 and there were 12 males (40%) and 18 females (60%) with male to female ratio of 2:3. All patients presented with shortness of breath (100%); with eighteen patients were in NYHA class III (60%) and 12 patients were in NYHA class IV (40%) (Table 1).


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Age (years)Mean ± SD 27.6 ± 11.1Range 16-50GenderMale 12 (40%)Female 18 (60%)NYHAIII 18 (60%)IV 12 (40%)

Table (1): Preoperative demographic and clinical data of all patients.

Preoperative echocardiographic data showed that all patients had severe rheumatic MR (30 patients, 100%), 4 patients had combined moderate MS due to commissural fusion (13.3%) and 5 patients had combined moderate to severe functional tricuspid regurge (16.7%). Also, echocardiography showed that, 27 patients had posterior leaflet retraction (90%) and 3 patients had anterior leaflet retraction (10%) (Table 2).

Variable No %

Severe mitral regurge 30 100

Combined moderate mitral stenosis 4 13.3

Posterior leaflet retraction 27 90

Anterior leaflet retraction 3 10

Commissural fusion 4 13.3Combined moderate to severe tricuspid regurge 5 16.7

Prolapsed anterior leaflet 4 13.3

Dilated annulus 30 100

Table (2): Preoperative echocardiographic data.

Mitral valve repair was done by leaflet augmentation (either anterior or posterior) with autologous pericardial patch briefly fixed in 0.6% gluteraldehyde solution and flexible annuloplasty ring (Cosgrofe-Edward flexible physioring) in all patients (100%). Posterior leaflet augmentation was done in 27 patients (90%) and anterior leaflet augmentation was done in 3 patients (10%). Commissurotomy was done for 4 patients (13.3%) and artificial chordae were done for prolapsed A2 segment for 4 patients (13.3%) (Table 3).

Variable

Flexible ring 30 (100%)

Anterior leaflet augmentation 3(10%)

Posterior leaflet augmentation 27(90%)

Commissurotomy 4(13.3%)

Artificial chordae 4(13.3%)

Devega repair for TV 5(16.6%)

Ring size 30.53 ± 0.91(30-32)

Aortic cross-clamp time (minute) 47.37 ± 8.3 (35-70)

Cardiopulmonary bypass (minute) 68.8 ± 11 (52-100)

Table (3): Operative procedures and data.

Postbypass TEE was done intraoperatively for all patients. There was no MR in 22 patients (74.4%), mild MR in 5 patients (16.6%), and mild to moderate MR in 3 patients (10%), with only one case showed associated mild MS (Figure 3). No SAM was detected intraoperatively by TEE.

Period of mechanical ventilation was ranged from 5-36 hours with mean ± SD of 10.3 ± 6.3 hours. ICU period was ranged from 2-4 days with mean ± SD of 2.28 ± 0.43 days. No early morbidity was detected in our study as there were no bleeding, no mediastinitis and no heart block, but there was one case early mortality at 2nd day postoperatively due to low cardiac output state which was not responding to inotropes, TTE was done in ICU revealed mild to moderate MR, no SAM and no pericardial effusion but there was picture of left ventricular (LV) stunning.

Follow-up showed that there was improvement in NYHA functional class in all patients after 3 months, six months and one year which was statistically very highly significant (p < 0.001) when compared with the preoperative data (Table 4).

Follow-up transthoracic echocardiography showed that there was improvement in MR grade in all patients after 3 months, 6 months and one year postoperatively; which wese statistically very highly significant (p < 0.001) when compared with the preoperative data (Figure


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3). Also, there were significant decrease in left atrium (LA) size and LV size, with improvement of LV function 3 months, 6 months and one year postoperatively and this were statistically highly significant (p <0.01) when compared with the preoperative data (Table 5). No evidence of calcification or tearing of the pericardial patch as well as no SAM were detected in our patients based on echocardiographic follow up evaluation.

Only one case (3.3%) was reoperated after one year due to severe MR and severe MS (Figure 3). Patient became symptomatically with NYHA functional class III and with cardiomegaly. The cause of MR was due to progression of rheumatic activity with leaflet thickening, pericardial fibrosis, commissural fusion and thickening of papillary muscle based on echocardiographic evaluation. In reoperation, there is no perforation of

NYHAPreoperative

(n = 30)3 months (n = 29)

6 months (n = 29)

One year (n = 29)

I - 18(62.1%)* 25(86.3)* 26(89.8)*

II - 11(37.9)* 3(10.3)* 2(6.8)*

III 18(60%) - 1(3.4)* 1(3.4)*

IV 12(40%) - - -

Table (4): NYHA functional class changes after 3 and 6, and one year postoperatively.*p < 0.001: Very highly significant

Variable Preoperative 3 months 6 months One year

EF (%)65.7 ± 6.2 (50-75)

66.4 ± 5.1 (50-73)

66.2 ± 5.2 (52-71)

67.96 ± 5.69* (48-75)

FS (%)36.2 ± 5.3 (26-43)

36 ± 4.7 (26-43)

37 ± 4.8% (27-43)

37.4 ± 4.9* (25-43)

LVEDD (mm)57.7 ± 4.9 (48-70)

48.5 ± 9.5* (40-65)

47 ± 9.5* (38-60)

43.5 ± 9.6** (37-64)

LVESD (mm)36.1 ± 5.7 (28-51)

33.2 ± 5.6* (27-50)

33.2 ± 5.6* (26-50)

30.5 ± 6.7** (25-49)

LAD (mm)50.4 ± 5.75 (44-67)

46 ± 5.6* (41-65)

45 ± 5.6* (41-65)

40.1 ± 7.1** (35-63)

MVA (cm) changes3.76 ± 1.2 (1.5-5.5)

2.9 ± 0.2* (2.5-3.3)

2.87 ± 0.36*(2-3.5)

2.9 ± 0.28* (2.5-3.5)

Mean pressure gradient (mmHg)

5.3 ± 2.4 (3-12)

3.2 ± 0.4* (3-4)

3.2 ± 0.4* (3-4)

3.26 ± 0.45* (3-4)

Table (5): Echocardiographic data preoperatively, after 3 months, 6 months and one year postoperatively.(NB: EF= Ejection fraction, FS= Fraction shortening, LVEDD= Left ventricular end diastolic dimension, LVESD= Left ventricular end systolic dimension, LAD= Left atrial dimension, MVA= Mitral valve area).*p < 0.05 (Significant)**p < 0.01 (Highly Significant)


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pericardium patch, but there is fibrosis of pericardium patch, fusion of commissure and subvalvular apparatus. Mitral valve replacement was done for heir with mechanical valve size 27 (Carbomedic bileaflet). The cause of MR was due to progression of rheumatic activity with fibrosis of pericardial patch, and fusion of commissure and subvalvular apparatus. There were 2 cases (6.6%) in our study showed moderate MR with follow-up echocardiography after 6 months, but with mild symptoms (NYHA class II) and with no increase of LV and LA dimensions; so, patients were advised for continuing follow-up (Figure 3).

Figure (3): Echocardiography of MR grade preoperatively, postbypass and, follow-up after 3 months, 6 months and after one year.* case had also mild MS# case had also moderate MS$ case had also severe MS

No other late morbidity in our study was recorded as haemolysis, infective endocarditis and thromboembolism.

DISCUSSION

Rheumatic heart disease is the commonest form of cardiovascular ailment that affects younger people in developing countries (7). Mitral valve dysfunction is a well-known complication in long-term rheumatic heart disease. The mitral valve leaflet changes occurred due to rheumatic heart disease includes fibrosis, thickening, and shortening with or without calcification. Consequently, these changes may result in short, “shrunken” anterior & posterior leaflets. These short leaflets do not provide adequate coaptation and results in MR (8).

Rheumatic mitral valve disease especially in young is usually accessible to reconstructive surgery (9). However, patients with rheumatic mitral valve changes, who have fibrotic and retracted leaflets, pose significant operative challenges. Technical problems and concerns

of long-term results of rheumatic mitral valve repair as persistence or recurrence of mitral regurgitation can occur in spite of undersized annuloplasty due to severity of tissue retraction precluding leaflet coaptation (6, 9). Moreover, the long-term results of mitral repair for rheumatic mitral valve insufficiency are still suboptimal (5, 9).

Repair of rheumatic mitral valve disease with patch augmentation is to lengthen the severely shortened and retracted leaflets to reestablish coaptation; it is done beside other method of repair as ring annuloplasty, artificial chordae, chordae transfer and commissurotomy (4). The operations for leaflet extension seem to be the best option for rheumatic mitral valve reconstruction. This technique allows a better mobilization of the leaflet, a larger cooptation area, less turbulence and minor degree of residual stenosis, in addition to make possible the usage of a Carpentier ring of a higher diameter (2, 10).

Pericardium has been attractive to the cardiac surgeon for a long time. Because autologous pericardium is non antigenic, it is preferred over the standard bovine pericardium, and this is corroborated by excellent results. In addition, Xenograft tissue carries the small but proved risk of transmission of viral disease, including human immunodeficiency virus (11). The benefits conferred by using autologous tissue are, its ready availability, its long-term durability, low thrombogenicity, easy of handling, and has good pliability, the easily accomplished surgical technique, the effective functioning of the remodeled valve, and the preservation of the natural shape of the valve. These benefits make this technique a useful surgical alternative for extensive mitral valve reconstructive procedures (12).

Use of fresh autologous pericardium has been discouraged because of problems encountered after implantation, namely progressive contracture, thickening fibrosis, loss of pliability, early degeneration, and endocarditis (11). The method of preserving autologous pericardium is extremely important in determining tissue durability and preventing calcification (11, 12). The scientific procedure of using autologous tissue treated with a brief immersion in gluteraldehyde solution was established by Chauvaud et al. in 1991 (2). On the basis of that experimental study, the clinical use of gluteraldehyde pretreated pericardium became established for mitral valve reconstructive procedures (5, 12, 13, 14). The use of autologous pericardial patch briefly fixed with gluteraldehyde in mitral valve repair


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offer durable results with no calcification or retraction. It has been applied successfully for anterior and posterior leaflet augmentation in cases of rheumatic mitral valve disease repair (1, 2, 4, 6, 8-11, 16).

In our study, there was statistically significant improvement in NYHA functional class in all our patients 3 months, 6 months and one year postoperatively. In the study of Romanoet al. (8), all patients demonstrated clinical improvements in NYHA functional class following repair. Also, in the study of NG et al. (11), 80% of patients were in NYHA functional class I at follow up following repair. These also were in agreement with results of Kumar et al. (5) and Chauvaud et al. (15).

There were statistically significant decreased LA size, LV size and improvement of LV function with follow-up echocardiography in our study. In the study of NG et al. (11), they reported that LV end-diastolic diameter decreased significantly after operation, as did the end-systolic diameter. The reduction in left atrial diameter was substantial.

As regard early mortality, only one case (3.3%) mortality occurred at second day postoperatively due to low cardiac output state. This meets with study performed by Chauvaud et al. (15), as early mortality was 2% mainly due to myocardial failure. However, Omeroglu et al. (16), reported that early death did not occur after repair.

In our study, no early morbidity occurred and no incidence of SAM and this is in agreement with studies performed by NG et al. (11) and Omeroglu et al. (16). But this was in contrary to the study performed by Chauvaud et al. (15), as re-exploration for bleeding was done for 5% of patients, pacemaker implantation was done for 0.7% of patients and mediastinitis occurred in 0.7% of patients.

We have observed no evidence of calcification or tearing of the pericardial patch; in our patients based on echocardiographic follow up evaluation. Many studies showed the same findings (1, 11, 16). In our study, there were 2 cases had moderate MR and moderate MS on follow-up echocardiography after 6 months and one year. The first case had moderate MR with prolapse of A2 and mild retraction of posterior leaflet and the second one had moderate MR, moderate MS with commissural fusion and thick leaflet with mild retraction of posterior

leaflet. Clinically, the both patients had become NYHA class II but with no increase in LV and LA dimensions and advised for continuing follow up.

No other late morbidity in our study was recorded as haemolysis, infective endocarditis and thromboembolism. In the study of NG et al. (11), they reported that no patient experienced thromboembolism or recurrent endocarditis during the postoperative course and there had been no major hemorrhagic complications. These was in contradiction to the study performed by Chauvaud et al. (15), as thromboembolic complication was 0.8% events per 100 patients-year of follow-up in late postoperative period. Haemolysis required hospitalization and blood transfusion (seen in one event per 100 patient-years of follow-up). Only, 3 patients from 980 patients developed subacute infective endocarditis. These patients were treated conservatively and all 3 survived, 13% per year had moderate to severe MR and freedom from reoperation at 11 years was 65.2 ± 10%. Also in the study performed by Kumar et al. (5), thromboembolism was 0.58 events per 100 patient-years. Haemolysis was 0.8 events per 100 patient-years, all had undergone annuloplasty. Infective endocarditis was 0.3 events per 100 patient-years, all were successfully treated conservatively. 18% had moderate MR and 5% had severe MR. These 5% of severe MR underwent reoperation (1% per year).

In our study, only one case (3.3%) had reoperation with mitral valve replacement after one year postoperatively due to severe MR and moderate MS. Patient became symptomatically with NYHA functional class III and with cardiomegaly. The cause of MR was due to progression of rheumatic activity with leaflet thickening, pericardial fibrosis, commissural fusion and thickening of papillary muscle based on echocardiographic evaluation. In reoperation, there is no perforation of pericardium patch, but there is fibrosis of pericardium patch, fusion of commissure and subvalvular apparatus. This meets with the study performed by Chauvaud et al. (15) with reoperation rate was 2% per year, the cause of reoperation was mitral valve apparatus fibrosis in 83% and technical failure in 17%. Also, in study performed by Romano et al. (8), reoperation was 5% per year mainly due to progression of rheumatic activity. In study performed by Kumar et al. (5), the reoperation was 1% per year. The causes of reoperation were: dehiscence of the repair and moderate to severe MR due to reappearance of leaflet thickening, commissural and subvalvular fusion. In contrary, study performed by Omeroglu et al. (16), reoperation was 12% per year; it was mainly due to severe


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MR. Also, NG et al. (11) reported that the incidence of reoperation was 4.8%.

In conclusion; mitral valve repair with leaflet augmentation briefly fixed in gluteraldehyde solution is ideal solution to get rid off retracted leaflet in rheumatic mitral valve repair. Our study demonstrated excellent short term results of repair and this technique should be considered for all cases with severe mitral valve regurge due to retracted, shortened mitral valve leaflets. However, long-term follow up to detect long-term durability of patch augmentation of leaflet is needed.

REFERENCES1. Acar, C.; De Ibarra, J.S. and Lansac, E.: Anterior leaflet

augmentation with autologous pericardium for mitral repair inrheumaticvalveinsufficiency.JHeartValveDis2004;13:741-746.

2. Chauvaud, S.; Jebara, V. and Chachques, J.C. et al.:Valve extension with glutaraldehyde-preserved autologouspericardium: Results in mitral valve repair. J Thorac CardiovascSurg1991;102:171-8.

3. Carabello, B.A.: Indications for mitral valve surgery. JCardiovascSurg2004;45:407-18.

4. Zegdi,R;Khabbaz,Z;Chauvaud,S.;etal.:Posteriorleafletextensionwithanautologouspericardialpatchinrheumaticmitralinsufficiency.AnnThoracSurg2007;84:1043-4.

5. Kumar,A.S.; Talwar, S. and Saxena,A. et al.: Results ofmitral valve repair in rheumatic mitral regurgitation. Interact CardiovascThoracSurg2006;5:356-361.

6. Aubert,S.;Flecher,E.andRubin,S.etal.:Anteriormitralleaflet augmentation with autologous pericardium. Ann

ThoracSurg2007;83:1560-1.7. Choudhary,S.K.;Talwar,S.andDubey,B.etal.:Mitralvalve

repair in a predominantly rheumatic population: Long-termresults.TexHeartInstJ2001;28(1):8-15.

8. Romano,M.A.; Patel, H.J. and Pagai, F.D. et al.:Anteriorleafletrepairwithpatchaugmentationformitralregurgitation.AnnThoracSurg2005;79:1500-1504.

9. Grinda,JM.;Latremouille,C.;D’Attellis,N.etal.:Triplevalverepair for young rheumatic patients. European Journal ofCardio-thoracicSurgery21(2002)447–452.

10. Tenorio, EM; Moraes Neto, F; Chauvaud, S. et al.:Experiencewiththeposteriorleafletextensiontechniqueforcorrectionof rheumaticmitral insufficiency inchildren.RevBrasCirCardiovasc2009;24(4):567-569.

11. NG, Choi-Keung: Joachim Nesser and ChristianPunzengruber et al.: Valvuloplasty with glutaraldehyde-treated autologous pericardium in patients with complexmitralvalvepathology.AnnThoracSurg2001;71:78-85.

12.Scrofani,R.;Moriggia,S.andSalati,M.etal.:Mitralvalveremodeling: Long-term results with posterior pericardialannuloplasty.AnnThoracSurg1996;61:895-899.

13. Gregori Junior, F.: Reconstrutive surgery of regurgitatingmitralvalveinchildren.BrazJCardiovascSurg2005;20(2):159-166.

14.Chitwood,W.R.:Mitralvalverepair:Anodysseytosavethevalvels.JHeartValveDis1998;7:255-261.

15.Chauvaud,S.;Fuzellier,J.andBerrebi,A.etal.:Long-term(29 years) results of reconstructive surgery in rheumaticmitralvalveinsufficiency.Circulation2001;104:1-12.

16.Omeroglu, S.N.; Kirali, K. and Mansuroglu, D. et al.: Isposteriorleafletextensionandassociatedcommissurotomyeffective in rheumatic mitral valve disease? Long-termoutcome.TexHeartInstJ2004;31:240-5.


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New Technique For Surgical Management Of Right Sided Active Infective Endocarditis

Ibrahim M. YassinMDOsama S. Abd El-Moneim MD

Addrees reprint request to :Ibrahim M. Yassin,MD, and Osama*Department of cardiac surgery,Tanta University,Egypt**Department of cardiac surgery,National Heart Institute,Cairo,Egypt*** Saud Al Babtin Cardiac centre,Al Dammam,KSAEmail:[email protected]:04/131/1010

Background: Tricuspid valve (TV) endocarditis is being increased during the last two decades because of the growing number of patients addicted to intravenous drug abuse and patients with anti-arrhythmic devices such as pacemakers and implantable defibrillators or long-term intravenous catheters. Mortality is reduced when treatment combines antibiotics plus surgical treatment. Simple reparative techniques can be applied in minimally destructed valves, however, when tissue destruction is extensive, few surgical options are available with their well known draw backs. In Nov.2006, we started our new technique, Pericardial Curtain Tech., in repairing these massively destroyed valves .This study summarizes our midterm follow up experience with TV reconstruction in patients with TV endocarditis with different degrees of valve destruction using autologous pericardium.Methods: Between June 2003 and Dec. 2009, TV reconstruction was performed in 15 patients (mean age, 33 ± 12 years; 3 women, 12 men). All patients presented with active endocarditis and moderate-severe TV incompetence. The known simple reconstructive techniques for leaflet defects were done after debridement of vegetations and excision of the endocarditic lesion in 9 patients ± ring annuloplasty ( simple sutures, patch plasty with autologous pericardium , and even sliding plasty of residual valve tissue and bicuspid valve formation with construction of a new commissure). We have innovated a surgical patching technique for the extensively destructed tricuspid valve, complete extensive resection of infected or destroyed leaflet tissue, then ,leaflet reconstruction from the edge to the annulus with pericardial tissue and lastly re-establishment of the subvalvular chordal support( The pericardial curtain technique ).This technique was applied in 6 patients with extensive destruction and severe dysfunction of the tricuspid valve. Patients were diagnosed and followed up postoperatively at 3,6,12 m. then every 6m. By Trans esophageal echo.(TEE) .Trans thoracic echo.(TTE) and Lab. Studies if indicated .Results: There were no perioperative deaths or recurrence of infection. Immediate postoperative echo studies revealed satisfactory haemodynamic parameters across the tricuspid valve in all patients included in our series. The degree of regurge ranged ( 0 to mild ) and the mean PG ( 2± 1.3 mmHg ). Postoperatively NYHA classification improved in all patients from ( 2.6 ± 0.7 to 1.1 ± 0.5). Late mortality was (2/9) for patients with TV simple reconstruction (both were drug abusers and died from non cardiac causes) and (1/6) in the TV Curtain technique group at the latest follow-up (100% complete; mean, 42 ± 17 months).There was insignificant changes in the haemodynamics across the valve or degenerative changes of the pericardial patch during the follow up period. Conclusions: Tricuspid valve repair is always possible in cases of active endocarditis even when the valve is massively destroyed. Autologous

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pericardial reconstructive techniques yield excellent midterm results with regard to freedom of recurrence of endocarditis and valvular competence and should be considered as the primary surgical option in these patients. The Pericardial Curtain Technique is safe , reproducible and feasible saving the patient from the drawbacks of the currently available techniques ( valvectomy or valve replacement ).

Persistence of sepsis and congestive heart failure have been the two classic indications for surgical treatment of tricuspid endocarditis (1). At Broussais Hospital the surgical strategy applied for infections of

the atrioventricular valves is based on three principles: early indication for operation, extensive debridement of all infected tissue, and repair of the valve apparatus (2). Reports on tricuspid endocarditis are increasing during the last two decades because of the growing number of patients addicted to intravenous drug abuse and patients with antiarrhythmic devices such as pacemakers and implantable defibrillators or long-term intravenous catheters(1,3). In contrast to left-sided endocarditisLSE, right-sided endocarditis RSE usually involves previously normal valves. Uncomplicated right-sided and left-sided endocarditis is successfully treated medically in 80% of patients; however, in the remaining 20%, conservative treatment is not effective and surgical treatment is required (4,5). Treatment options range from total valve excision without consecutive valve replacement to valve replacement and reconstruction. All procedures are controversial with regard to hemodynamic consequences and long-term prognosis. Valve excision without replacement results in massive tricuspid regurgitation and ventricularization of right atrial pressures as a result of a larger V wave and requires reoperation in more than 20% of patients because of right heart failure resulting from the massive regurgitation (6,7). Valve replacement with either a biologic or a mechanical valve exposes the patient to valve-related complications and the risk of recurrent endocarditis, especially in patients addicted to intravenous drugs and, in mechanical valves, also precludes the possibility of endocardial pacing.

On the other hand, several reports on tricuspid reconstruction demonstrate that this treatment option offers good results with respect to hemodynamics and long-time survival. A number of different reconstructive techniques have been described, including debridement of vegetations, complete resection of infected or destroyed

leaflet tissue, leaflet reconstruction with pericardial tissue, sliding plasty of residual valve tissue, bicuspid valve formation with construction of a new commissure, and ring annuloplasty (8,9). In this study, we report our experience in patients with tricuspid endocarditis and the extensive use of various reconstructive techniques using only autologous pericardium whatever the degree of valve destruction. We are including the midterm results of our newly innovated technique started in Nov.2006, in repairing the massively destroyed tricuspid valve leaflet and subvalvular support due to active endocarditis

Methods: Between June 2003 and Dec. 2009, 15 consecutive

patients with active tricuspid valve endocarditis underwent surgical treatment at our institutions (National Heart Institute-NHI, Cairo, Egypt and Saud Al Babtin Cardiac centre (SBCC), Al Dammam, KSA . In Nov. 2006, we started to aggressively use reconstructive techniques rather than valve replacement in all patients presenting with active infective tricuspid valve endocarditis whatever the degree of destruction of the valve. We made retrospective study to analyze our results after tricuspid valve reconstruction for active infective tricuspid endocarditis during at least a midterm follow-up period. The ethics committee approved the study and waived the need for patient consent.

Patient Characteristics:In 15 patients, tricuspid valve endocarditis (TVE)

was isolated. Nine patients had small valvular destruction and needed only simple reparative techniques and six had major destruction and required our innovated technique (Pericardial Curtain Technique). Three were diagnosed as isolated TVE, Two were diagnosed with additional endocarditis of the mitral valve(TVE+MVE), and one had additional endocarditis of the aortic valve and aortic root abscess (TVE+ AVE +Ao. Root Abscess). All patients were first do.

Before the operation all patients exhibited signs of acute infection, such as high fever and leukocytosis. Five patients presented with septic pulmonary emboli. Causes of tricuspid endocarditis were intravenous drug abuse in 12 patients, infected pacemaker leads in 2 patients, and In one patient no apparent cause for endocarditis could be detected. In twelve patients, blood cultures revealed Staphylococcus aureus (n = 9), Staphylococcus epidermidis (n = 2), Enterococcus faecalis (n = 1). In three patients no bacterial growth was detected, which


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was most likely because of previous antibiotic therapy. In the drug addict group, all patients were HIV negative but nine of them were hepatitis C positive. Preoperatively, 6 patients were in New York Heart Association (NYHA) functional class II, 6 patients were in NYHA class III, and 3 patients were in NYHA class IV.

In all patients, preoperative transthoracic echocardiography was performed, and the diagnosis of tricuspid valve endocarditis was established according to the Duke endocarditis service criteria. All patients had significant tricuspid valvular incompetence with grade III in 7 patients, and grade IV in 8 patients.

Indication for Surgery:In brief and according to guidelines, In our series

the indication for surgery was largely based on the clinical and echo-cardiographic findings:1-Moderate to severe heart failure caused by valvular

dysfunction.2-Mobile vegetation >10 mm in LSE and >20mm in RSE

(with or without embolization)3-Uncontrolled infection in spite of adequate antibiotics

for 3 weeks.

If the clinical situation allowed, we tried to postpone surgery until the infection decreased.

Surgical Methods:In all patients tricuspid valve reconstruction was

attempted and was successfully achieved whatever the degree of valvular destruction. The known reconstructive techniques used by many authors and published before (10) for leaflet defects ± limited subvalvular apparatus destruction was done in 9 patients ± ring annuloplasty of our series (mean age, 32 ± 12 years; female/male, 2/7) : debridement of vegetations and simple sutures (1), excision of the endocarditic lesion and patch plasty with autologous pericardium in the anterior and septal leaflets (4), Resection of the infected or destroyed leaflet tissue and the affected subvalvular tissues and quadrangular excision of healthy leaflet tissue of the opposing leaflet then transposition and Sewing in of the transposed leaflet tissue and closure of the defect on the opposing leaflet (2),sliding plasty of residual valve tissue and bicuspid valve formation with construction of a new commissure was done in(2) patients with endocarditic lesion limited to the posterior leaflet. In those patients, bicuspid valve formation of the tricuspid valve was performed , the posterior leaflet was completely excised, the anterior and

septal leaflets were partially mobilized, plication sutures were put in place, and a sliding plasty of the remaining two leaflets was performed. These two cases were done before 2006, later on, we were infaced with another case with posterior leaflet endocarditic lesion, due to infected pacemaker, affecting the leaflet and subvalvular apparatus, we excised it completely and used our new technique.

Our new technique was performed in 6 patients (mean age, 33 ± 11 years; female/male, 5/1) because of extensive valvular destruction. Those patients underwent what we called Pericardial Curtain Technique :

The technique was applied to (3) patients with isolated tricuspid valve endocarditis(TVE)

(mean age, 31 ± 13 years; female/male, 0/3) where Vegetectomy & TV repair was done, (2) patiens had mitral valve endocarditis beside (TVE + MVE) (female/male, 1/1) where Vegetectomy &TV+ MV repair was done, and one male patient had aortic valve endocarditis and aortic root abscess beside the tricuspid affection where Vegetectomy, TV repair, root abscess repair and AV replacement.

Acute IE may cause damage & destruction of the two important components:1- Leaflet component.2- Chordal support component.

Our surgical strategy of the tricuspid repair in all cases was based on:1-Eradication of infection by generous excision of all

vegetations and infected tissues with safety margin and see what is left behind (minor or major and only leaflet or both the leaflet and the subvalvular apparatus and to what extent).

2- Repairing native valves rather than replacing them. 3- Avoiding implantation of prosthetic material except

if mandatory need for Gore-Tex artificial chordae.(The main concept is to try only using autologus pericardium and the adjacent healthy chordate tendinae). Ring annuloplasty was only done if the intraoperative evaluation of the valve necessitated that to support the valve or prevent further dilatation of the annulus but the main concept is to avoid its use.

Our surgical strategy in the 6 cases with massive destruction of the tricuspid apparatus (both leaflet and chordal support components) which is Pericardial Curtain Technique was based on:


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1-Leaflet component: Repair of the Major Leaflet Defect with large pericardial patch from annulus to edge

2-Chordal support component: Re-establishment of Chordal Support by:

(a)Alfieri stitch (b)Adjacent intact chordae (c)Artificial Gore-Tex Chordae

The site of insertion of the artificial chordate is either to the adjacent papillary ms. or direct to IVS trabeculations

Pericardial Curtain Technique : was designed essentially for the massive destruction of the anterior(2cases) and septal(3cases) leaflets and their subvalvular destructed apparatus as we found no problem in the two cases of the posterior leaflet completely destroyed leaflet and subvalvular apparatus when we did bicuspid valve formation of the tricuspid valve , the posterior leaflet was completely excised, the anterior and septal leaflets were partially mobilized, plication sutures were put in place, and a sliding plasty of the remaining two leaflets was performed and inforced with a ring annuloplasty. Recently, and in (one case) with destroyed posterior leaflet, we applied this new technique with similar results.

In cases of Anterior leaflet, massively destroyed leaflet and subvalvular apparatus with large vegetations (2cases), total removal of the vegetation and debridement was performed and The pericardial patch was fixed to the adjacent intact chordae from both sides then the free edge was supported by Alfieri Stitch. (Fig.1)

(Fig.1): Anterior leaflet infective endocarditis (A.) a big vegetation attached and destroying 2/3 of anterior leaflet of TV & ( B. &C. )total removal and debridement &(D) The pericardial patch is fixed to the adjacent intact chordae (from both sides)&(E) The free edge is then supported by Alfieri Stitch &(F) Final result

In the case of aortic valve endocarditis and large vegetation with aortic root abscess and severly destroyed septal leaflet of the tricuspid valve and its subvalvular apparatus, the big vegetation attached and destroying the whole aortic valve was removed with the native aortic cusps and the valve was replaced after debridement of the root abscess and repair of the cavity then the big vegetation attached and destroying almost all of the septal leaflet of TV, complete excision of the vegetation and the destroyed septal leaflet and the subvalvular apparatus with safety margin and Curtain patch from edge to annulus of the septal leaflet was inserted. The pericardial patch was fixed to the adjacent intact chordae (from both sides). The free edge is then supported by artificial chordae. (Fig.2)

(Fig.2): Lt. and Rt. sided infective endocarditis (same patient): A. a big vegetation attached and destroying the whole aortic valve. B. Aortic root abscess. C. a big vegetation attached and destroying half of the septal leaflet of TV(Aortic valve replacement, repair of the root abscess,and Curtain patch from edge to annulus of the septal leaflet. The pericardial patch is fixed to the adjacent intact chordae (from both sides). The free edge is then supported by artificial chordae.

The same was done in another two cases (3cases) with severly destroyed septal leaflet of the TV.

The new technique was applied to (one case) of the six cases with isolated TVE, where the posterior leaflet and the subvalvular apparatus was completely destroyed. The pericardial patch is fixed to the adjacent intact chordae (from both sides). The free edge is then supported by artificial chordae.(Fig.3)

(Fig.3): In posterior leaflet defects:The pericardial patch is fixed to the adjacent intact chordae (from both sides). The free edge is then supported by artificial chordae.


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When intraoperative evaluation of the TV shows the need for a prosthetic annuloplasty ring to be implanted to stabilize the valve geometry and to prevent future ring dilatation, The predominant size of rings implanted was 30 mm.

Intraoperative evaluation of the TV repair is the same as we do in the mitral valve ,the 50cc syring of saline and visual assessment then interuption of the leaflets with the sucker to see the difference then our usual gold standard after going off bypass and stabilization of the haemodynamics is the TEE evaluation to evaluate the degree of any residual regurge and the mean PG across the valve. There was good correlation between the saline test and the TEE results intraoperatively.

TTE was done for all patients after removal of all the drains and and before discharge of the patients and keeping it as a baseline.

Antibiotic Treatment: All patients received parenteral and oral antibiotics for at least 6 weeks postoperatively. Specific antibiotics were given in those patients who had positive blood or valve cultures, and broad-spectrum empirical therapy was performed in all other cases.

Follow-Up: Follow-up included transthoracic echocardiography and evaluation of functional recovery according to NYHA classification and was performed 3monthes after discharge and then at 6 months intervals.

Results: There were no perioperative deaths or recurrence of

infection. Immediate postoperative echo studies revealed satisfactory haemodynamic parameters across the tricuspid valve in all patients included in our series. The degree of regurge ranged ( 0 to mild ) and the mean PG ( 2± 1.3 mmHg). Late mortality was (2/9) for patients with TV simple reconstruction (both were drug abusers and died from non cardiac causes) and (1/6) in the TV Curtain technique group at the latest follow-up (100% complete; mean, 42 ± 17 months), this patient also continued drug abuse and died from unclear most probably non cardiac cause. There was insignificant changes in the haemodynamics across the valve or degenerative changes of the pericardial patch during the follow up period. At the latest follow-up transthoracic echocardiography showed no recurrent tricuspid incompetence in 11 patients and tricuspid valve incompetence grade I in 4 patients. (two patients undergone the new technique and the other two

undergone simple repair by patching of the remaining defect). Postoperatively NYHA classification improved in all patients from ( 2.6 ± 0.7 to 1.1 ± 0.5 ) and continued till the last follow up visit.

Discussion : The incidence of tricuspid valve endocarditis

has risen during the last three decades (1,3,11,12) for several reasons: (1) The number of people addicted to intravenous drug abuse that predisposes to tricuspid valve endocarditis is growing (13). (2) Advances in interventional electrophysiology have prolonged the survival of patients with heart block or malignant tachyarrhythmia, and there is a concomitant use of implantable devices as pacemakers and defibrillators (14,15) . (3) There is an increase in patients who are treated with long-term central venous catheters (16). In the last few years, the immunodeficiency viral affection is encountered to predispose and facilitate the severity of endocarditis infection.

Although the number of our series is small, we noticed that the sequence of the predisposing factors to tricuspid valve endocarditis mentioned above was obvious and the persistence of drug abuse was the most common cause of mortality in these patients even after management surgically and complete cure. Screening of these patients for HIV infection is an essential step before interference specially if the history is not clear. All of our patients were negative for HIV.

Fortunately, most cases (approximately 80%)(4,5,17) of uncomplicated right-sided endocarditis can be treated successfully with antibiotics. Endocarditis is termed uncomplicated in the absence of intracardial or extracardial complications, hemodynamic compromise, or infection with a highly virulent microorganism(18). The abnormal cardiovascular hemodynamics associated with isolated tricuspid or pulmonary valve endocarditis often allows time for medical treatment because of the greater tolerance for tricuspid valve regurgitation and pulmonary embolizatio

The greatest management problem in patients with tricuspid valve endocarditis is the question of whether and when they need surgical intervention. Our recommendation for surgery is to wait, if possible, until the peak of serum levels of systemic signs of infection as well as the peak of clinical infective illness has been transgressed. Because of our experience, pressor support


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during and after surgery is excessive when the operation is performed during the height of clinical infective illness and can be substantially aggravated by the sequelae of substantially high doses of norepinephrine. As stated by Chang and associates (1), indications for surgery can be divided into definite reasons like persistent sepsis and significant congestive heart failure, probable reasons like large vegetation size, involvement of left-sided heart valve(s), gram-negative organisms, or candida, and reasons that are no indication for surgery by itself like persisting fever, recurrent pulmonary embolizations, and polymicrobial infections. We are in agreement with those statements, but think that owing to the advancements in echocardiography during the last decades, our decision whether to perform surgery or not was more directed by echocardiographic findings than in older reported series.

In our series the indication for surgery was largely based on the clinical and echocardiographic findings and according to the guidelines as mentioned above in the methodology(intractable heart failure due to the valvular dysfunction, uncontrolled infection despite 3weeks on antibiotics and presence of large mobile vegetations >20mm on the tricuspid valve with or without embolization )

Successful surgical treatment of acute infective endocarditis should include radical debridement of infected tissue (20) and restoration of physiologic valve function, and several very diverse surgical approaches have been published (8,9). Valvectomy without simultaneous replacement as proposed by Arbulu and associates (3,6,7) is the most aggressive treatment and was especially promulgated in intravenous drug abusers owing to the radical debridement and the avoidance of any prosthetic material, which is of special importance in patients with ongoing intravenous drug abuse. However, 20% of these patients do not tolerate this massive tricuspid regurgitation despite intensive medical treatment and need a second operation for implantation of a prosthetic valve as a result of progressive right heart failure(7).

Valve replacement is another treatment option, and the development of bileaflet mechanical valves and biologic valves has greatly improved the prognosis of patients after tricuspid valve replacement (21). Mechanical valves in the tricuspid position are at a significantly higher risk for thrombosis compared with valves in the aortic or mitral position (22) and, consequently, are at higher risk for early reoperation (23). However, in long-term follow-up mechanical valves are favorable over biologic valves

as a result of valvular degradation in biologic valves (24), and therefore mechanical valves should be chosen in younger patients with good long-term prognosis. Nevertheless, patients addicted to intravenous drug abuse and patients with transvenous pacemaker leads are at higher risk to become reinfected, and compliance to long-term anticoagulation is unpredictable specially for the artificial valves in the tricuspid position.

So, it can easily looks to any cardiac surgeon that repairing the tricuspid valve is the best option in general and specially in active endocarditis. It is a salvage procedure in a high risk patient asking for the best chance for his morbidity.

During the past decades tricuspid valve reconstruction has become a more frequently used treatment alternative in active infective tricuspid valve endocarditis with a number of different treatment modalities such as Kay plasty (25), partial replacement of the tricuspid valve by mitral homografts (26), commissuroplasty, sliding plasty, the use of pericardial patches (8) , the use of artificial chordae(9) , and reconstruction of the tricuspid valve annulus with an autologous pericardial patch (27).

Our strategy of dealing with these patients since we started our experience with surgical interference of patients with active endocarditis was clear and as mentioned in the methodology was based on the concept that Repairing native valves rather than replacing them is the best option for these patiens and for doing this, our approach is to firstly, eradicate the infection by generous excision of all vegetations and infected tissues with safety margin and then see what is left behind(minor or major defect and only leaflet or both the leaflet and the subvalvular apparatus and to what extent) and avoiding implantation of prosthetic material except if mandatory need for Gore-Tex artificial chordae. The main concept is to try only using autologus pericardium and the adjacent healthy chordate tendinae.

We found during reviewing of the literatures that our strategy is to a great extent going with the experience of others. As mentioned before,it is going with the guidelines used at Broussais Hospital for management of infections of the atrio-ventricular valves which is based on three principles: early indication for operation, extensive debridement of all infected tissue, and repair of the valve apparatus(2).


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Also, we found that we are in agreement with some other series (14,28), in that tricuspid valve reconstruction was performed without the use of any foreign material to avoid recurring endocarditis .

Nevertheless, we deny and do not agree that they apply their concept even if significant residual tricuspid valve insufficiency was present as we consider that valve competence in the operating room using the simple test mentioned in the methodology and then TEE is our end point and it is our main target we are aiming even if it is mandatory to use Gore –Tex artificial chordate or ring annuloplasty.

Both of these two studies (14,28), agreed that the use of prosthetic annuloplasty ring might have led to a better functional result in some of their patients. We think that the avoidance of prosthetic material should not compromise radical eradication of all infected tissue, or valvular competence .We think that this concept plays a very important role in long-term freedom of recurring endocarditis and stability of the clinical outcome of these patients.

In our series the main focus was on tricuspid valve reconstruction and an optimal long-term functional result with no or only limited tricuspid insufficiency. Therefore, we implanted an annuloplasty ring in patients undergoing tricuspid valve repair in cases when the valve looks in need for stabilization or the ring is dilated to avoid future tricuspid ring dilatation and resulting tricuspid insufficiency.

Although some authors reported that initial moderate insufficiency is well tolerated by the patients undergoing tricuspid valve repair for infective tricuspid endocarditis and generally improves with time(14) , Nevertheless, it is, in our opinion, necessary to stabilize valve geometry to achieve a long-term competent valve. This is especially crucial in patients with massive destruction of one or two leaflets, which necessitates extensive repair with resection of a leaflet or a commissuroplasty or in our new pericardial curtain technique.

Implantation of an annuloplasty ring should add only a little risk for recurring endocarditis because it could be shown that the rate for spontaneous prosthetic endocarditis is very low in the tricuspid position. This finding can be explained by the fact that the infection most often only involves the free margin of the valve, including the leaflets, but only rarely the annular region

itself. Local factors, such as differences in blood supply of the annular area and the surrounding myocardium, may account for these different manifestations of endocarditis among mitral, aortic, and tricuspid valves (21).

Our approach is also supported by the growing number of successful reports on mitral valve repair involving ring annuloplasty in active endocarditis. Since Dreyfus and coworkers (2) reported in 1990 one of the first series of mitral valve repair in active endocarditis, many authors (30-32) have confirmed not only the feasibility of mitral valve repair in the active phase of endocarditis but could also show that mitral valve repair is superior to mitral valve replacement in regard to event-free long-term survival and recurrence of endocarditis. Although the fear is that implantation of an annuloplasty ring might present additional risk for recurrent endocarditis, all authors implanted annuloplasty rings in the vast majority of these patients to prevent future annular dilatation. In five studies with a medium follow-up of between 23 and 73 months, no recurrence of endocarditis could be observed (22-26) .

The results of our study clearly demonstrate that in patients with active infective endocarditis, tricuspid valve reconstruction with limitation of the use of any synthetic material even the annuloplasty ring as much as we can is always possible whatever the degree of destruction of the valve. This is true for both freedom of recurring endocarditis and acceptable valvular competence with good midterm results. From our experience, if intraoperative saline syring testing of the valve shows good competence, usually the TEE results come in harmony with this simple test. Consequently, valve replacement should be the last option, and only in cases of failed repair due to lack of experience.

Limitation of the study: Like other published series, our study is necessarily

limited by its retrospective nature and relatively small sample size. Unfortunately we cannot make any statement on the number of patients receiving medical treatment alone during the study period, as many patients are referred to our center solely for surgical repair of their active infective endocarditis. Therefore, we have no conclusive information about the total numbers of patients with this disease in the referring centers. Furthermore, cardiologists and infectious disease specialists from our institution were not able to provide absolute numbers, as these patients often have multiple morbidities and acute infective endocarditis is not the main diagnosis of


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their admission. They usually are referred for fever of unknown origin, dyspnea, or cardiac decompensation.

Conclusions: Tricuspid valve repair is always possible in cases

of active endocarditis even when the valve is massively destroyed. Autologous pericardial reconstructive techniques yield excellent midterm results with regard to freedom of recurrence of endocarditis and valvular competence and should be considered as the primary surgical option in these patients. The patching technique (pericardial curtain) made patching of major leaflet defects feasible and accurate.The use of Alfieri stitch & artificial chordae for the re-establishment of leaflet support is safe and effective. The Pericardial Curtain Technique is safe , reproducible and feasible saving the patient from the drawbacks of the currently available techniques ( valvectomy or valve replacement ).

References:1.ChangP.,OgilbyJ.D.,SegalB.Tricuspidvalveendocarditis.

AmHeartJ1989;117:1140-1146.2.DreyfusG.,SerrafA.,JebaraV.A.,etal.Valverepairinacute

endocarditis.AnnThoracSurg1990;49:706-713.3.ArbuluA,HolmesRJ,AsfawI.Surgicaltreatmentofintractable

right-sided infective endocarditis in drug addicts: 25 yearsexperienceJHeartValveDis1993;2:129-137.

4.BayerAS,BlomquistIK,BelloE,ChiuCY,WardJI,GinztonLE.TricuspidvalveendocarditisduetoStaphylococcusaureus:correlationoftwo-dimensionalechocardiographywithclinicaloutcomeChest1988;93:247-253.

5.GrahamDY,ReulGJ,MartinR,MortonJ,KennedyJH.Infectiveendocarditis indrugaddicts:experienceswithmedicalandsurgicaltreatmentCirculation1973;48(Suppl):37-41.

6.ArbuluA,Asfaw I. Tricuspid valvulectomy without prostheticreplacementTen years of clinical experience. J ThoracCardiovascSurg1981;82:684-689.

7.Robin E, Thomas NW, Arbulu A, Ganguly SN, MagnisalisK. Hemodynamic consequences of total removal of thetricuspid valve without prosthetic replacement Am J Cardiol 1975;35:481-486.

8.LangeR,DeSimoneR,BauernschmittR,TanzeemA,SchmidtC,HaglS.Tricuspidvalvereconstruction,atreatmentoptioninacuteendocarditisEurJCardiothoracSurg1996;10:320-326.

9.BortolottiU,TursiV,FasoliG,MilanoA,FrigatoN,CasarottoD.Tricuspidvalveendocarditis:repairwiththeuseofartificialchordaeJHeartValveDis1993;2:567-570.

10.Gottardi R, Bialy J, Devyatko E,Tschernich H, Czerny M,Wolner E, Seitelberger R:Midterm Follow-Up of TricuspidValve Reconstruction Due toActive Infective Endocarditis.AnnThoracSurg2007;84:1943-1948

11.HeiroM,HeleniusH,MakilaS,etal.Infectiveendocarditisin

aFinnishteachinghospital:astudyon326episodestreatedduring1980–2004Heart2006;92:1457-1462.

12.MylonakisE,CalderwoodSB.InfectiveendocarditisinadultsNEnglJMed2001;345:1318-1330.

13.United Nations The evolution of the world drug problemUnited Nations World Drug Report 2006: United NationsOfficeonDrugsandCrime.2006.pp.31-50UnitedNations:Chapter 1.1.

14.MondHG, IrwinM,MorilloC,EctorH.Theworldsurveyofcardiacpacingandcardioverterdefibrillators:calendaryear2001PacingClinElectrophysiol2004;27:955-964.

15.MondHG.Theworldsurveyofcardiacpacingandcardioverterdefibrillators: calendar year 1997—Asian Pacific, MiddleEast,SouthAmerica,andCanadaPacingClinElectrophysiol2001;24:856-862.

16.Tarng DC, Huang TP. Internal jugular vein haemodialysiscatheter-inducedrightatriumendocarditis—casereportandreviewof the literatureScandJUrolNephrol1998;32:411-414.

17.BayerAS,Blomquist IK,BelloE,ChiuCy,WardJI,GinztonLE. Tricuspid valve endocarditis due to StaphylococcusaureusChest1988;93:247-253.

18.LangeR,HaglS,SebeningF,etal.InfektiöseendocarditisIn:Hombach V, editor. Kardiologie, Bd. 3, KardiovaskuläreChirurgie.Stuttgart:Schattauer;1998.pp.191-226.

19.Banks T, Fletcher R,Ali N. Infective endocarditis in heroinaddictsAmJMed1973;55:444-451.

20.Yee ES, Ullyot DJ. Reparative approach for right-sidedendocarditisOperative considerations and results ofvalvuloplasty.JThoracCardiovascSurg1988;96:133-140.

21.ScullyHE,ArmstrongCS.TricuspidvalvereplacementFifteenyears of experience with mechanical prostheses andbioprostheses. J Thorac Cardiovasc Surg 1995;109:1035-1041.

22.KangCH,AhnH,KimKH,KimKB.Long-termresultof1144CarboMedics mechanical valve implantations Ann ThoracSurg2005;79:1939-1944.

23.Dalrymple-HayMJ,LeungY,OhriSK,etal.Tricuspidvalvereplacement:bioprosthesesarepreferableJHeartValveDis1999;8:644-648.

24.VanNootenGJ,CaesF,TaeymansY,etal.Tricuspidvalvereplacement:postoperativeand long-termresultsJThoracCardiovascSurg1995;110:672-679.

25.KayJH,Maselli-CampagnaG,TsujiKK.SurgicaltreatmentoftricuspidinsufficiencyAnnSurg1965;162:53-58.

26.LaiDTM,ChardRB.Commissuroplasty:amethodof valverepair for mitral and tricuspid endocarditis Ann Thorac Surg 1999;68:1727-1730.

27.d’UdekemY,SluysmansT,RubayJE.TricuspidvalverepairfortricuspidvalveendocarditisafterFallotrepairAnnThoracSurg1997;63:830-832.

28.CarozzaA,RenzulliA,DeFeoM,etal.Tricuspidrepair forinfective endocarditis: clinical and echocardiographic results TexHeartInstJ2001;28:96-101.

29.Fuzillier JF, Acar C, Jebara VA, et al. Plastie mitrale aucours de la phase aigue de léndocarditeArch Mal Coeur


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1993;86:197-201.30.PodesserBK,RödlerS,HahnR,etal.Mid-termfollow-upof

mitral valve reconstruction due to active infective endocarditis JHeartValveDis2000;9:335-340.

31.SenniM,MerloM,SangioriG,etal.Mitralvalverepairandtransesophageal echocardiographic findings in a high-risk

subgroup of patients with active, acute infective endocarditis

JHeartValveDis2001;10:72-77.

32.Sternik L, Zehr KJ, Orszulak TA, Mullany CJ, Daly RC,

SchaffHV.Theadvantageofrepairofmitralvalveinacute

endocarditisJHeartValve


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Early postoperative outcome of total arterial coronary revascularization versus conventional CABG

Ahmed Khallaf MD,Ashraf Esmat MD,Tarek Eltawel MD,and Yahia Balbaa MD


Dr. Ahmed Khallaf MD,

Depatement of cardiothoracic

surgery Cairo University.

Email : [email protected]

Codex : 04/132/1010

Backgrawnd: Although the long term superiority of arterial grafts over venous in CABG is well proven, still the fear from the complexity of the procedure and the potential complications are hindering factors for its widespread use. Our study is aiming at the assessment of the immediate postoperative results of arterial grafting in comparison to conventional single mammary + SVGs .Methods: Our study included 200 patients undergoing elective CABG for multivessel disease and were divided into 2 groups. Group A: 100 patients who had CABG using arterial grafts other than the LIMA with or without vein grafts. Group B: 100 patients undergoing conventional CABG using LIMA to LAD plus additional SVGs.Results: , the mean cross clamp (ischemic) time was 77.8 ± 17.49 minutes for group A ; versus 39.1 ± 8.96 minutes for the conventional group B.there was no significant difference between the two groups regarding incidence of bleeding, reopening, ischemia or infection. There were no mortalities in our study.Conclusion: Extended arterial coronary revascularization (EACR)is a safe procedure with acceptable complications when compared to conventional CABG using a single mammary with veins .

Some surgeons still consider that the golden standard CABG procedure is the LIMA to LAD with SVGs to other vessels (1). Although logic suggests that a second ITA graft would further improve the long term results of revascularization, bilateral ITA grafting has not been universally popular because of the increased

time required for harvesting and the potential risk of chest complications, which occur more in obese and diabetic patients (2).

Complete arterial grafting can be achieved by using a combination of ITAs, radial artery, gastroepiploic artery and inferior epigastric artery as well. Most patients require three conduits, but if additional grafts are needed, sequential anastomoses, Y or T grafting, Graft extension or a combination of these techniques can be used (3)

However, due to the tendency for early postoperative spasm in arterial grafts, some research studies expressed some doubts that coronary revascularization based entirely on arterial grafting may not be entirely reliable and/ or effective in supporting the myocardium on short term basis. Others added that higher morbidity rates can be encountered especially if the operative time is markedly elongated. Moreover, local ischemic complications of the sternum and/ or hand may occur due to ITA and RA harvesting (4).

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Methods :We assessed the immediate postoperative results

of arterial grafting in comparison to conventional single mammary + SVGs mainly regarding the procedure time, postoperative complications including ischemia, infection and myocardial function.

This study included 200 patients undergoing CABG surgery at Kasr-El-Einy hospital & Sheikh Zayed hospital from Jan 2007 till Dec 2008.Inclusion criteria:

Any patient submitted to CABG surgery within the mentioned period of time.Exclusion criteria: 1) Single vessel disease.2) Associated valvular disease requiring surgery.3) Contraindications to arterial grafting as emergency

CABG or low EF (<30%)The patients were divided into 2 groups:Group A: 100 patients who had CABG using arterial

grafts other than the LIMA with or without vein grafts.Group B: 100 patients undergoing conventional

CABG using LIMA to LAD plus additional SVGs.Demographic data:

In group A there were 91 men (91%) and 9 women (9%). In group B there were 94 men (94%) and 6 women (6%). In group A the mean age was 56.5 years; while in group B the mean age was 55.Preoperative assessment:

For both groups, routine labs were done in addition to 12 lead ECG, chest x-ray, and echocardiography, Duplex on the carotids, radial arteries, and peripheral arterial and venous systems. CT chest was done for patients over 65 years of age for assessment of Aortic calcifications. Coronary angiography was done and careful history taking and clinical examination performed.Surgical techniques:

All patients underwent the surgery through full median sternotomy and on CPB using Aortic and common atrial cannulation. Myocardial protection was achieved using antegrade warm blood cardioplegia.For group A:

All the patients had at least one arterial graft in addition to the LIMA. The conduits used were in most cases the left radial artery (except in left handed patients where the right radial artery was used instead). Others had the RIMA used (except in insulin dependant diabetic patients). Some patients had the radial artery anastomosed to 2 or 3 vessels. The proximal anastomosis of the RIMA or the radial arteries was to the LIMA in a Y or T fashion. For patients with bilateral ITA grafts, the Mammaries

were harvested in a skelitonized manner.For group B:

All patients had a LIMA to LAD anastomosis in addition to one or more SVGs. The vein grafts were used whether for a single distal anastomosis or sequentially to 2 or more vessels.Operative and postoperative assessment:Operative recording was done for:1) Number of anastomoses.2) Ischemic and total CPB times.3) Need for inotropic support or IABPPostoperative recording was done for:1) Duration of mechanical ventilation.2) Drainage, need for blood transfusion, and reoperation

for bleeding.3) Duration of ICU stay4) New evidence of ischemia.5) Postoperative arrhythmias as AF, ventricular

arrhythmias.6) Wound complications (sternal dehiscence)

Hospital mortality was defined as deaths occurring within 30 days of the operation.Statistical analysis:

Quantitative variables were expressed using mean and standard deviation, they were compared using t-student test. Qualitative variables were compared using Chi-square or Fischer’s exact test. In all tests, p value was considered significant when p <0.005 and considered highly significant when p <0.001.

Results:Demographic data:

P valueGroup bGroup a

0.38755.4 (8.54)

56.5 (8.90)

Age (mean+SD)

0.59394/691/9Gender (m/f)

There was no significant difference between the 2 groups regarding the age or gender.

Preoperative clinical data:P

valueGroup

BGroup

A0.8816866Hypertension

1.00001COPD

-5151DM

0.3242128Hypercholesterolemia

0.2641421Obesity

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0.56885Renal dysfunction

0.0422412Ejection fraction 30-50%

0.91.791.76Euro scoreFrom these data we can notice that there was no

significant difference between the 2 groups regarding the preoperative comorbidities.

Distribution of conduits and number of distal anastomoses for both groups:

The distal anastomotic points were 350 in group A, while in group B 284 anastomoses were done. The conduits used were as follows:

Group BGroup A

9898LIMA

025RIMA

090Radial

18058SVG

Details of surgery:The mean duration of surgery was 307.4 ± 64.46

minutes for group A patients; versus 191.5 ± 36.59 minutes for group B patients (p< 0.001). The mean time for aortic cross clamping (ischemic time) was 39.1 ± 8.96 minutes for group B cases; versus 77.8 ± 17.49 minutes in group A cases (p< 0.001) and consequently, the total CPB time was 63.9 ± 17.15 minutes in group B patients; versus 109.7 ± 26.49 minutes in group A patients (p< 0.001). The operative details are demonstrated in the next table : Postoperative Variables and Complications:Inotropic support:

Inotropic support was needed to aid the hemodynamics in 34 patients of group A cases; versus 59 patients of group B cases (p< 0.001) . ICU stay:

The mean period of ICU stay was 65.2 ± 47.43 hours for group A cases; versus 69.2 ± 38.82 hours for group B cases (p= NS

Mechanical ventilatory support:The mean time of mechanical ventilatory support

was nearly the same in both groups and in hours was 9.9 ± 4.5 in group A patients; versus 9.9 ± 4.4 hours in group B patients (p=NS). Hospital stay:

The time from admission till discharge from the hospital for all the patients was nearly comparable, it was in group A patients 8.5 ± 2.59 days; versus 8.2 ± 3.27days in group B (p=NS). Hospital mortality:

No hospital mortalities were recorded in either groups. Atrial fibrillation:

Postoperative atrial fibrillation was encountered in 4 cases of group A patients; versus only 1 patient in group B (p=NS) .Reoperation for bleeding:

Significantly higher rate of reopening for bleeding in Group A patients was noted (10 cases); compared to group B patients (2 cases only) (p=0.033) which can be attributed to the relatively longer CPB time leading to depletion of the coagulation factors as evidenced by exclusion of surgical bleeding from the anastmotic points performed in all the 10 cases. Acute renal failure:

Apart from the 5 and 8 patients with preoperative renal dysfunction in groups A and B respectively, it should be mentioned that this event was newly developed equally in 4 cases of each group .CVA:

Only one patient in group B developed postoperative stroke; while no such complication was observed in any patient of group A cases (p=NS). This patient did not have any past history suggesting TIAs and his carotid duplex did not show any hemodynamically significant lesions .IABCP support :

The support of Intra-Aortic Balloon Counter-Pulsations catheter was needed to aid the hemodynamic status in only one patient from group B postoperatively; versus no patients in group A (p=NS) .

Group An = 100

Group Bn = 100

P value

Cross clamping time (min) 77.8 (17.49) 39.1 (8.96) <0.001

Total CPB time (min) 109.7 (26.49) 63.9 (17.15) <0.001

Total operative time (min) 307.4 (64.46) 191.5 (36.59) <0.001

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MI :Despite all our technical precautions, newly

developed postoperative Myocardial Infarction complicated the outcome of 7 patients in group B one of whom required the support of IABCP to aid the hemodynamics; versus only 1 patient in group A (p=NS). Sternal dehiscence :

Postoperative deep sternal wound infection occurred equally in one patient in each group (p=NS).The patient in group A was diabetic, did not receive BIMAs. Postoperative dyspnea progressed with fever, leucocytosis and wide retrosternal space with fluid collection in plain chest radiographs. For both patients, re-wiring was performed after adequate debridement and thorough irrigation of the retrosternal spaces was done followed by the insertion of two retrosternal drainage tubes connected to an underwater-seal. Infection subsided afterwards in parallel with sternal healing. Both patients of groups A and B were discharged after 17 and 20 days respectively.

Discussion:The mean duration of surgery in our study was

307.4 ± 64.46 minutes for group A; versus 191.5 ± 36.59 minutes for group B (p< 0.001). The more prolonged total time of surgery in the extended arterial coronary revascularization( EACR) group can be attributed to the relatively more difficult technical demands of the arterial grafting technique and the fact that we adopted the technique of constructing all the composite grafting on arrested heart which enables us to make use of the arterial conduits to the maximal limit. Our operative time closely conforms well with those reported in other series like Possati et al(5), who reported 225 ± 2.2 and 181 ± 4.1 minutes (respectively).

Due to the relative complexity and the technical demand of the technique of composite arterial revascularization, the cross clamp time and hence the total cardiopulmonary bypass times were increased in the EACR group with statistical significance in relation to the conventional group. In our study, the mean cross clamp (ischemic) time was 77.8 ± 17.49 minutes for group A (EACR); versus 39.1 ± 8.96 minutes for the conventional group B (p<0.001) Our ischemic time was closely comparable to other mean cross clamp times reported in other series like Tatoulis et al. (6), who reported 55 ± 24 and 59 ± 22 minutes for TACR group versus the conventional CABG group (respectively); Tashiro et al. (7), who reported cross-clamp times of 49 ± 12 versus 45 ± 5 minutes respectively.

According to our results, hemodynamic support was needed for some of our patients in both groups. Intraoperative inotropic support (adrenaline) was needed to support the hemodynamics during weaning off-CPB in 34 patients (34%) of group A; versus 59 (59%) patients in group B (p< 0.001). Calafiore et al. reported the use of postoperative inotropic support in only 7.5 % of their TACR group for 10.6 ± 2.1 hours; veruss 12.2 % of the SVGs group for 9.8 ± hours (8). Pick et al. reported the respective values of 8.8 % for 10 hours and 13.6 % for 7.3 hours (9)

Our previous conclusion lies in line with those reported in other series like:, Calafiore et al. , , Tashiro et al, ., Tatoulis et al. They all reported that EACR, alone, was soundly capable of supporting the postoperative myocardial functions with some help offered by inotropic support and IABCP. The “relatively-higher” incidence rate of inotropes used in our study is attributed to the limited number of our cases in relation to those reported in the other studies, and also to the difference of the methodology of using such medications in our study related to the others.

Calafiore et al. reported that the incidence of forearm wound infection (the site of harvesting the RA) was lower than the incidence of lower limb wound infection (the site of SVGs harvesting). However, complications other than infection may occur at the site of RA harvesting such as forearm hematoma, and temporary parasthesia. Tatoulis et al. reported rates of 2.4%, 22%, 1.5% for hematoma, paraesthesia, and superficial wound infection (respectively) . Calafiore et al. reported rates of 1.9%, 18%, and 0.9% (respectively).

Due to our accurate preoperative RA examination and harvesting technique, none of the serious functional disturbances was noticed in any of our study cases (e.g. hand ischemia, forearm hematoma, or wound infection). Temporary mild parasthesia of the thumb finger was noticed in many of group A cases. However, it was spontaneously ameliorated with no residual effect. In our study, only one patient in each group, had sternal wound infection. The postoperative complications and side effects noticed at the ITA harvest site occurred as deep sternal wound infection. Our rate of infection which is 2/200 patients (1%) in the two groups is less than those reported by others like: Barner et al. who reported 2.1% (10); Calafiore et al. who reported 1.2% ; and Tatoulis et al., who reported 1.6% . This complication was well-controlled afterwards without any serious residual

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consequences. Our choice of avoiding the use of BIMA grafts in patints with IDDM, COPD and obesity has been successful in preserving the sternal blood supply (hence decreasing the incidence of sternal complications) in the majority of our patients.

Intra-aortic balloon counter-pulsation catheter (IABCP) was instituted in one patient of group B cases (1%) versus none of group A patients (p=NS). In most of the studies, IABCP was used to obtain a systolic blood pressure > 90 mmHg, and a cardiac index greater than 2.2 liters/minute/meter2.

Conclusion:Extended arterial coronary revascularization

(EACR)is a safe procedure with acceptable complications when compared to conventional CABG using a single mammary with veins, if we consider its well proven long term results and freedom from reintervention.

References:1. Hasia T-Y, Yuh D (2007) Primary coronary artery bypass

surgery. In: Yuh DD, Vricella LA, Baumgartner WA (eds.)Manual of cardiothoracic surgery, 1st ed. McGraw-HillCompanies,pp429-447.

2. EagleKA,GuytonRA,DavidoffR,EdwardsFH,EwyGA,Gardner TJ, Hart JC. Herrmann HC, Hillis LD, HutterAMJr, LytleBW,MarlowRA,NugentWC,OrszulakTA.ACC/

AHA2004guidelineupdateforcoronaryarterybypassgraftsurgery: a report of the American College of Cardiology/American Heart Association Task Force on PracticeGuidelines (Committee to Update the 1999Guidelines forCoronaryArtery BypassGraft Surgery).American Collegeof Cardiology Web Site. Available at http://www.acc.org/clinicaL/guidelines/cabg/cabg.pdf.

3. ShumackerHB(1992)TheEvolutionofCardiacSurgery.In:IndianaUniversityPresspub.byBloomington.

4. LindberghCA(1935)Anapparatusforthecultureofwholeorgans.JExpMed62:409-431.

5. PossatiGF,GaudinoM,AlessandriniF,etal.(1998)Midtermclinicalandangiographicresultsofradialarterygraftsusedformyocardialrevascularization.JThoracCardiovascSurg116:1015-1021.

6. Tatoulis I, Buxton BF, Fuller IA, Royse AG (1999) Totalarterialcoronaryrevascularization:techniquesandresultsin3220patients.AnnThoracSurg68:2093-2099

7. TashiroT, Nakamura K, IwakumaA, Zaitu R, Iwahashi H,MuraiA,KimuraM(1999)InvertedTgraft:noveltechniqueusing composite radial and internal thoracic arteries. Ann Thoracicsurg67:629-631.

8. CalafioreAM, DiMauroM (2006) Complex arterial grafts:Operatvetechniques.In:Guo-WeiHe(ed.)ArterialGraftsforCoronaryBypassSurgerypubbySpringer-VerlagLtd.,2ndedition,pp243-247.

9. PickAW,OrszulakTA,AndersonBJ,SchaffHV(1997)Sin-gleversusbilateralinternalmammaryarterygrafts:10-yearoutcomeanalysis.AnnThoracSurg64:599-605

10.BarnerHB,JohnsonSH(1996)TheradialarteryasaT-graftforcompletearterialrevascularization.

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Early results of Skeletonized versus Pedicled radial artery in revascularization

of coronary patients Ibrahim M. Yassin, M.D.,**Salah S. Atta,M.D., ***Mohamad Attiya, M.D.

Addrees reprint request to :Dr. Ibrahim M. Yassin* Department of Cardiothoracic Surgery, Tanta University, Egypt - Saud AL-Babtin Cardiac Centre ,SBCC,KSA ** Department of Cardiology, Assuit University, Egypt - Saud AL-Babtin Cardiac Centre ,SBCC,KSA*** Department of Cardiothoracic Surgery, Ain Shams University, Egypt - Saud AL-Babtin Cardiac Centre ,SBCC,KSAEmail:[email protected] : 04/133/1006

Background: The radial artery (RA) is resurging as a graft used for myocardial revascularization because of its presumed advantageous long-term patency rates. The vessel can be harvested as a pedicle or skeletonized..Methods: Randomized selection of 50 patients (group A) underwent vascularization using skeletonized radial artery and another 50 patients (group B) underwent vascularization using pedicled radial artery. The RA was injected with papaverine to prevent spasm of the vessel during and after harvesting. These patients were operated upon in the period from October 2005 to October 2009 in Ain Shams University Hospitals (ASUH), Egypt and Saud Al- Babtain Cardiac Centre (SBCC), KSA. Operative data and early results and graft patency after approximate of one year were compared in both groups.Results: Preoperative parameters were comparable in both groups. Harvesting the RA as a skeletonized vessel took longer time as compared with pedicle preparation (group A vs B group 39.1 ± 3.5 minutes vs 22.4 ± 3.9 minutes (p < 0.001). The length of the RA after skeletonization with scissors and clips was 19.8 ± 1.3 cm in contrast with 18.1 ± 0.9 cm (p < 0.01) after dissection as a pedicle. The number of hemostatic titanium clips was similarly higher in group A as opposed to group B, 53.7 ± 6.2 vs 39.7 ± 6.2 (p < 0.01). Mean blood flow through the graft after performing the proximal anastomosis was similar in both groups (48.3 ± 20.1 mL/min versus 51.8 ± 22.3 mL/min, respectively). There was no hospital mortality in both groups, incidence of peri-operative myocardial infarction (2% both), length of ICU stay (2.1±1.4 versus 2.2±1.6 days). Patients of the B group required significantly more frequent re-sternotomy due to bleeding within the early postoperative course 8% vs 0% (p < 0.01). Major complications were observed in one patient (2%) in group A and 2 patients (4%) in group B (p = not significant [NS]). None were related to the radial artery graft. Angiography after a mean follow up of (13.0±1.4 monthes) was obtained in 40 patients of group A and 35 patients in group B and revealed that the stenosis free graft patency rate of group A was (37 of 40, 92.5%) and was superior to that of group B (30 of 35, 85.72%) with p < 0.01.Conclusion: Skeletonization using scissors and clips is more time consuming and technically more demanding, but produce significantly longer grafts increasing the possibility for more sequential anastomoses. It is safe and contributes to reducing the incidence of early graft stenosis.


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Coronary artery bypass grafting (CABG) using arterial grafts is gaining more advocates since the long-term patency rate of arterial grafts is reported to be superior to saphenous vein grafts [1]. The internal

mammary arteries (IMAs) are the most widely used arterial conduits and their patency rates are reported to be 90% or better even 10 years after surgery [1, 2]. Studies have shown that bilateral internal mammary artery grafting has yeilded better event-free rates than single IMA grafting in selected patients [1, 3]. The graft patency of the right internal mammary artery (RIMA) is shown to be similar to that of the left internal mammary artery (LIMA) [2]. These LIMA and RIMA are considered to be the first and second choices of arterial conduit in most CABG cases, the third choice remains questionable. The radial artery (RA) was introduced as a coronary bypass graft more than 30 years ago [4]. The use of the RA as a bypass graft has returned again in coronary artery bypass grafing surgery after Acar and colleagues [5] reported on their experience in 1992 revival of its use. The RA being a well sized artery is more accepted as a conduit because of its adaptation to systemic blood pressure and its larger diameter as compared with all other arterial bypass grafts [5, 6]. The main problem for the utilization of the RA are its vasospastic properties, which are important since the diameter of the RA is usually far lower than that of a saphenous vein, and a reduction of the vessel diameter due to spasm may significantly reduce the blood flow [7]. One of the methods to avoid spasm of the RA is to harvest the vessel together with its accompanying veins in a pedicle [5, 8–11]. Many publications recommend harvesting of the RA as pedicled graft together with its accompanying veins and perivascular tissue. The reasons are the vasospastic properties of the vessel [9]. Moreover, the pedicle technique is simpler and less time consuming. In contrast, skelotonization is it requires careful and meticulous dissection of the graft. So,skeletonization of the RA is less frequently used [12–14].

Methods: Randomized selection of 50 patients (group A)

underwent vascularization using skeletonized radial artery and another 50 patients (group B) underwent vascularization using pedicled radial artery. The RA was harvested in a skeletonized fashion( group A ) with the use of scissors and titanium clips, and in ( group B )as a pedicled graft, also with the aid of scissors and clips . In both groups, the RA was treated with papaverine to prevent spasm of the vessel during and after harvesting.

These patients were operated upon in the period from October 2005 to October 2009 in Ain Shams University Hospitals(ASUH), Egypt and Saud Al- Babtain Cardiac Centre (SBCC), KSA. Operative data and early results and graft patency after approximate of one year were compared in both groups. Patients with carpal tunnel syndrome, arterial obstructive disease, pathologic Allen test or Doppler examination( small RA diameter, or visible calcification) were not candidates for radial harvesting. Radial artery harvesting was also avoided in patients with renal dysfunction on dialysis . The radial artery was harvested from the non-dominant hand in all cases. All RA vessels were taken by the same surgeon after an Allen test had been performed to assess the integrity of the palmar arch of the non-dominant hand. Delayed capillary refilling exceeding 10 seconds was considered a contraindication for a RA harvesting.

Patients with good targets at least 1.5mm seen in the angiography whatever the territory of the target ( good diagonal, obtuse marginal, posterolateral or posterior descending branch ) and the degree of stenosis between 70-100% ; were considered to be revascularized with the radial artery. In addition, we even considered the patient with two good calibered targets as a good candidate for skeletonized radial artery as the sequential anastomosis is more feasible and the length is better with easy handling. All the revascularized vessels were with stenosis more than 70%. (Table1)

This study was approved by the Medico-Ethical Review Committee, and an informed consent was signed by every patient before enrollment. All the surgical procedures were done by the same surgical team with the same methodology, and the only difference is the RA, being harvested whether pedicled or skeletonized.

The following factors were assessed during RA preparation and during the period of follow up of the study groups: 1- Time interval needed for graft preparation. 2- Length of the graft. 3- Amount of titanium clips used.4- Mean blood flow after completion of the anastomosis.5- Early postoperative morbidity and mortality.6- Patency of the graft after about one year.

RA harvesting technique:The skin incision and the preparation of the RA

strongly considered the topographical anatomy to avoid


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injury to the cutaneous nerve. We strongly recommend no use of electro-cautery in both extremities so, only, the scissors and forceps are used during opening of the skin over its whole length then gentle dissection and clipping of the branches with division between two clips and regular complete haemostasis till completely freeing the RA. From its bed whether pedicled or skeletonized . The skeletonization was performed with a «no touch» technique. All side branches were clipped with titanium clips. The vessel was prepared, beginning from the bifurcation of the brachial artery. For harvesting a pedicle, the RA with adjacent veins and covering fascia was mobilized beginning from the middle of the vessel. The RA is then covered with gauze swabs soaked with diluted papaverine (50 mg papaverine diluted in 100 mL 0.9% NaCl) for topical treatment in situ. After giving heparin (by the end of harvesting of the mammary artery) and during division of the distal end of the mammary artery, bulldog is applied to the distal end of the radial artery and left for two purposes: first is to follow the O2 saturation on the monitor transmitted from the thumb of the same hand to assure the adequacy of the ulnar artery on the same side and proceed on the maneuver and secondly to make the artery dilate against the hydrostatic blood pressure of the patient. After cannulation and going on cardiopulmonary bypass and during preparation of the other grafts, The distal end is separated (Fig.1); the proximal end was cannulated and perfused with a papaverine solution to be flushed. The intraoperative measurement of the free blood flow was performed after completion of all anastomoses and weaning from extracorporeal circulation. In the Skeletonized group (group A), the RA was freed from the surrounding tissue and veins very gently with the Metzenbaum scissors and with proper applying of two clips and division of the branch in between, Transit time Flowmetry (Butterfly Flowmeter Version 111) evaluation to all grafts was done as a routine . Doppler probes

( 2.5 to 3 mm ) were used in conjunction with the flow meter Sterile gelly was applied to improve recording. The flow was recorded within 10 seconds and displayed in mL/min under consideration of the mean arterial pressure. All patients received intravenous nitroglycerine (30 to 100 µg/min) intra-operatively and for the first 24 hours. All received aspirin (100 mg daily) commencing the first postoperative day and the calcium channel antagonist amlodipine (5 mg orally daily) for 6 months

Definitions and data collection:operative mortality was considered as death within

the hospital stay. Cardiac enzymes and electrocardiogram

were evaluated immediately after admission to ICU and at the all in-hospital days of stay(usually 5days). A diagnosis of postoperative myocardial infarction was made according to the following criteria: new Q-waves in two or more contiguous electrocardiographic leads, poor R-wave progression, new left bundle-branch block, and unstable ventricular rhythm. Values of the myocardial-specific Troponin cTNI were considered significant reaching a level of more than 10 ng/ml at 24 h postoperatively. RA graft failure was defined as complete occlusion, a string sign (conduit 1 mm diameter for some or all of its length), or a discrete stenosis exceeding 60% anywhere within the conduit or at either anastomosis.

Statistical-analysis:Statistical analysis was performed using the SPSS

11.0 (SPSS Inc, Chicago, IL). All appropriate data were assessed for mean and standard deviation. A p less than 0.05 was considered statistically significant.

Results: Preoperative and demographic data: were

comparable in both groups (Table 1).

Intra-operative analysis: Harvesting the RA as a skeletonized vessel took more time as compared with pedicle preparation (group A vs group B 39.1 ± 3.5 minutes vs 22.4 ± 3.9 minutes; p < 0.001) . The amount of placed hemostatic titanium clips was similarly higher in group A compared with group B (53.7 ± 6.2 vs 39.7 ± 6.2; p < 0.01). The length of the RA after skeletonization with scissors and clips was 19.8 ± 1.3 cm, in contrast with 18.1 ± 0.9 cm (p < 0.01) after dissection as a pedicle. Mean blood flow through the graft after establishing the proximal anastomosis was similar among both groups with no statistically significant difference(48.3 ± 20.1 mL/min vs 51.8 ± 22.3 mL/min).(Table 2).

In group A, sequential anastomoses to two big territories using the skeletonized radial artery in 15 patients (30%) was done while we did not apply this to any of the patients in group B as it was technically difficult.

Early Post-operative analysis: Hospital mortality was 0% in both groups, Incidence of peri-operative myocardial infarction was similar in both groups (2%) not in the territory of the RA, length of ICU stay (2.1±1.4 versus 2.2±1.6 days). Patients of the B group required


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Group A(n =50)

Group B(n =50)

p Value

Clinical characteristics

Age (years) (36–70) 62.9 ± 7.9 (34–68)63.8 ±

8.8NS

Female sex 10 20% 11 22% NS

Coronary risk factors

Hypertension 39 78% 41 82% NS

Insulin user 32 64% 32 64% NS

Hyperlipidemia 45 90% 43 86% NS Smoking 20 40% 19 38% NS Obesity 12 24% 13 26% NS

Family history 28 56% 27 54% NS

Angiographic profile

Left main disease 8 16% 9 18% NS

Number of diseased vessels (1–3) 2.8 ± 0.3 (1–3) 2.7 ± 0.4 NS

Target vessel stenosis

70% to 89% 15 30% 16 32% NS

90% to 99% 25 50% 24 48% NS

100% 10 20% 10 20% NS

Comorbidity

Peripheral vascular disease 17 34% 18 36% NS

Cerebral vascular accident 3 6% 4 8% NS

COPD 7 14% 5 10% NS

Renal dysfunction 7 14% 5 10% NS

Table 1. Preoperative Patient DNS = not significant. COPD: Chronic Obstructive Pulmonary Disease

Group A(n =50)

Group B(n =50)

p Value

Preparation time (min) 39.1 ± 3.5 22.4 ± 3.9 <0.001

Graft length (cm) 19.8 ± 1.3 18.1 ± 0.9 < 0.01Clips use 53.7 ± 6.2 39.7 ± 6.2 < 0.01Mean FBF (mL/min) 48.3 ± 20.1 51.8 ± 22.3 NS

MAP (mm/Hg) 75 ± 6.3 77 ± 4.8 NS

Table 2: Graft harvestingFBF = free blood flow after proximal anastomosis; MAP = mean arterial pressure at time of measurement;NS = not significant


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significantly more frequent re-thoracotomy due to bleeding within the early postoperative course (8% vs 0%) (Table 3). Major complications were observed in one patient (2%) in group A (cerebrovascular accicent) and 2 patients (4%) in group B(cerebrovascular accicent and acute renal failure) (p = not significant [NS]). None were related to the radial artery graft.

Group A(n =50)

Group B(n =50)

p Value

Hospital Mortality 0% 0% NS

Perioperative MI 2% 2% NS

Length of ICU stay 2.1 ± 1.4 2.2 ± 1.6 NS

Exploration for bleeding 0% 8% < 0.01

Patency of the graft

after 13.0 ± 1.4 Monthes 92.5% 85.72% < 0.01

Table 3. Early Post operative Morbidity and Mortality:

Angiographic data after approximate one year(13.0±1.4 months): Angiography after a mean follow up of (13.0±1.4 months) was obtained in 40 patients of group A and 35 patients in group B and revealed that the stenosis free graft patency rate of group A (37 of 40, 92.5%) was superior to that of group B (30 of 35, 85.72%) with p < 0.01. These 8 patients with graft failure varied in its appearance angiographically between complete occlusion within the conduit (3), a string sign in small length of the conduit(2) and string sign in all of the length of the conduit(1), and a discrete stenosis exceeding 60% within the conduit (2). No graft failure was detected at the anastomotic site proximally or distally angiographically. The three cases of group A were (2) discrete lesions and (1) small length string sign.

Fig.1. The skeletonized radial artery after being harvested and separated distally

Discussion: The skeletonization technique with scissors and

clips throughout our experience during this study, has some advantages, which makes the technique quite attractive, mainly providing a long graft which allows us to harvest the radial artery with sufficient length for coronary artery bypass and so frequency of the composite grafting has been reduced. Also,it makes sequential bypass grafting easier. Moreover, the skeletonized graft is free of adventitial tissue and so, the optimal anastomotic site can be identified much easier and also, makes prevention of vasospasm through topical application of vasodilative drugs simple. The vessel diameter is usually larger, facilitating side-by-side-anastomosis and its visual control, and thus may leave less anastomotic stenosis.

Because the RA, similar to the coronary arteries, is characterized as an artery of the muscular type, it tends to develop arteriosclerosis. The incidence of arteriosclerosis is much higher in the RA as compared with the internal mammary artery. After skeletonization, arteriosclerotic plaques are readily visible, which is not the case in a pedicled graft.

Skeletonized radial harvesting facilitates grafting techniques including sequential bypass or bypass to a high-flow and mildly stenosed coronary artery. Extensively reversed vasospasm and a larger caliber of the graft makes the anastomosis easier.

In the most recent publications, many colleagues prefer harvesting of the RA with an ultrasonic scalpel, which was introduced into clinical practice in 1987 [15]. This presumably allows a non-traumatizing preparation of the RA, it is easy to handle, and does not require much time [16–20].

In our series, both groups consumed more time in harvesting the RA than that recorded in these publications. Skeletonization (group A) with scissors and clips mandated an additional more time for graft harvesting and also, the need of more hemostatic clips are clear issues. In all cases of the study,the time of harvesting of the skeletonized radial artery did not exceed that of the skeletonized LIMA which was used in all of our cases and so,it had no influence on the total operative time. The economic facor for the use of more clips is nonetheless specially if it results in less amount of postoperative bleeding as shown in the study .


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As the endothelium plays a vital protective role by releasing endothelium-derived relaxing factor (EDRF), a potent vasodilator and inhibitor of platelet aggregation, endothelial damage can promote the atherosclerotic process, leading to the early or late failure of the graft. There have been many concerns expressed in regard to the possible detrimental effect of skeletonization on the endothelial integrity and function [21].

To our concern scissors and clips still more safe for the endothelial lining of the graft specially if it is harvested with the non touch technique as we showed in the methodology in details .This opinion is supported by some authors and denied by others.

Fukata et al. reported that the thermal degeneration was limited to the surrounding connective tissue and that the media or intima of the vessel wall was not affected by the ultrasonic scalpel [22].

Rukosujew et al., 2004[23], showed that endothelial damage is more apparent with harvesting the RA using harmonic scalpel. Also, they showed in the same publication that skeletonization of the RA using harmonic scalpel causes much damage to the endothelial lining of the graft, the study was dealing with electron microscopical examination of the specimens of the grafts.

On the other hand and In a more recent study done by a Japanese group, Shi et al.,2009 [24], concluded that the skeletonization of the GastroEpiploicArtery with an ultrasonic scalpel was found to be as safe as a non-skeletonized dissection in preserving the vascular contractile ability or endothelium-dependent and -independent relaxation of the graft.

We believe that the non touch technique we used in both of our groups is the least harmful for the endothelial lining of the RA. and that these occasional endothelial lesions are unavoidable, and should be considered as not clinically relevant.

To our knowledge,Only two papers were comparative studies [12, 25] (skeletonized conduits vs. pedicled conduits) in this field.

In a prospective study by Amano et al. [12], 112 patients underwent isolated CABG using a pedicled RA and 131 using a skeletonized RA. Ninety-six patients that received a skeletonized RA and 76 patients that

received a pedicled RA underwent angiography. Patency rates for skeletonized and pedicled RAs were 98.6% (141/143 distal anastomoses) and 98.8% (85/86 distal anastomoses), respectively (P=ns). Perfect patency was also assessed and revealed values of 96.5% in the skeletonized group and 84.9% in the pedicled group (P=0.0016).

Miyagi et al. [25] performed a prospective study involving 174 consecutive patients who underwent on-pump CABG surgery. Patency was compared between non-skeletonized and skeletonized RAs. RA acted as the second target vessel and LITA was used as a primary conduit. Angiography was performed 14.7±2.9 days postoperatively in 75 patients (90 anastomoses) who received a non-skeletonized conduit and 13.7±1.9 days postoperatively in 38 patients (47 anastomoses) who received a pedicled conduit. Patency rates were 96.7% and 100%, respectively [P=not significant (ns)]. Angiography was repeated 386.8±149.3 days postoperatively in 44 patients (51 anastomoses) who underwent the pedicled technique and 267.1±148.7 days postoperatively in 11 patients (13 anastomoses) who received a skeletonized artery. Patency rates were 96.2% and 100%, respectively (P=ns). Perfect patency rates, at early angiography were 86.7% in the non-skeletonized group and 98.1% in the skeletonized group (P=0.034) and at mid-term angiography, 77.5% in the pedicled group and 100% in the skeletonized group (P=0.048).

Two more studies were found to deal with the early results of the patency and advantages of skeletonization of the radial artery[26-27]

A prospective study by Hirose et al. [26] performed CABG in 50 consecutive patients using skeletonized RAs. Twenty-one RA grafts and 36 distal anastomoses were evaluated by angiography at one year (0.9±0.1 years). One RA graft occlusion was established to affect one distal anastomosis, producing a perfect graft patency rate of 95.2% (20/21) and a perfect anastomosis patency rate of 97.2% (35/36 anastomoses).

Hirose et al. [27] prospectively collected data for 391 patients who underwent isolated CABG surgery. Skeletonized RA grafting was performed in 246 patients. Angiographic control was performed within three months of surgery in 192 patients and in seven patients one year after surgery (1.2±0.2 years). The early RA patency rates and perfect patency rates were 98.0% and 96.0%,


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respectively. Six RA anastomoses occlusions (2.0%) were revealed. After one year, no graft occlusions or stenoses were demonstrated.

Our results are going in harmony with the prementioned four studies ,encouraging going more with skeletoniztion of the radial artery .

The pedicled radial artery anastomosed to the mildly stenosed coronary artery often showed a narrowing in early angiography, because of flow competition between the graft and the native coronary artery [28]. Thus a mildly stenosed coronary artery used to be bypassed with the saphenous vein, accepting the risk of vein graft disease. We believe that the complete reverse of vasoconstriction by removing all surrounding tissue can attribute to a better patency rate and more resistance to any competitive flow. So, in this situation now we can use the skeletonized radial artery as a valveless, large-caliber conduit that can deliver high flow. The role of the adventitia should be further analyzed in relation to the vasospasm.

In our study,we could not show evidence of that point as the difference in the degree of stenoses was (NS) as shown in (Table 1). We recommend more comparative studies on larger populations to investigate this point which is crucial in accepting the radial artery as an excellent unique conduit.

To optimize the high blood flow through the radial artery graft, proximal anastomosis of the radial artery graft should be the ascending aorta rather than creating a composite graft with the LIMA.

Limitations of the study:The most important limitation of this study was the

small number of patients and the short term results of the study.So, We recommend more studies with more number and more period of follow up. Also, other methods of harvesting like ultrasonic scalpel and chemical preparation of the radial artery while harvesting it skeletonized maybe more beneficial and less demanding.More selective studies on less stenotic coronary vessels may be highly valuable in the reputition of the radial artery as a conduit for CABG. Unfortunately ,To our knowledge, we could not find any publication dealing with the mid term(5Ys.) or long term(10Ys.) results of skeletonization of the radial artery.

Conclusion:The underlying study has shown that skeletonization

with scissors and clips is a technically more challenging and time consuming procedure, but it provides greater length of the graft and allows simple and safe utilization of the graft for sequential anastomoses. Early patency results after one year are excellent and statistically significant in comparison to the pedicled one. Mid term(5Ys.) and long term(10Ys.) are needed.

References:1.Reardon M.J., Conklin L.D., Reardon P.R., Baldwin J.C.

Coronary artery bypass conduits: review of current status. J Cardiovasc Surg (Torino) 1997;38:201-209.

2.Barner H.B. Arterial grafting: techniques and conduits. Ann Thorac Surg 1998;66:S2-S5.

3.Lytle B.W., Blackstone E.H., Loop F.D., et al. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg 1999;117:855-872.

4.Carpentier A., Guermonprez J.L., Deloche A., Frechette C., Dubost C.: The aorta- to-coronary radial artery bypass graft. A technique avoiding pathologic changes in grafts. Ann Thorac Surg 1973;16:111-121.

5. Acar C., Jebara V., Portoghese M., et al. :Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652-660.

6.Acar C., Ramsheyi A., Pagny J.Y., et al. :The radial artery for coronary artery bypass grafting: clinical and angiographic results at five years. J Thorac Cardiovasc Surg 1998;116:981-989.

7.He G.W., Yang C.Q., Starr A.: Overview of the nature of vasoconstriction in arterial grafts for coronary operations. Ann Thorac Surg 1995;59:676-683.

8.Bhan A., Choudhary S.K., Saikia M., Sharma R., Venugopal P.: Harmonic scalpel: initial experience. Asian Cardiovasc Thorac Ann 2001;9:3-6.

9.Buxton B., Fuller J., Gaer J., et al. :The radial artery as a bypass graft. Curr Opin Cardiol 1996;11:591-598.

10.Reyes A.T., Frame R., Brodman R.F.: Technique for harvesting the radial artery as a coronary artery bypass graft. Ann Thorac Surg 1995;59:118-126.

11.Tatoulis J., Buxton B.F., Fuller J.A. :Bilateral radial artery grafts in coronary reconstruction: technique and early results in 261 patients. Ann Thorac Surg 1998;66:714-720.

12.Amano A., Takahashi A., Hirose H. Skeletonized radial artery grafting: improved angiographic results. Ann Thorac Surg 2002;73:1880-1887.

13.Garcia-Rinaldi R., Soltero E.R., Carballido J., Mojica J.: Intraluminal milrinone for dilation of the radial artery graft. Tex Heart Inst J 1999;26(3):189-191.


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14.Taggart D.P., Mathur M.N., Ahmad I. :Skeletonization of the radial artery: advantages over the pedicled technique. Ann Thorac Surg 2001;72:298-299.

15.Boddy S.A.M., Ramsay J.W.A., Carter S.S.C., Webster P.J.R., Levison D.A., Whitfield H.N. :Tissue effects of an ultrasonic scalpel for clinical surgical use. Urol Res 1987;15:49-52.

16.Isomura T., Suma H., Sato T., Horii T. :Use of the harmonic scalpel for harvesting arterial conduits in coronary artery bypass. Eur J Cardiothorac Surg 1998;14:101-103.

17.Lamm P., Juchem G., Weyrich P., Schütz A., Reichart B. :The harmonic scalpel: optimizing the quality of mammary artery bypass grafts. Ann Thorac Surg 2000;69:1833-1835.

18.Posaciolu H., Atay Y., Cetinda B., Saribülbül O., Buket S., Hamulu A.: Easy harvesting of radial artery with ultrasonically activated scalpel. Ann Thorac Surg 1998;65:984-985.

19.Ronan J.W., Perry L.A., Barner H.B., Sundt T.M., III Radial artery harvest: comparison of ultrasonic dissection with standard technique. Ann Thorac Surg 2000;69:113-114.

20.Royse A.G., Royse C.F., Groves K.L., Yu G. :Blood flow in composite arterial grafts and effect of native coronary flow. Ann Thorac Surg 1999;68:1619-1622.

21.Matsumoto K, Tsuneyoshi I, Iguro Y, Kinjo T, Yotsumoto G, Ueno M, Kanmura Y, Sakata R. :Effects of ultrasonic skeletonization on internal thoracic and gastroepiploic arteries for coronary artery bypass grafting. Eur J Cardiothorac Surg 2006;30:592–596.

22.Fukata Y, Horike K, Kano M. :Histological study on the influences of an ultrasonic scalpel on skeletonized vessel wall. Ann Thorac Cardiovasc Surg 2002;8:291–297.

23.Rukosujew A., Reichelt R., Fabricius A., Drees G., Tjan T., Rothenburger M., Hoffmeier A., Scheld H., Schmid C.:Skeletonization versus pedicle preparation of the radial artery with and without the ultrasonic scalpel .Ann Thorac Surg 2004;77:120-125

24. Shi j , Iesaki T, Kubota N., Sumiyoshi K., Kajimoto K., Kikuchi K., Hiroyuki Daida H., Amano: Skeletonization with an ultrasonic scalpel is as safe as a non-skeletonized dissection in preserving the endothelial function of the human gastroepiploic arteryInteract CardioVasc Thorac Surg 2009;8:216-220.

25.Miyagi N, Oshima N, Shirai T, Sunamori M. Skeletonised harvesting improves early-term and mid-term perfect patency of a radial artery graft. Jpn J Thorac Cardiovasc Surg 2006;54:472–476.

26.Hirose H, Amano A. Skeletonized radial artery grafting: one-year patency rate. Heart Surg Forum 2004;7:E277–E282.

27.Hirose H, Amano A, Takahashi A, Takanashi S. Skeletonization of the radial artery with the ultrasonic scalpel: clinical and angiographic results. Heart Surg Forum 2003;6:E42–E47

28.Amano A., Hirose H., Takahashi A., Nagano N. Coronary artery bypass grafting using the radial artery: mid-term results in a Japanese institute. Ann Thorac Surg 2001;72:120-125.


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Local experience in management of postCABG Pericardial Effussion

Derar AlShehab MD ,*Moataz S.,MD,**Mohamed Abd.Rahman MD,***Ayman A.,MD,****

Addrees reprint request to :Dr. Derar Al Shehab MD* Derar Al ShehabThoracic surgeon - chest disease hospital - Ministry of health Kuwait** Moataz Salah EldinAssociate Professor Cardiothoracic Surgery – Zagazig University Specialist Cardiothoracic Surgery, Chest disease hospital , Kuwait .*** Mohammed Abdul Rahman Lecturer cardiothoracic surgery – Ain Shams university .Senior registrar Cardiothoracic Surgery, Chest disease hospital , Kuwait . **** Dr / Ayman Anwar Senior registerart Cardiology , Chest disease hospital , Kuwait .Specialist Cardiology – Alexandria university Address of correspondence :Dr / Moataz Salah EldinE-mail : [email protected] : 00965-97600657Codex : 04/134/1006

Background: The optimal therapy for symptomatic pericardial effusions remains controversial . Management of late pericardial effusion with or without tamponade which is a rare cause of morbidity and mortality after coronary artery by pass grafting , remains undefined whether surgical subxiphoid drainage or thoracoscopic pericardial “window” is the optimal operative approach to pericardial effusion. Video-assisted thoracoscopy with the creation of a pericardial window is a minimally invasive method of pericardial drainage. It also allows an excellent view of both the pleural cavity and pericardium . This paper compares outcomes after the two most commonly used techniques, Operative open pericardial drainage (whether subxiphoid drainage=SUX or via left anterior minithoracotomy) versus VATS = Video Assisted Thoracoscopic Surgery . drainage and pericardial window creation . We hypothesized that the true window into the pleural space created by the VATS might be more effective in management.Methods: Between January 2006 and January 2009, 21 echocardiographically diagnosed pericardial effusion post CABG (17 men ( 81 % ), 4 women ( 19 % ); mean age 55 years ± 9.7 ). Signs of tamponading were positive in 15 (71.4%) . video-assisted thoracoscopy was performed for 12 of them and surgical drainage was done for 9 patients at our center according to echo findings. For VATS group pericardial windows were created under general anesthesia and single-lung ventilation using 2 to 3 trocars. Results: Total of 21 pericardial drainage procedures were performed; mean follow-up was 6 months. Twelve patients (57%) had VATS drainage , while nine of them (43د%) requried either subxiphoid drainage ( 6 patients ( 66.6%) )- and remaining, 3 required left anterior minithoracotomy for direct pericardio-pleural window creation . Echocardiographic features of tamponade were documented in 15 patients (71.4%) before intervention Recurrence rate within 30 days was 9.5% ( 2 cases out of total 21 ) ; and both cases were in the VATS group 16.7% ( 2 out of 12 patients) . Anesthesia time was longer in thoracoscopy (115 ± 35.5 min. vs 70 ± 15.0 minutes for open operative drainage; p < 0.001). Procedural morbidity was higher after subxiphoid drainage (2 0ut of 6 [33.3%] vs 1 out of 12 [8.3%] in VATS group; p < 0.01) . Conclusions: VATS procedure for pericardial drainage is as effective as Subxiphoid and left minithoracotomy procedure for pericardial effusion. It is also safe and allows to explore the intrpleural space and perform other intrapleural procedures.

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Cardiac tamponade is a potentially lethal complication after an open heart operation, and occurs in 0.5% to 6% of cases [1, 2]. Tamponade can be either early or late in the postoperative period. Early

postoperative tamponade is more common, and is easly recognized due to close hemodynamic monitoring in the intensive care unit or recovery room. Late postoperative tamponade on the other hand, is less common, it was first documented in 1968 by Prewitt and colleagues [3]

By definition tamponade may occur any time after 7 days post cardiac operation up to 6 months [4]. Due to the fact that majority of cardiac surgical patients now are being discharged from the hospital by the fifth postoperative day, it is more likely that the Initial encounter of the patient with late tamponade will not be with the cardiac surgeon. The different presentations of this entity makes diagnosis challenging, with mortality rates as high as 18% [5]. Nowdays younger age of patient population has been documented [6].

Increased awareness of this entity among clinicians can lead to early recognition, appropriate management, and the prevention of morbidity and mortality in these young and often otherwise healthy patients.

A variety of treatment modalities are available, the optimal treatment of symptomatic pericardial effusions remains controversial , many options have been marked such as observation, anti-inflammatory administration, pericardiocentesis with or without percutaneous catheter drainage, and finally surgical intervention . Recently there are two surgical options most commonly used :

(1) Direct surgery in the form of either subxiphoid drainage (SUX), or Left mini prastenal thoracotomy video-assisted thoracoscopic pericardial “window”(VATS). There is no available data to guide the choice between these two approaches. [7].

A pericardial window consists of a partial pericardiectomy that creates a free passage of fluid in the pericardium presumably allowing longer-term drainage into an adjacent space, usually the pleural space. Pericardial resection creating such a window can be performed through a limited anterior thoracotomy, formal thoracotomy [8], or thoracoscopy which was implemented in the 1990s as a treatment option [9 -10] .

Methods :A retrospective chart review was conducted and a

total of 21 patients identified in 3 years period ( 2006- 2009 ) in a single institute . All of them underwent surgical drainage in the form of( SUX) ; Left anterior minithoracotomy or VATS . 17 patients were males (81%) and 4 (19%) were females. Age ranging between 50 to 70 years ,mean age was 55 ± 9.7 years . The choice of procedure was suggested in most of the cases by the cardiothoracic surgeon. All of them underwent an echocardiogram and the surgical procedure was chosen based on the echocardiogram results .If the effusion was mostly posterior and inferior without clear bands of adhesion or multiple septations, the patient was mostly referred for VATS. However , if the collection is inferior or posterior with clear septations they were referred to either SUX or Left anterior minithoracotmy drainage.

An echocardiographic data prior to surgical drainage were interpreted for effusion size and the presence of tamponade physiology as indicated by right atrial compression or right ventricular diastolic collapse, or both (11). A thoracoscopic pericardial window procedure was performed in 12 patients ( 57%), and the SUX procedure was performed in 6 patients (28.6%) ; while 3 patients ( 14.3%) had left anterior minithoracotomy.

Follow up of the patients was from the day of the surgical procedure until discharge.

Recurrence in this study was defined as a reaccumulation of effusion within 6 months from original procedure documented by an echocardiography and represent either moderate and/or large amount of fluid, or hemodynamically significant, regardless of the need for further therapy within 6 months of the original procedure .

Operative techniques:Majority of patients were more or less

hemodynamically stable when brought to the operating room, despite that, 15 patients (71.4%) had a clear evidence of tamponade either by echo or clinically (tachycardia or mild pulsus paradoxus, or both ) .

Two patients were hemodynamic unstable before the induction of general anesthesia.

These patients improved after urgent pericardiocentesis with SUX drainage procedure which was performed immediately. In VATS procedure, single-lung ventilation with a double-lumen endotracheal tube was used in all of


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our 12 cases. Thoracoscopy was performed through a 10-mm camera port, in the seventh intercostal space in the mid-axillary line, and the procedure was completed through one or two working ports. Nine (75%) of the VATS procedures were done from the left side and three cases ( 25%) from the right side . An approximately 6 cm in diameter was resected anterior to the phrenic nerve, creating a window communicating the pleural space. A single chest tube (28 to 32 F) was placed into the operative pleural space in all cases. In the SUX group 6 patients (28.6 % of total 21) incision was made through the lowermost 5-cm of the previous sternotomy incision. Blunt extraperitoneal dissection is carried out to expose the pericardium. After drainage of the effusion, a single thoracostomy tube (28 to 32 F) is placed and left to drain for at least 72 hours.

Total of 3 patients (14.3%) required left anterior mini thoracotomy for drainage and creation of pericardio- pleural window . After drainage of the effusion a single thoracostomy tube ( 28 to 32 F ) inserted in 6th space mid axillary line and left to drain the pleural space and left for 72 hours .

Results : A twenty - one patients post CABG were identified

for evaluation and management of late post operative pericardial effusion in the period between January 2006 and January 2009. All of them underwent surgical procedure in the same institute . Twelve patients(57 % ) were operated via VATS . 10 of them were males (83.3%) and 2 were females(16.7%) Table1 . Nine patients of the total number (\43%) underwent surgical intervention other than VATS; Seven patients (\77.8%) were males while 2 (22.2%) of them were females ;in this group 6 (66.6%) patients had subxiphoid drainage . Five of them were males (83.3%) and One(16.7%) was a female . Three Patients (33.4%) , two males (66.6%) and One female (33.4%) had left anterior minithoracotomy , exploring bare area of the heart for percardio -pleural window creation .An echocardiography was done for all patients included in this study . Two patients only out of the total number (9.5%) were admitted on emergency bases (evidence of tamponading either clinically and/or by echo finding) .

Anaesthesia was conducted in all patients by the same team through inserting a double lumen endotracheal tube for one lung ventilation throughout the procedure (VATS) .

variablesOpenSurgical.

(SUX &Lt.Ant.Thx)VATS

Number 9(43%)6(SUX)

3(Lt Ant Thx)12(57%)

Male 7 10

Female 2 2

Age 50-70y 50-70y

Table ( 1 ) : Data of patients included in the study ( n= 21 )Subxiphoid= SUX and Left anterior thoracotomy = Lt.Ant.Thx

Time of anaesthsia was 115.0 minutes ± 35.5 ( mean = 84± 15 min.) for the VATS group ;

Where as it was 70.0 min.± 15.0 ( mean= 55± 10 min.) for subxiphoid or left anterior minithoracotomy group Table 2 .

variablesOpen Surgical

SUX &Lt.Ant.ThxVATS P-value

Anaesthesia time (Minutes)

70± 15( mean=55±10)

115±35.5( mean=84±15)

< 0.01

Morbidity2 /9

SUX(2)&Lt.Ant.Thx(0)1 / 12 < 0.01

Recurrence 0 2 < 0.01

Table (2) : VATS group ( n = 12 / 21 ) vs Subxiphoid= SUX and Left anterior thoracotomy = Lt.Ant.Thx ( n = 9 /21).

All patients were followed regularly for 6 months after the original procedure clinically and by echocardiography. Two patients (9.5 %) were found to have a recurrence . both of them were in the VATS group which included 12 patients ( 16.7%) .

On the other hand, no evidence of recurrence was reported in the other two groups .

Concerning the morbidity post intervention we had three cases ( 14.3%) .

They were in the group which had subxiphoid drainage . All of the three morbidities were minor in the form of wound infection which required a longer hospital stay for wound care and delayed wound healing .


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Statistical analysis : Statistical analysis was performed using Statview

for Windows (v. 5.0.1, SAS Institute, Cary, NC). Differences between groups were

demonstrated using the 2 test, . A p value of less than 0.05 was necessary to achieve statistical significance. Categorical data are presented as numbers with percentages , while numerical data are presented as means with standard deviation. Univariate analysis was conducted using SPSS version 16 (spssinc., usa ) .

Discussion : In our study the VATS procedure was superior to

SUX in many aspects : it allowed Us to assess the left internal mammary artery graft

to LAD .In addition to the above , VATS procedure provided

an excellent assessment capability for pleural cavity , pericardium and allowed us to biopsy any suspicious lesion .

Another advantage of VATS procedure is allowing an adequate resection of pericardium to create a pericardio-pleural window , also it was less traumatic and patient complained of less pain . It was surprising that despite the adequacy of pericardio-pleural window we had 16.7 % ( 2/ 12 patients ) recurrences post VATS , Compared to SUX which had no recurrence .

As various approaches have been described for the diagnostic and therapeutic modalities of pericardial effusion post CABG , including pericardiocentesis, percutaneous catheter drainage and balloon pericardiotomy, subxiphoid pericardial drainage,

Pericardio-peritoneal shunt, subxiphoid pericardial fenestration, and pericardial window through anterior thoracotomy . The optimal drainage procedure for nonconstricting effusions is still controversial, and varies according to individual needs and circumstances (12) .

In this study, we had evaluated three types of management of post CABG pleural effusion ; patients who underwent subxiphoid or left anterior minithoracotomy and those who underwent VATS for draining pericardial effusions that were : moderate or large in size and associated with echocardiographic abnormalities suggesting tamponade . In this study only two patients of 15 ( 13.3%) who showed evidence of tamponading in echocardiographic study on admission had to be shifted to theatre for urgent decompression as both showed haemodynamic instability .

General anesthesia was well tolerated in the two groups . Also, a single-lung ventilation was indicated in VATS group .

One potential benefit of VATS in comparison with SUX is that it allows certain intrathoracic procedures to be performed simultaneously with the pericardial procedure such as revision of the left internal mammary artery as a graft to left anterior descending artery ; like its course , distal anastomosis and if there is any bleeding point .

Our results indicate that the technique is well suited for these purposes. It provided us an excellent view of the pleural cavity and the pericardium in all cases, so that all suspicious sites, whether pericardial, pleural, lung, or mediastinal, could be precisely localized for biopsy (13). In this study, the follow-up was 100 %, and recurrence was confirmed by echocardiography. Recurrence was uncommon, occurring in 16.7 % of VATS patients (two out of twelve) comparable with previous series (14) . We hypothesized that the creation of a pericardial window into the pleural space might produce a lower recurrence rate in the VATS group but that was not the case. The procedure was also technically and therapeutically advantageous: the surgical approach was less traumatic than for anterior thoracotomy, and a more extensive pericardial resection was possible compared with the subxiphoid route (15) . Furthermore, better visualization was afforded than with the subxiphoid approach. Loculated effusions, even those located posteriorly that cannot normally be reached without open thoracotomy, were easily drained by VATs the recurrence was higher in the VATS group which we accused for one of two reasons :(1) Small number of cases ,which give us a poor

estimation of the real recurrence rate.(2) Working cautiously as the field contains an important

grafts which should be avoided .

Recurrence rate was not significantly different between the two groups, as no recurrence reported in our study in an interval of 6 months post original intervention in the group of subxiphoid drainage . Anaesthesia time was longer in the VATS group as it required a meticulous processing . One of the major adventages of thoracoscopic drainage is that it is less traumatic and did not need reopening of the sternotomy wound which decreased the risk of wound complications . Procedural morbidity was low overall, but it was significantly higher in the subxiphoid group (two out of six patients = 33.3 ) while it was 8.3% in the VATS group (one patient out of twelve ) and it was related mainly to complications associated with dissection and accessing the pleural space .


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Several series of SUX. reported complication rates of less than 4%(16), but higher rates have been also reported(17) . Most series of VATS report no complications; however Geissbuhler and colleagues (18) reported a 12% incidence. In our study, hospital morbidity was 33.3% among patients having SuX, which is higher than the rates reported in other series(19), and 8.3% among VATS patients we interpret that by the fact that patients with greater comorbidities were selected for the SUX procedure, which was perceived by the surgeons to be less invasive. Patients with concomitant critical illness and those who otherwise seemed not to be clinically suited to the somewhat more complex VATS procedure were likely offered SUX or left anterior minithoracotomy which was performed in three patients( 14.3%) as the simplest option for direct window creation .

Conclusion :Both VATS and SUX approaches were equally

effective in controlling pericardial effusions. However, when adjusted for confounding variables, VATS is superior to SUX in term of lower complication rate and morbidity rate .it is also proved to be beneficial for concomitant intrpleural procedure to be performed.VATS drainage is also a safe procedure regardeless of the echogardiographic fiindings of mild tamponade.

References :1. Craddock D.R., Logan A., Fadali A. Reoperation for

hemorrhage followingcardiopulmonarybypass.BrJSurg1968;55:17-20.2. StevensenL.W.,ChildJ.S.,LaksH.,KernL.Incidenceand

significanceofearlypericardial effusions after cardiac surgery. Am J Cardiol

1984;54:848-851.3. PrewittT.A.,RackleyC.E.,WilcoxB.R.,ScatliffJ.H.,Young

D.T. Cardiac tamponade as a late complication of open heart surgery.Am

HeartJ1968;76:139-141.4. Ofori-KarkyeS.K.,TybergT.I.,GehaA.S.,HammondG.L.,

CohenL.W.,LangouR.A.Latecardiactamponadeafteropenheartsurgery:incidence,

role of anticoagulants in its pathogenesis and its relationship to

postpericardiectomysyndrome.Circulation1981;63:1323-1328.5. GarciaJ.M.,ReyesE.,CheanvecchaiC.,EfflerD.B.Delayed

cardiac tamponade followingopenheartsurgery.ClevelandClinQuart1974;41:103-

108.6. Premaratne S., Zhang W., Arakaki H.Y., Nakasone C.K.,

McNamaraJ.J.Effectofanticoagulants of the incidence of late pericardial tamponade

following open heart surgery: the Hawaii experience. J Cardiovasc Surg (Torino)

1997;38:107-111.7. MooresDWO,AllenKB,FaberLP,etal.Subxiphoiddrainage

for pericardial tamponadeJThoracCardiovascSurg1995;109:546-5528. PiehlerJM,PluthJR,SchaffHV,etal.Surgicalmanagement

of effusive pericardial diseaseJThoracCardiovascSurg1985;90:506-516.9. Shapira OM, Aldea GS, Fonger JD, Shemin RJ. Video-

assisted thoracic surgical techniques in the diagnosis and management of pericardial

effusion in patients withadvancedlungcancerChest1993;104:1262-1263.10.Nataf P, Cacoub P, Regan M, et al. Video-thoracoscopic

pericardial window in the diagnosis and treatment of pericardial effusions Am J Cardiol

1998;82:124-126.11. Naunheim KS, Kesler KA, Fiore AC, et al. Pericardial

drainagesubxiphoidvstransthoracic approach. Eur J Cardiothorac Surg 1991;55:99-

104.12.Prager R.L., Wilson C.H., Bender H.W. The subxiphoid

approach to pericardial disease.AnnThoracSurg1982;34:6-9.13.LevinB.H.,AaronB.L.The subxiphoidpericardialwindow.

SurgGynecolObstet1982;155:804-806.14.Press O.W., Livingston R. Management of malignant

pericardial effusion and tamponade.JAMA1987;257:1088-1092.15.SugimotoJ.T.,LittleA.G.,FergusonM.K.,etal.Pericardial

window: mechanism of efficacy.AnnThoracSurg1990;50:442-445.16.ParkJ.S.,RentschlerR.,WilburD.Surgicalmanagementof

pericardial effusion in patientswithmalignancies.Cancer1991;67:76-80.17.OsuchJ.R.,KhandekarJ.D.,FryW.A.Emergencysubxiphoid

pericardial decompression for malignant pericardial effusion. Am Surg

1985;51:298-300.18. Kopecky S.L., Callahan J.A., Tajik J., Seward J.B.

Percutaneouspericardial catheter drainage: report of 42 consecutive cases.AmJ

Cardiol1986;58:633-635.19.Okamoto H., Shinkae T., Tamakido M., Saijo N. Cardiac

tamponadecausedby primary lung cancer and themanagement of pericardial

effusion. Cancer 1993;71:93-98.


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BMI and outcome of cardiac surgery in Scottish populationAhmed Abdelgawad MD,Alan Dawson MD,Lisa Lawman MD,Y Hegazy, MD,Hussien Elshafei MD

Addrees reprint request to :Dr. Ahmed Abdelgawad MD, Cardiothoracic unit foresterhill hospital arl, aberdeen, uk

Email : [email protected] : 04/135/1008

Bakgrawnd : The increasing prevalence of obesity is a public health concern and perceived as a potential risk factor in open heart surgery. Increasing evidence suggests that obesity is associated with increased systemic inflammation, thrombogenicity, and endothelial dysfunction. Multiple Studies have been conducted in this area with conflicting results and we wished to analyse a Scottish cohort of obese patients to determine the outcomes of cardiac surgery relative to a normal/mildly overweight cohort.Methods : A single-centre retrospective evaluation of a prospectively collected database was performed between April 2008 and April 2009. The primary outcome was in-hospital mortality and complication rates in the post-operative period. The patients were categorized as obese of they had a Body Mass Index (BMI) of greater than or equal to 30. A normal/mildly overweight cohort (BMI: 18.5-29.9) was identified to serve as controls. The overall incidence of complications including: cardiac, vascular, renal, neurological and infective complications were recorded and analysed.Results : A total of 610 patients were included, 198 of whom were obese. Obesity was significantly associated with age, type II diabetes mellitus, operative priority and euroscore (p=0.007, p=0.012, p=0.023 and p=<0.001, respectively). There were no associations between obesity and in-hospital mortality, cardiac complications, vascular complications, renal tract complications, neurological complications and infective complications. Similarly, obesity was not associated with gender, hypertension, pre-operative creatinine and haemoglobin, pulmonary function, cardiac function, the type of cardiac procedure, duration of ventilation, cardiac intensive care unit times, and high dependency unit times, length of ward and hospital stay. Conclusions : Cardiac surgery can be performed without significant increase in peri-operative and 30-day mortality in an obese Scottish population. Patients can expect satisfactory outcomes after cardiac surgical procedures without significant concern regarding post-operative complications.

Obesity is a medical condition with an incidence which has risen to epidemic proportions during the past few decades and seems likely to continue to increasing (1). It has the propensity to harbour many disease processes and, indeed, it is a risk factor for the development if diabetes mellitus, hypertension,

certain forms of cancer and coronary artery disease (2–4). Obesity has also been proposed to be a risk factor for peri- and post-operative morbidity and mortality in patients undergoing cardiac surgery, as witnessed by its inclusion in the Parsonnet system for stratification of risk for perioperative death (5). Adam and colleagues (6) documented an approximate 2.5- fold increased risk of death in a non-smoking male cohort with a Body Mass Index (BMI) of 40. The metabolic syndrome that is associated with central obesity is characterized by insulin resistance, hypertriglyceridemia, a proinflammatory

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and a prothrombotic state (7). The aim of this study was to assess the effects of obesity on a Scottish population who have received cardiac surgery in the recent past.

Methods:Study design

This study was a single-centred retrospective analysis of a prospectively collected database of all adult cardiac surgeries performed at the North of Scotland Cardiothoracic Surgery Unit in Aberdeen Royal Infirmary, Scotland between April 2008 and April 2009. A total of 610 patients who had received cardiac surgery during this period were identified.

Inclusion and exclusion criteriaObesity was defined as a Body Mass Index (BMI)

of greater than 30 and we used all patients with a BMI of 18.5 – 29.9 as normal controls. Any patient undergoing coronary artery bypass grafting, valve replacement, a combination of both or any other cardiac surgical intervention requiring a median sternotomy were included. Thoracic surgical procedures were excluded from this study. Since our unit manages adult patients, no paediatric cases are included.

Control groupAll patients in the database between April 2008

and April 2009, with a BMI of between 18.5 and 29.9 kilograms per metre squared acted as the control group. This group of patients had the same inclusion and exclusion criteria applied. The time frame employed in this study allowed reliable representation of the range of cardiac procedures undertaken at our centre.

Pre-operative demographic characteristicsPre-operative demographic data was collected

including: age, gender, pre-operative priority, left ventricular ejection fraction, logistic score, euroscore, pre-operative haemoglobin and pre-operative creatinine. In addition, co-morbidities in the pre-operative period including: hypertension, chronic lung disease and renal insufficiency were collected.

Peri-operative and operative characteristicsThe operative data focussed on: the type of cardiac

procedure; the number of bypass grafts performed where appropriate; the type of conduit chosen (internal mammary artery and saphenous vein); if cardiopulmonary bypass was performed; the cardiopulmonary bypass time if

applicable; the cross clamp time; and the total ventilation time. The length of stay in the cardiac intensive care unit (CICU), cardiac high dependency unit (HDU), the cardiothoracic ward and finally the total length of hospital duration were calculated.

Operative procedureAll patients eligible for this study received their

operation at the North of Scotland Cardiothoracic Surgery Unit of Aberdeen Royal Infirmary which was performed by the same group of surgeons. All patients underwent median sternotomy, cardiopulmonary bypass with moderate hypothermia, and cardioplegic arrest with crystalloid/blood cardioplegia solution, delivered antegradely, retrogradely or both. This is the standard intra-operative myocardial protection protocol employed at our centre. Some of the cases included were performed by the off-pump method and so the operative procedure outlined above was followed, but cardiopulmonary bypass and delivery of the cardioplegia solution were omitted. All surgical wounds were closed with single stainless steel wires used in a simple or figure of eight configuration.

In the post-operative period, patients were managed in a dedicated cardiac surgery intensive care unit with a step down high dependency unit according to well defined care path protocols. All post-operative care was directed and delivered by the surgical team.

Postoperative characteristicsPost-operative data consisted of the overall

thirty day mortality, the requirement for re-operation, complications of the bodily systems, namely: cardiac, vasculature, renal, gastrointestinal, neurological and infective complications.

Statistical analysesUnivariate analyses of all the above parameters

between BMI group, that is normal or obese, were performed. Normally distributed continuous data was analysed using the independent sample t-test, otherwise the Mann Whitney U test was applied.

Categorical data was analysed using the Pearson Chi-Square analysis. All statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS, Version 17 Inc, Chicago, USA, 2008).

Statistical significance was accepted if the p-value was less than 0.05.


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Results :A total of 610 patients were included in this

study; 412 with a normal/mildly overweight BMI (18.5-29.9 kilograms per metre squared (kg/m2) and

198 with obesity (BMI: greater than 30kg/m2). Patient demographics and pre-operative characteristics are summarized in Table 1. The obese cohort were younger and dominated by males (69%). This group were also

VariableBMI: 18.5-29.9

(n = 412)BMI: >30.0(n = 198)

p-value

Age (years) (mean ± SD*) 66.9 ± 11.0 64.5 ± 9.8 0.007a

Male gender (%) 70.9 69.2 0.74b

BMI (kg/m2) (mean ± SD*) 25.9 ± 2.7 33.6 ± 3.5 <0.001a

Smoking status (%)

Never 36.7 34.8

Ex-smoker 48.5 54.0 0.32c

Current 14.8 11.1

Diabetes Mellitus (%)

None 84.7 74.7

Type I 4.1 6.6 0.012c

Type II 11.2 18.7

Hypertension (%) 72.8 75.3 0.59b

Preoperative creatinine (mean ± SD*) 108.15 ± 73.9 111.13 ± 61.0 0.60a

Preoperative haemoglobin (mean ± SD*) 134.56 ± 19.1 135.54 ± 19.1 0.56a

Operative priority (%)

Elective 68.9 78.8

Urgent 29.1 19.2 0.023d

Emergency/Salvage 1.9 2.0

Preoperative pulmonary disease (%) 13.6 15.7 0.58b

Preoperative renal disease (%) 5.3 4.0 0.64b

Logistic score (mean ± SD*) 6.9 ± 8.9 5.3 ± 7.4 0.018a

Euroscore (mean ± SD*) 5.4 ± 3.2 4.5 ± 3.2 <0.001a

Left ventricular function (%)

Good (LVEF** >=50%) 71.9 79.1

Fair (LVEF** 30-49%) 22.5 16.0 0.17c

Poor (LVEF** <30%) 5.6 4.8

Table 1: Demographic characteristicsaIndependent sample t-test, bYates continuity correction, cPearson Chi-Square, dLinear-by-linear association, *Standard deviation, **Left ventricular ejection fraction


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found to be more likely to have type II Diabetes mellitus as well as a higher euroscore (p=0.012 and p<0.001, respectively). Interestingly, they were more likely to have urgent operations compared to the normal/mildly overweight cohort (p=0.023). There were no significant differences between both groups regarding pre-operative pulmonary or renal disease. Similarly most patients from both groups had good left ventricular ejection fraction.

Table 2 documents peri-operative and operative characteristics. Most of the patients from both the normal/mildly overweight and obese groups underwent coronary artery bypass grafting (58.7% and 61.1% respectively) followed by isolated valve surgery. There

were no statistical differences noted between the two groups regarding: the number of grafts performed; use of left internal mammary artery or saphenous vein as the conduit. Again, there were no differences in cardiopulmonary bypass times, cross clamp times, hours of ventilation, intensive care unit stay, high dependency unit stay, ward stay and hospital stay.

Table 3 summarises the unadjusted morbidity and mortality for both groups. There were no statistical differences between both groups in either 30-day mortality or any of the post-operative complications namely; cardiac, vascular, renal tract, neurological, and infective.


(n = 412)BMI: >30.0(n = 198)

p-value

Procedure (%)

CABG only 58.7 61.1

Valve only 19.4 22.2 0.98a

CABG + Valve 17.0 12.1

Other 4.9 4.5

Number of grafts (mean ± SD*) 2.5 ± 0.8 2.4 ± 0.8 0.070b

Use of internal mammary artery (%) 76.3 77.2 0.92c

Use of saphenous vein (%) 95.2 94.5 0.93c

Bypass performed (%) 98.1 98.0 0.58d

Bypass time (minutes) (median (IQR**)) 90 (48.75) 86 (41.25) 0.065e

Cross-clamp time (minutes) (median (IQR**)) 55.5 (44.75) 53.0 (39.25) 0.076e

Ventilation (hours) (median (IQR**)) 6.0 (11.2) 5.7 (10.7) 0.36e

CICU duration (hours) (median (IQR**)) 22.5 (22.3) 23 (24.1) 0.52e

HDU duration (hours) (median (IQR**)) 29.3 (27) 29.5 (27.8) 0.96e

Ward duration (hours) (median (IQR**)) 121.3 (70.8) 121.0 (73.2) 0.94e

Length of stay (hours) (median (IQR**)) 191.2 (91.2) 192.2 (96.6) 0.66e

Table 2: Perioperative and operative characteristicsa Linear-by-linear association, b Independent sample t-test, c Yates continuity correction, d Fisher’s exact test, e Mann-Whitney U test, *Standard deviation, **Interquartile range


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DiscussionObesity is becoming more prevalent with each

year that passes by and obese patients are presenting for cardiac surgery. There have been reports concluding negative associations between obesity and mortality after cardiac surgery. We therefore wished to assess the effects of obesity in a Scottish population undergoing cardiac surgery. To our knowledge, this is the first report of the effects of cardiac surgery in obese patients based on a Scottish population.

Multiple studies have attempted to address the issue of BMI and cardiac surgical outcomes, however, the

limitations of small sample sizes, varied definitions of obesity and inclusion of very few patients at the higher end of the obesity spectrum have acted to confuse the overall conclusions drawn8. Our analysis retrospectively reports on a small, but potentially increasing subset of Scottish patients who present for cardiac surgery with a BMI consistent with obesity. Some studies document elevation of morbidity and mortality in obese patients undergoing cardiac surgery (8-15), while others show more deleterious effects in cachectic populations (9-15). This study did not examine underweight patients due to the small number that our centre has experienced and the inability therefore to draw any statistical inferences with


(n = 412)BMI: >30.0(n = 198)

p-value

Mortality (30 day) (%) 1.5 3.0 0.23a

Morbidity (%)

Cardiac complications 34.5 39.9 0.22b

Atrial fibrillation 30.8 33.8 0.51b

Cardiac arrest 1.9 3.0 0.40c

Intra-aortic balloon pump 2.4 1.0 0.35c

Vascular complications 1.7 1.5 0.58c

Renal tract complications 10.7 10.1 0.94b

Urinary tract infection 2.9 1.5 0.23c

Postoperative renal failure 3.2 3.5 1.0b

Postoperative dialysis 2.2 0.5 0.11c

Neurological complications 4.6 3.5 0.69b

Stroke 1.5 1.5 0.60c

Psychosis 2.0 2.0 1.0c

Infective complications 15.3 17.2 0.63b

Chest infection 10.7 11.6 0.84b

Sternal wound infection 1.7 2.5 0.34c

Leg wound infection 2.7 2.0 0.43c

Bacteraemia 0.2 1.0 0.25c

Table 3: Unadjusted morbidity and mortalitaLinear-by-linear association, bYates continuity correction, cFisher’s exact test


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confidence. unadjusted 30 day mortality with the none obese group.

In 2002, Prabhakar et al. documented a significantly increased mortality rate of 2.6% in patients who were of normal weight or mildly overweight relative to 3.1% in the extremely obese group (p<0.0001). Meanwhile, Jin et al (2005) reported a significant reduction in mortality in those who were overweight relative to the extremely obese cohort (3.1% vs. 1.9%, respectively; p<0.01). A more recent study authored by Wigfield et al. conveyed a 30-day mortality of 4.9% in the normal weight group which fell to 3.7% in the obese group and rose to 5.4% in the extremely obese group, but this was statistically insignificant (p=0.78).

This study reports an unadjusted 30-day mortality of 1.5% in the normal/mildly overweight cohort which increased to 3.0% in the cohort of obese patients. Despite the higher incidence of mortality in the obese patients (7 deaths relative to 6 in the normal/mildly overweight cohort), this was statistically insignificant (p=0.23). This supports the more recent studies performed in this area which have concluded that BMI, in isolation, is not associated with post-operative mortality.

Diabetes mellitus is present in a significant percentage of patients with obesity, and the relative contribution of diabetes versus obesity toward surgical mortality and morbidity have been conflicting (16-17). Although the obese group suffered more commonly from Type II diabetes mellitus and required urgent surgery, these independent variables did not affect the outcome of cardiac surgery.

Our study also indicates that there was no difference using the left internal mammary artery for bypass grafting in the obese cohort compared to the normal/mildly overweight group. This may mean that there was no extreme difficulty dissecting out the left internal mammary artery in the obese group, steering the surgeon to use other conduits. This means that the expected adverse effects of not using this conduit on the long term for these younger obese patients will not happen (18).

LimitationsThis observational study reporting on a subset

of adult cardiac surgical patients has a number of limitations. First, the retrospective design makes it subject to selective bias.

Similar to previous studies, this study is guilty of a small sample size in the obese cohort. However, the sample included consists of all the obese patients operated upon at our institution during the four years and it provides an idea regarding the general trend in this population. A larger observational study with propensity analysis would be an appropriate next step in which to draw more solid conclusions from.

ConclusionOur analysis demonstrates that obese Scottish

patients can be operated upon safely without anticipated increased peri- or post-operative morbidity and 30-day mortality. Although this group are more likely to be diabetic, and more likely to necessitate urgent intervention, this does not affect the outcome of their cardiac surgical procedure. Moreover, the use of the internal mammary artery in the obese cohort during coronary artery bypass grafting did not seem to be affected by the fact that the patients were obese. We conclude therefore, based on our sample of patients, that alterations in peri-operative management of obese patients in terms of weight loss pre-operatively, is of less importance especially because these patients are severely limited by their cardiac disease.

References1. Haslam DW,James WPT. Obesity. Lancet. 2005;366:1197-

1209.2. Barret-Connor EL. Obesity, arteriosclerosis, and coronary

arterydisease.AnnInternMed.1985;103:1010–1019.3.Simopoulos AP, Van Nallie TB. Body weight, health and

longevity.AnnInternMed.1984;100:285–295.4.St JeorST,Brownell KD,AtkinsonRL,BouchardC,Dwyer

J, Foreyt JP, Heber D, Kris-Etherton P, Stern JS, WillettW. Obesity. Workshop III. AHA prevention conferenceIII. Behavior change and compliance: keys to improvingcardiovascularhealth.Circulation1993;88:1391–1396.

5. Parsonnet V, Dean D, BernsteinAD.A method of uniformstratification of risk for evaluating the results of surgery inacquiredadultheartdisease.Circulation.1989;79:I3–I12.

6.AdamsKF,SchatzkinA,HarrisTB,KipnisV,MouwT,Ballard-Barbash R, Hollenbeck A, Leitzmann MF. Overweight,obesityandmortalityinalargeprospectivecohortofpersons50to71yearsold.NEnglJMed.2006;355:763-778

7.DepresJP.Healthconsequencesofvisceralobesity.AnnMed.2001;33:534-541.

8.PrabhakarG,HaanCK,PetersonED,CoombsLP,CruzzavalaJL,MurrayGF.Therisksofmoderateandextremeobesityforcoronaryarterybypassgraftingoutcomes:astudyfromthe society of Thoracic Surgeons’ database. Ann ThoracSurg.2002;74:1125-1130.


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9.JinR,GrunkemeierGL,FurnaryAP,HandyJR.Isobesityarisk factor formortality in coronaryarterybypasssurgery?Circulation.2005;111:3359-3365.

10.Ascione R, Reeves B, Rees K,Angelini G. Effectivenessof coronary artery bypass grafting with or withoutcardiopulmonarybypassinoverweightpatients.Circulation.2002;106:1764-1770.

11. Kuduvalli M, Grayson A, Oo A, Fabri B, Rashid A. Riskof morbidity and in hospital mortality in obese patientsundergoing coronary artery bypass grafting. Eur JCardiothoracSurg.2002;22:787-793.

12.BirkmeyerN,CharlesworthD,HernandezF,LeavittBJ,MarrinCAS,MortonJR,OlmsteadEM,O’ConnorGT.Obesityandrisk of adverse outcomes associated with coronary arterybypasssurgery.Circulation.1998;97:1689-1694.

13. Ennker J, Schoeneich R, Schroder T, Schoeneich F,Ennker IC, The impact of morbid obesity on the peri andpostoperative course after aortocoronary bypass surgery.DtschMedWochenschr.2001;126:419-423.

14.WigfieldC,LindseyJ,MunozA,ChopraP,EdwardsN,LoveR. Isextremeobesitya risk factor forcardiacsurgery?AnanalysisofpatientswithaBMI>40.EurJCardiothoracSurg.2006;29:434-440.

15.HabibRH,ZachariasA,SchwannTA,RiordanCJ,Durham

SJ, Shah A. Effects of obesity and small body size on

operativeandlongtermoutcomesofcoronaryarterybypass

surgery:apropensitymatchedanalysis.AnnThoracSurg.

2005;79:1976-1986.

16. Carson JL, Scholz PM, ChenAY, Peterson ED, Gold J,

Schneider SH, Diabetes mellitus increases short term

mortality and morbidity in patients undergoing coronary

arterybypassgraftsurgery.JAmCollcardiol.2002;40:418-

423.

17.HakalaT,PitkanenO,HalonenP,MustonenJ,TurpeinenA,

HippelainenM.Earlyandlateoutcomeaftercoronaryartery

bypass surgery in diabetic patients. Scand Cardiovasc J.

2005;39:177-181.

18.DamgaardS,SteinbruchelDA,KjaergardHK.Anupdateon

internalmammaryarterygraftingforcoronaryarterydisease.

CurrOpinCardiol.2005;20:521-524.

19.CheungW,Outcomesofthemorbidlyobesehavingcardiac

surgery.CritCarResus.2005;7:166-172.


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Cardiac surgery in nonagenarian. Should we operate?Cardiac surgery in nonagenarian

Addrees reprint request to :Dr.Ahmed Rezk, MD,*Department/ InstitutionDepartment of Cardiac surgerya, Cardiologyb , Anesthesiology cKing Fahad Military Hospital, Southern Region, Khamis Mushyat, Saudi ArabiaCorresponding AuthorDr Ahmed Rezk, Department of Cardiac Surgery, Mail Code-61961King Fahad Military HospitalPO Box 5306, Khamis Mushyat, Saudi ArabiaE-mail:[email protected]: +966-7-2572709Fax-+966-7-2572709Codex : 04/136/1010

Ahmed Rezk, MD,*Mushabab Almurayah, MD**Adel Almasswary, MD**Ali Youssef, MD** Wagih.Ouda , MD***

Background: Growth of the elderly population worldwide will continue to accelerate and will have a profound impact on health care resources in the future. Patients aged 90 years and older represent a rapidly growing subset of this population, many of whom are functionally limited by cardiovascular disease. The question to operate or not to operate is still debatable. The aim of this study was to review our local experience with nonagenarians concerning postoperative morbidities, mortality, and short-term survival status.Methods: A consecutive series of nonagenarians (14 patients) who underwent cardiac operations between May 2007 and December 2009 were retrospectively reviewed. Data included baseline preoperative clinical status, intraoperative characteristics, and perioperative course and short-term clinical outcomes. Results: There were 2 women (14.3%) and 12 men (85.7%). There were 6 coronary artery bypass grafting (CABG) procedures (43%), 3 aortic valve replacements (AVR) (21.5%), one combined mitral valve replacement (MVR) and CABG (7%), 2 combined AVR and CABG (14%), one double valve procedure (7%) and one removal of left atrial clot (7%). Thirty-day mortality was 14% (2 deaths total; one operative death and one cardiac arrest at ICU day 2 postoperative). Short-term follow up (range, one month to one year), 11 patients 78.5 % are still alive. One patient is missing follow up. Two patients died during follow up from non cardiac causes. 7 patients (50%) have quality of life similar to average aged matched population wiyhout known cardiac disease. Conclusions: Although morbidity, mortality, and cost may be higher in nonagenarian, advanced age itself (>90 years) should not be a contraindication to an open-heart operation.

In the 1960s the majority of open-heart surgeries for acquired cardiovascular disease were performed on patients in their fifth decade of life. Advances in anaesthesia, surgical technique and perioperative care have allowed surgery in the elderly patients. Similar to United States and European countries, life expectancy in Saudi Arabia continues

to increase; thus the number of nonagenarians exposed to cardiovascular diseases will grow. As cardiac surgeons, physicians and anesthetist we will be confronted to evaluate the surgical treatment in this group of patients. However, the perception by elderly patients, their families and the referring physician is that they may have lower functional reserve and more co morbidities than younger patients with an increased rate of complications or death. Yet, there are studies that show the benefits of cardiac surgery in octogenarians and very few others in nonagenarian patients (1-4). Therefore, the purpose of this study is to review our experience with nonagenarians, regarding postoperative morbidity and mortality, short-term survival status and quality of life.

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Methods :Over a 36 months period (May 2007 –December

2009), 14 consecutive patients who were 90 years of age or older underwent cardiac surgical procedures at king fahad military hospital, Khamis mushyat, Saudi Arabia. A retrospective analysis of these patients was performed. Their demographic profiles, perioperative results, and short-term outcomes were recorded. Information was obtained through data base and chart review and follow up at outpatient clinic. Operative data were collected, which included preoperative data, the type of surgery, postoperative results and short –term outcome.

Surgical procedures were performed with general anesthesia through a median sternotomy; under cardiopulmonary bypass (CPB) with cold-blood cardioplegia for myocardial protection. Coronary artery disease was defined as a reduction of vessel

Diameter by at least 70% on the coronary angiogram. Stenosis of 50% or more in the left main trunk was considered as double vessel disease in the absence of any other coronary stenosis. Valve surgery was based on current guidelines. Hospital mortality was described as any death occurring within 30 days of the operation or during the same hospital admission. Low cardiac output syndrome was defined as a need for inotropic drugs for more than 48 h in the postoperative period. All relevant variables are expressed as mean ± standard deviation (mean±S.D.) unless stated otherwise.

Results :Preoperative data

The total number of nonagenarians undergoing cardiac surgery at our hospital is increasing in the last decade; however, we studied 14 patients operated over the last 36 months. Table 1 summarised the preoperative data. All cases were elective except only one case performed as an emergency procedure and one case done as an urgent. All the cases were primary operations (no redo cases).

Operative data :Table 2 summarised surgical procedures. In the

patients underwent CABG (isolated or combined with valve surgery), LIMA was used in 5 cases. All the valves implanted were bioprosthetic. In the patient who had double valve procedure, mitral valve was repaired. The patient who had left atrial clot removal, had lone atrial fibrillation complicated by left atrial clot with

distal embolization to the lower limb. This was the only emergency procedure performed. All other cases in our series were elective or urgent.

n (%)Variable

12/2 (86/14)Men/Women

94±3.3Agea (years)

45.3±10.5LVEFa (%)

2.5±0.6NYHA class

8 (57%)Hypertension

7 (50%)Dislipidemia

7 (50%) Diabetes mellitus

5 (36%) Previous MI

1 (7%)AF

2 (14%)Chronic renal insufficiency

8 (57%) Carotid artery stenosis

4 (28%)Smokers

3 (21%)Respiratory disease (COPD/bronchial asthma)

Table 1 Patient clinamean±S.D.; AF: Atrial Fibrillation; LVEF: Left Ventricle Ejection Fraction; MI: Myocardial Infarction; NYHA: New York Heart Association; PTCA: Percutaneous Transluminal Coronary Angioplasty. COPD: chronic obstructive pulmonary disease.

%nType of surgery

43%6 Isolated primary CABG

21.5%3Isolated AVR

14%2 AVR+CABG

7%1 MVR+CABG

7%1 Double valve procedure

7%1Removal of left atrial clot

Table 2. Surgery data AVR: Aortic Valve Replacement; CABG: Coronary Artery Bypass Graft; MVR: Mitral Valve Replacement.

Postoperative data :Thirty-day mortality was 14% (2 deaths total; one

operative death and one cardiac arrest at ICU day 2

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postoperative). Postoperative complications summarised in table 3. One patient experienced low cardiac output syndrome and ventricular fibrillation and cardiac arrest 2 hours after arrival to ICU. Crash back on bypass was performed and

%nVariable

21.5%3Perioperative MI

28.5%4Low cardiac output syndrome

43%6Renal impairment

14%2Pulmonary complication

7%1Cardiac arrest

50%7Atrial fibrillation

7%1Stroke

21.5%3Sepsis

7%1Wound infection

Table 3. Postoperative complications MI: myocardial infarction. ical characteristic

Additional graft to RCA was constructed and the patient survived and discharged from hospital after 2 months in reasonable general condition with residual vocal cord paresis (post traumatic/intubation). Short-term follow up (range, one month to one year), 11 patients 78.5 % are still alive. One patient is missing follow up. One patient died after 6 months from surgery after being readmitted for respiratory failure (patient was preoperatively was COPD type II respiratory failure). Another patient admitted 2 years after surgery and died by sepsis post peritonitis. 7 patients (50%) have quality of life outcomes similar to that of related norm-based populations based on age and disease process.

Comment :Since its inception in the 1950s, cardiac surgery,

using the heart-lung machine, has been routinely performed on a daily basis worldwide [5, 6]. As the age of the population increases with time due to greater preventive medicine measures and better medical therapies for chronic diseases, these procedures are being performed in an ever-aging population [7]. Based upon population studies, life expectancy at the age of 80 is 8.5 years, and at the age of 85 and over, it is 6.3 years [8]. It has been demonstrated that elective cardiac surgery can safely be performed in octogenarians with minimal

increase in mortality, however, at a price of increased morbidity [9-14]. Here, we present our data for cardiac surgical procedures in nonagenarians. The mortality rate in the few reports about cardiac surgery in nonagenarians, their vary from 7 to 18% [15,16,17,18,19]. The risk factors for postoperative death among these studies were: mitral valve replacement, emergency surgery, preoperative low EF, prolonged CPB time, NYHA functional class, combined procedures (CABG±AVR/MVR, double valve replacement) and prior CABG. In our series, the overall 30-day mortality rate was 14%, the major cause of death being cardiovascular complications (ventricular fibrillation and cardiac arrest). The late mortality was among the patients with marked Perioperative morbidity mainly COPD in one patient and ischemic cardiomyopathy among the other patient who had combined MVR and CABG. In the literature, morbidity rates had been reported to be as high as 100% [15,16,17,18,19]. In our series, Perioperative MI and sepsis was around 21%, and low cardiac output was around 28% while renal dysfunction and AF were common complications (43 and 50%). Some authors have shown that older age is strongly related to a neurological event [20], the latter being associated with a previous history of stroke and advanced atherosclerotic disease. In our series, we did encounter one case with postoperative stroke (7%). The patient recovered with residual hemi paresis.

Conclusion:Our small cohort showed that although morbidity,

mortality, and cost may be higher in nonagenarian, however, advanced age itself (>90 years) should not be a contraindication to an open-heart operation.

References 1.BacchettaMD,KoW,GirardiLN,MackCA,KriegerKH,Isom

OW,LeeLY.Outcomesofcardiacsurgeryinnonagenarians:a10-yearexperience.AnnThoracSurg2003;75:1215–122

2. Bridges CR, Edwards FH, Peterson ED, Coombs LP,Ferguson TB. Cardiac surgery in nonagenarians andcentenarians.JAmCollSurg2003;197:347–356.

3. CraverJM,PuskasJD,WeintraubWW,ShenY,GuytonRA,Gott JP, JonesEL. 601 octogenarians undergoing cardiacsurgery:outcomeandcomparisonwithyoungeragegroups.AnnThoracSurg1999;67:1104–1110.

4. EdwardsMB,TaylorKM.Outcomesinnonagenariansafterheartvalvereplacementoperation.AnnThoracSurg2003;75:830–834.

5. Gibbon J.H. Application of a mechanical heart-lungapparatustocardiacsurgery.MinnMed1954;37:171-180.

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6.AmericanHeartAssociation.Medicalprocedures,facilitiesandcosts.2001heartandstrokestatisticalupdate

7.STSNationalDatabase.TheSocietyofThoracicSurgeons.January1999

8USBureauof theCensus. .Statisticalabstractof theUnitedStates: 2000, 120th ed Washington, DC: U.S. CensusBureau,2000.

9.TsaiT.p,ChauxA.,KassR.M., et al.Aortocoronary bypasssurgeryinseptuagenariansandoctogenarians.JCardiovascSurg1989;30:364-368.

10.KoW.,KriegerK.H.,LazenbyD.,etal.Isolatedcoronaryarterybypass grafting in one hundred consecutive octogenarianpatients:amultivariateanalysis.JThoracCardiovascSurg1991;102:532-538.

11. Weintraub W.S., Craver J.M., Cohen C., et al. Influenceof age on results of coronary artery surgery. Circulation1991;84(Suppl3):226-235.

12.TsaiT.P.,ChauxA.,MatloffJ.M.,etal.Ten-yearexperienceofcardiacsurgeryinpatientsaged80yearsandover.AnnThoracSurg1994;58:445-451.

13. Craver J.M., Puskas J.D., Weintraub W.W., et al. 601octogenarians undergoing cardiac surgery: outcome andcomparison with younger age groups. Ann Thorac Surg1999;67:1104-1110.

14.AlexanderK.P.,AnstromK.J.,MuhlbaierL.H.,etal.Outcomesof cardiac surgery inpatientsage 80years: results fromthe National Cardiovascular Network. J Am Coll Cardiol2000;35:731-738.

15.BacchettaMD,KoW,GirardiLN,MackCA,KriegerKH,IsomOW,LeeLY.Outcomesofcardiacsurgeryinnonagenarians:a 10-year experience. Ann Thorac Surg 2003; 75:1215–1220.

16. Bridges CR, Edwards FH, Peterson ED, Coombs LP,Ferguson TB. Cardiac surgery in nonagenarians andcentenarians.JAmCollSurg2003;197:347–EdwardsMB,TaylorKM.

17.Outcomes innonagenariansafter heart valve replacementoperation.AnnThoracSurg2003;75:830–834.356.[

18.Miller DJ, Samuels LE, KaufmanMS,Morris RJ, ThomasMP, Brockman SK. Coronary artery bypass surgery innonagenarians.Angiology1999;50:613–617.

19. B.Praschkera,, P. Leprince, N.Bonnet, A.Rama, V. Bors, L. Lievre, A. Pavie and I.Gandjbakhch. Cardiacsurgeryinnonagenarians:hospitalmortalityandlong-termfollow-up.InteractCardioVascThoracSurg2006;5:696-699.

20.WeintraubWS,ClementsSD,WareJ,CraverJM,CohenCL, Jones EL, Guyton RA. Coronary artery surgery inoctogenarians.AmJCardiol1991;68:1530–1534.

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Current results of primary repair of truncus arteriosus in early infancy

Alaa-Basiouni S. MD

Addrees reprint request to :Dr. Alaa Basiouni Said MahmoudKing Faisal Specialist Hospital and Research CenterCardiothoracic surgery dept. MBC J 16P.O.Box 40047Jeddah 21499 Saudi Arabia.Email : [email protected] : 04/137/1006

Background: Repair of truncus arteriosus in early infant period has become standard practice in many centers. We report the current clinical outcomes of primary repair of truncus arteriosus in early infancy at a single institution.Methods: A retrospective analysis of 31 patients with mean age 2.6±1.3 months (range, 15 days to 6 months), and mean body weight 3.4±0.6 kg (range, 2.6 to 4.7 kg) who underwent primary repair of truncus arteriosus. Data were collected regarding demographics, anatomy, operative data, cardiac intensive care unit, and last available follow-up. Results: There were four hospital deaths (12.9 %); three of them were due to pulmonary hypertension. At median follow up of 8 months (range, 1-100 months) after surgery, there was no late death. One patient was reoperated on for right ventricle-to-pulmonary artery (RV-to-PA) conduit replacement, residual ventricular septal defect repair, and truncal valve repair. One patient was reoperated on twice for truncal valve repair and later on truncal valve replacement. Three patients required percutaneous balloon dilation and stenting of pulmonary artery branches.Conclusions: Truncus arteriosus can be performed in early infancy with acceptable perioperative mortality and morbidity. Pulmonary hypertension continues to be a risk factor of mortality.

Persistent truncus arteriosus is a rare congenital cardiac malformation accounting for 1.4-2.8 % of all congenital malformations.(1) It is characterized by a single, large arterial trunk originating from the base of the heart that supplies systemic, coronary and pulmonary blood flow, together with an infundibular

ventricular septal defect. Truncus arteriosus is believed to result from failure of proper conotruncal septation. (2)

The natural history of children born with truncus arteriosus is such that up to 80 % or more die within the first year of life without surgical intervention. (3)

The first successful surgical repair was performed in 1967 by McGoon, Rastelli and Ongley. (4) Since then, there have been many advances in the surgical management with a clear trend to perform primary repair in early infancy to avoid the severe morbidity produced by progressive pulmonary vascular obstructive disease. (5-15)

Although there have been significant improvements in cardiopulmonary bypass techniques and small body technology, truncus arteriosus continues to be associated with significant morbidity and a reported mortality between 3.4-17.9%.(5-18) The aim of this study was to report the current clinical outcomes of primary repair of truncus arteriosus in early infancy at a single institution.

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Methods:Study population

A retrospective analysis was performed on all patients who had primary complete repair of truncus arteriosus at our institution between October 2001 and March 2009. The records of all patients were reviewed and preoperative data collected included demographics, initial clinical features, echocardiographic and catheter findings. The patients were classified in functional classes prior to surgery according to Schreiber and colleagues. (9) Asymptomatic patients were in functional class I, patients with tachypnea, failure to thrive and poor feeding were classified as class II, intubated patients with mildly impaired cardiac function were classified as class III, and patients intubated for more than one week and receiving increased antifailure medication were in class IV. Cardiac anatomic type was classified according to Van Praagh classification. (19)

The intraoperative data included surgical technique, cardiopulmonary bypass time, cross clamp time, method of ventricular septal defect repair, conduit for RV-to- PA continuity reconstruction, and additional procedures. The immediate postoperative study included mortality and intensive care unit (ICU) morbidity expressed as duration of ventilatory support, duration of intensive care unit stay, and number of registered complications.

Early death (hospital death) was defined as death occurring from the intraoperative period up to 30 days after surgery. Death occurring after that period was defined as a late death. Respiratory complications were defined as mechanical ventilation more than 5 days, or failed extubation. Infectious complications were defined as septicemia, wound infection, or upper airway infection. Renal complications were defined as haemodialysis or the need for peritoneal dialysis. Neurologic complications were defined as seizure, cerebral infarction, or clinical disturbance of consciousness. Pulmonary hypertension was considered when nitric oxide was used in the immediate postoperative period.

Surgical management:The operative technique was uniform throughout

this study using standard cardiopulmonary bypass (CPB) and cold antegrade blood cardioplegia. The pulmonary arteries were snared at the onset of cardiopulmonary bypass to prevent overcirculation of the lungs and to preserve systemic and coronary blood flow. The left atrium was vented through the interatrial septum in all

cases. Care was taken to separate the pulmonary arteries from the truncal vessel without injuring the coronary arteries. The resultant truncal defect was closed primarily if there were no concerns of potential distortion of the truncal valve or compromise of the coronary arteries. In some patients the truncus was completely transected to facilitate detachment of the pulmonary arteries, and the aorta was reconstructed by direct end-to-end anastomosis, without any augmentation. The truncal valve function was assessed intraoperatively by delivering cardioplegia and inspecting the truncal valve from below through the right ventriculotomy and repair was done when necessary. The ventricular septal defect was closed through the right infundibular ventriculotomy with a bovine patch usually by means of running continuous suture technique. The right ventricular outflow tract was reconstructed in all patients with the Contegra bovine jugular venous valve conduit (Medtronic Inc, Minneapolis, MN). The opening in the native pulmonary arteries was extended if necessary to at least the same diameter as the chosen conduit. The sternum was electively left opened (without a trial of sternal closure in the operating room) in patients with long bypass time, ventricular dysfunction, persistent mediastinal bleeding, or mechanical circulatory support. Delayed sternal closure was usually done within 24-48 hours of the operation in the ICU.

In all patients, antiplatelet therapy (aspirin 5 mg/kg daily) was initiated early on the first postoperative day through the nasogastric tube if no bleeding and was continued after hospital discharge.

Management of pulmonary hypertension:To minimize the likelihood of pulmonary

hypertensive episodes, an electively induced pop-off inter-atrial septal defect was kept opened at the time of repair. In the ICU patients were kept warm and moderately hyperventilated, with pCO2 30-35 mmHg and a target systemic pH of 7.5 to 7.55. Patients were maintained on sedation with continuous fentanyl and midazolam hydrochloride intravenous infusion and neuromuscular blockade for the first 24 to 48 hours. Phosphodiesterase inhibitor (Milrinone lactate) was used in all patients until extubation or no signs of pulmonary hypertension. Inhaled nitric oxide, 5-40 PPM, for selective pulmonary vasodilatation was used electively in all patients with preoperative data suggesting high risk of postoperative pulmonary hypertensive crisis.

Follow-up: Patients were followed until their last clinic visit. It included late death, reoperation and the

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requirement of intervention cardiac catheterization.

Statistical analysis :Statistical analysis was performed with SPSS

statistical program (SPSS 12 Inc., Chicago, Illinois). Data were presented as mean ± standard deviation or median with ranges or percentages as appropriate.

Results:The preoperative patients’ characteristics

The preoperative patient demographics, echocardiographic and associated anomalies are summarized in Tables 1. The mean age at operation was 2.6±1.3 months and the mean weight was 3.4±0.6 kg. Clinical presentations were as follow: 8 patients (25.8%) were in functional class 1; 15 patients (48%) were in class II; 5 patients (16%) were in class III; and 3 patients (9.6%) were in class IV. According to Van Praagh classification, the anatomical type of truncus arteriosus was as follows: A1; 15 patients (48%); A2, 11 patients (35%); and A3, 5 patients (16%).

The truncal valve had 3 leaflets in 22 patients (70.9%), 4 leaflets in 9 patients (29%). Truncus arteriosus valve regurgitation was graded by echocardiography as mild in 19 patients (61%), moderate in 7 patients (22.5%), and severe in one patient (3.2%). Three patients (9.6%) had single coronary ostium giving origin to both right and left coronaries. Cardiac catheterization was performed to define pulmonary vascular resistance in 5 patients who presented late with pulmonary hypertension.

Operative data (Table II):The mean cardiopulmonary bypass time was

150±40 minutes. The mean cross-clamp time was 112±22 minutes. Three patients required patch closure of the common trunk using glutaraldehyde-treated bovine pericardium. The common trunk was completely transected in 11 patients and the aorta was reconstructed by direct end-to-end anastomosis. A subcommissural suture of the truncal valve was performed in 8 patients (25.8%). Three patients required De Vega tricuspid valve annuloplasty. Elective 3 mm patent foramen ovale was kept open in 19 patients (61%) to act as a pop-off valve. Chest was kept opened in 6 patients (19%).

Postoperative data (Table III)Mortality

There were 4 hospital deaths (12.9%). Hospital deaths have been attributed to pulmonary hypertension and consecutive right ventricular failure in 3 of them.

The first patient was 6 months old; body weight 4.4 kg; type A3; class III; with preoperative pulmonary vascular resistance of 9.2 Wood unit which dropped to 2.2 Wood unit on oxygen. This patient had right ventricular dysfunction and died 27 days postoperatively after the development of sepsis and multiple organ failure. The second patient was 2 months old; body weight 3.7 kg; type A3; class IV with pulmonary hypertension and preoperative biventricular dysfunction. He was put on extracorporeal membrane oxygenation (ECMO) support for 6 days but could not be weaned successfully. The third patient was 11/2 months old; body weight 3 kg; type A2 and class II. He required prolonged mechanical ventilation postoperatively for pulmonary hypertension and arrested during replacement of central venous line 8 days postoperatively. The last patient was 15 days old; body weight 2.6 kg; type A1; class III with preoperative left ventricular dysfunction and severely regurgitant truncal valve. The truncal valve was repaired and not replaced. This patient came off pump on high inotropes and arrested on the same day of surgery at the ICU.

Morbidity:Table 3 showed early post operative data.

Nineteen patients (61%) required nitric oxide for severe pulmonary hypertension. Early reoperation, aside from delayed sternal closure, was performed in one patient for reexploration and control of mediastinal bleeding. Two patients had a postoperative seizure that was detected clinically, with no subsequent electroencephalographic evidence of seizure activity and no focal lesions were found in the subsequent brain magnetic resonance imaging scan. They were discharged on antiepileptic medications.

For the whole series (including the hospital deaths), the median duration of postoperative mechanical ventilation was 5.5 days (range, 3 to 30 days). One patient who had preoperative tracheostomy tube for severe subglotic stenosis was transferred under mechanical ventilation to another hospital. The median duration of postoperative intensive care unit stay was 7 days (range 4 to 30 days). The median postoperative stay was 11 days (range 8 to 30 days).

Follow-up (Table III)Twenty-seven survivors were followed-up to a

median of 8 months after repair (range, 1 month to 100 months). There was no late mortality during the follow-up. Twenty surviving patients (70%) were doing well

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without any additional medication except for aspirin. With regard to echocardiographic assessment of the truncal valve and the conduit function at follow-up, truncal valve insufficiency was mild in 15 patients (55%); moderate in 6 patients (22%), severe in 2 patients (7%) and 4 patients (14.8%) had no truncal valve regurgitation. The Contegra conduit valve insufficiency was mild in 11 patients (40%), moderate in 6 patients (22%), severe in 8 patients (29.6%), and two patients (7%) had no regurgitation. The mean gradient across the Contegra conduit was 25±12 mmHg.

ReinterventionsThree patients (11% of 27 survivors) underwent

intervention cardiac catheterization; with one them required two times intervention catheterization. The interventional cardiac catheterizations included percutaneous balloon dilatation and stenting of right pulmonary artery in two patients 22 and 34 months postoperatively. One of them required ballooning of the stent after 12 months. The third patient required balloon dilatation and stenting of both right and left pulmonary arteries 20 months postoperatively. Two patients are awaiting intervention owing to stenosis of the left pulmonary artery.

ReoperationTwo patients required reoperation. One patient

who did not have preoperative truncal regurgitation had developed severe truncal valve regurgitation and required redo truncal valve repair 4 months after repair and was discharged with mild truncal regurgitation. After 14 months he developed again severe truncal valve regurgitation which necessitated urgent truncal valve replacement for refractory congestive heart failure. This patient had mechanical aortic valve prosthesis and is on a regimen of warfarin sodium, aiming to maintain INR between 2.5 and 3.5.

The second patient had residual ventricular septal defect, truncal valve regurgitation and conduit-related right ventricular outflow tract stenosis 7 years postoperatively. Reoperation consisted of subcommissural suture truncal valve repair, closure of the residual ventricular septal defect and of removal of the previous Contegra conduit (12mm) and its replacement with a size 18 mm Contegra. No mortality or major morbidity was encountered after reoperation for both patients.

Variable

Median age at repair (month)Male/femaleMedian weight (kg)Clinical presentation Functional class I Functional class II Functional class III Functional class IVVan Praagh Truncus type Type A-1 Type A-2 Type A-3Truncal valve Tricuspid QuadricuspidTruncal valve regurgitation No Mild Moderate SevereAssociated defects Atrial septal defect Partial anomaly pulmonary venous return Bilateral superior vena cava Single coronary Right aortic arch Tricuspid valve regurgitationNon cardiac anomaliesDiGeorgi syndromeSubglotic stenosisBilateral chonal atresia

2.6±1.3 (15 days-6 m)14/17

3.4±0.6 (2.6-4.7 kg)

8 (25.8%)15 (48.3%)5 (16.1%)3 (9.6%)

15 (48.3%)11 (35.4%)5 (16.1%)

22 (70.9%)9 (29%)

4 (12.9%)19 (61%)7 (22.5%)1 (3.2%)

19 (61.2%)1 (3.2%)3 (9.6%)3 (9.6%)4 (12.9%)3 (9.6%)

1 (3.2%)1 (3.2%)1 (3.2%)

Table I. Patients’ characteristics, echocardiographic data, and associated congenital anomalies VariableMean cardiopulmonary by pass time (min)Mean aortic cross-clamp time (min)Mean temperature oCPatch closure of the truncal defectTruncal resection and end-to-end anastomosisTruncal valve repairTricuspid valve repairPartial anomalies pulmonary venous drainage repairPop-off interatrial septal defectOpen chestExtracorporeal membrane oxygenationContegra size 12 mm 14 mm

150±40112±22

28.1±1.93 (9.6%)

11 (35.4%)8 (25.8%)3(9.6%)1 (3.2%)

19 (61.2%)6 (19.3%)1 (3.2%)

24 (77.5%)7 (22.5%)

Table II. Operative data

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VariableEarly postoperative data Mortality Median mechanical ventilation & range (days) Median intensive care unit stay & range (days) Median hospital stay & range (days) Respiratory failure Exploration for bleeding Open chest Seizure Chylothorax Renal failure Sepsis Pulmonary hypertension Extracorporeal membrane oxygenationFollow-up (27/31 survivors) Median follow-up (month) Late death Echocardiographic data Truncal valve regurgitation None Mild Moderate Severe Contegra regurgitation None Mild Moderate Severe Reinterventions Ballooning and stenting of right pulmonary artery Ballooning and stenting of right and left pulmonary artery Reoperation Truncal valve replacement Contegra replacement, truncal valve repair and residual ventricular septal defect repair

4 (12.9%)5.5 ( 3-30)7 ( 4-30)11 (8-30)9 (29%)1 (3.2%)6 (19.3%)2 (6.5%)4 (12.9%)2 (6.5%)5 (16.1%)19 (61%)1 (3.2%)

8 m (1-100m)0

4 (14.8%)15 (55.5%)

6 (22%)2 (7.4%)

2 (7.4%)11 (40.7%)6 (22.2%)8 (29.6%)

2 (7.4%)1 (3.7%)

1 (3.7%)1 (3.7%)

Table III. Postoperative data and follow-up

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DiscussionEarly primary repair of truncus arteriosus is

becoming an increasingly successful approach to the management of this complex anomaly. The basic principles of the operative repair as originally described(4) remain essentially unchanged; separation of the pulmonary arteries from the truncus and closure of the resulting truncal defect; transventricular patch closure of the ventricular septal defect; and establishment of continuity between the RV-to-PA.

Since then there has been many advances in the surgical management with a clear trend to perform primary repair in early infancy to avoid complications

of pulmonary hypertension. With early surgery, patients’ survival has improved; however, overall operative mortality rates continue to be higher than those reported for other complex congenital heart disease of up to 17.9 %.(5-17) This retrospective study analyzed the outcome of 31 consecutive patients who underwent surgical correction of truncus arteriosus at a single centre in the current era. This has provided an acceptable number of patients and degree of homogeneity in surgical technique and perioperative management. In this study, we observed an early mortality rate of 12.9% in an unselected, consecutive population of patients over a period of 8 years. Our results are comparable to other reported mortality in the literature (Table IV).

Author Year Period No AgeWeightkg

MortalityNo (%)

Ebert et al (5)Pearl et al (6)Brizard et al (7)Williams et al (8)Schreiber et al (9)Brown et al (10)Thompsosn et al (11)Danton et al (12)Alexiou et al (13)Chen et al (14)Kalavrouziotis et al (15)Sinzobahamvva et al (16 )Henaine et al (17)

1984199119971999200020012001200120012005200620082008

1974-19811982-19901979-19951953-19971976-19981987-20001992-19991988-20001974-19941990-20041993-20051987-20071986-2003

100328220610660656123542935153

< 6 m< 12 m11 days- 28 m2 days-8m 11 m3 days-20 m< 1 m1m< 6 m15 days11 days-4m22 days35 days

1.9-5.23.52.7-9---5-3.23.23.7--3.133.2

11 (11%)5 (15.6%)11 (13.4%)37 (17.9%)18 (17%)10 (11%)3 (5%)8 ( 13%)4 (17.4%)5 (9.1%)1 (3.4%)5 (14%)26 (17%)

Table IV. Repair of Truncus Arteriosus: Operative Mortality in the Literature

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Hospital deaths have been attributed to pulmonary hypertension and consecutive right ventricular failure in three of them and the fourth one had a low weight (2.6 kg) with severe preoperative truncal valve regurgitation. Early studies (7, 8, 20, 21) demonstrated a correlation between increasing early mortality and higher levels of pulmonary hypertension. Surgical weight of 3 kg or less was identified as a significant risk factor for perioperative death.(7,22) Close monitoring of the patients before surgery, improvement of the surgical and postoperative management and the routine use of nitric oxide had effectively improved our outcomes as we had no operative mortality since 2006 (15 patients). Our experience and the experience of the others seem to support this observation as well. Schreiber and colleagues (9) reported that their early postoperative mortality was 21% between 1976 and 1989 which dropped to 13% between 1990 and 1998.

Truncal valve repair remains a challenging problem. In our study one patient required multiple reoperations for truncal valve regurgitation. This patient had mild truncal valve regurgitation at the time of truncal repair. During follow-up, this patient developed severe truncal valve regurgitation which was successfully repaired. Later on, he developed again severe truncal valve regurgitation which required replacement. Truncal valve replacement is reported to carry a high risk (23-27) and it is preferred to attempt repair even with residual regurgitation. Residual mild to moderate regurgitation after repair is usually well tolerated postoperatively after reduction of the volume overload. In our study, only subcommissural suture placement was used to correct prolapse and to improve central cusp coaptation in 8 patients and results were satisfactory. A variety of techniques have been used to repair truncal valve including suture valvuloplasty, leaflet excision, and remodeling technique. (24, 26-28)

Replacement of truncal valve with aortic homografts at the time of truncal repair is disappointing and having high tendency for calcification, obstruction, and increased difficulty of revision or replacement.(23, 25,29-31) Heinemann and colleagues (23) reported early death after truncal valve replacement using homografts in two patients. The same outcome was reported by McElhinney and colleagues (29) with severe allograft insufficiency developed less than a year after operation in 2 of their 3 early survivors and the third one died suddenly 2 months after operation.

In our study and other reports, (7, 10, 29) it was preferred to use mechanical valve when repair of truncal

valve was not satisfactory. However, it is difficult to control the use of anticoagulation in young infants and complications are unpredictable. Truncal valve replacement can be performed with a low risk and should be performed when severe regurgitation is present.

Right ventricular out flow tract construction: The first successful repair of truncus arteriosus was performed using aortic homograft including the aortic valve to establish continuity from the RV-to-PA.(4) The good hemodynamic profile with low resistance to right ventricular ejection and excellent tissue handling properties supported its use in truncus repair. However, some studies (32-33) reported rapid occurrence and progression of significant homograft insufficiency after using homografts to establish continuity from RV-to-PA. Chan and his colleagues (32) reported during a median follow up period of 28 months, homograft regurgitation in 100% of all implanted homografts and 50% of them had severe regurgitation The limited durability and lack of availability of homografts in this young population led to the search of an alternative conduit for RV-to-PA construction and Xenograft valved conduit and Dacron porcine conduits has been used successfully in the repair of truncus arteriosus. (34,35) Contegra bovine jugular vein conduit was one of the conduits which were used to overcome the mismatch between homograft demand and supply with the expectation of increasing longevity in human by resisting calcification. Herijgers and colleagues (36) demonstrated resistance of Contegra to calcification in juvenile sheep for 5 months. In our study, Contegra was the only conduit used for RV-to-PA construction and showed an acceptable performance. Although postoperative echocardiography showed free Contegra valve regurgitation in 7 patients, this did not have any clinical impact on the patients. This is may be analogous to transanular patch repair of right ventricular outflow tract obstruction which is well tolerated by the patients. The cause of free regurgitation may be due to the limited mediastinal space in an infant with distortion of the valve by compression.

In this study, only one patient required redo RV-to-PA reconstruction due to Contegra related stenosis. The time of follow-up is too short to median 8 months (range, 2-100 months) to allow definitive evaluation of the performance of Contegra in our study. However, it is expected that the use of small diameter Contegra for RV-to-PA construction may probably lead to reintervention as these conduits do not grow and can degenerate. There was a word of caution reported by Tiete and colleagues

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(35) in 2004 about the use of Contegra in the RV-to-PA reconstruction. They reported a clotting thrombus along the Contegra valve which was successfully treated with low-molecular weight heparin. This observation was also reported by Kocher and colleagues (37) in 2006 which led to patient death. Both authors recommended anticoagulation after using Contegra in the right ventricle to pulmonary artery reconstruction. During our follow-up we did not observe any Contegra related thrombus formation and we are using only antiplatelet (Aspirin) post operatively. We and others (12,38) think that in a high pressure circulation there is no need for anticoagulation and thrombus formation in their patients might have been due to other contributing factors.

In conclusion our data may support primary repair of truncus arteriosus in early infancy. Pulmonary hypertension remains an important risk factor for early mortality Contegra bovine jugular vein conduits have acceptable results in establishing RV-to-PA continuity. Additional data and analysis are necessary to evaluate the long term outcome of Contegra in RV-to-PA reconstruction.

References1) CalderL,VanPraaghR,VanPraaghS,SearsW,Corwin

R,LevyA,KeithJ,PaulM.Truncusarteriosuscommunis.Clinical, angiographic and pathological findings in 100patients.AmHeartJ1976;92:23-31.

2) Orts-liorcaF,FonollaJ,SobradoJ.Theformation,septationandfateoftruncusarteriosusinman.JAnat1982;183:41-56.

3) Marcelltti C, McGoon D, Mair D. The natural history oftruncusarteriosus.Circulation1976;54:108-111.

4) McGoon D, Rastelli G, andOngley.An operation for thecorrectionoftruncusarteriosus.JAmMedAssoc1968;205:69-73.

5) EbertP,TurleyK,StangerP,HoffmanJ,HeymannM,RudolfA. Surgical treatment of truncus arteriosus in the first 6monthsoflife.AnnSurg1984;200(4):451-456.

6) Pearl J, LaksH,DrinkwaterD,Milgalter E,Orrin-AlloniC,Giacobertti F, Williams R. Repair of truncus arteriosus ininfancy.AnnThoracSurg1991;52:780-786.

7) Brizard C, Cochrane A, Austin C, Nomura F, Karl T.Management strategy and long term outcome for truncusarteriosus..EurJCardiothoracSurg1997;11:687-696.

8) WilliamsJ,DeleeuwM,BlackM,FreedomR,WilliamsW,McCrindleB.Factorsassociatedwithoutcomesofpersistenttruncusarteriosus.JAmCollCardiol1999;34:545-553.

9) Schreiber C, EickenA, BallingG,WottkeM, SchumacherG,UnPaekS,MeisnerH,hessJ,LangeR.Singlecentreexperienceonprimarycorrectionofcommonarterial trunk:Overall survival and freedom from reoperation after more

than15years.EurJCardiothoracSurg2000;18:68-73.10) Brown J, Ruzmetov M, Okada Y, Vijay P, Turrentine M.

Truncusarteriosusrepair:Outcomes,riskfactors,reoperationandmanagement.EurJCardiothoracSurg2001;20:221-227.

11) Thompson L, McElhinney D, Reddy V, Petrossian E,SilvermanN,HanleyF.Neonatalrepairoftruncusarteriosus:Continuing improvement in outcomes. Ann Thorac Surg 2001;72:391-395.

12)DantonM,BarronD,StumperO,Wright j,DeGiovanni J,SiloveE,BrawnW.Repairoftruncusarteriosus:Aconsideredapproach to right ventricular outflow reconstruction. Eur JCardiothoracSurg2001;20:95-104.

13)AlexiouC,KeetonB,SalmonA,MonroJ.Repairoftruncusarteriosus in early infancy with antibiotic sterilized aortichomograft.AnnThoracSurg2001;71:S371-374.

14)ChenJ,GlicksteinJ,DavisR,MercandoM,HellenbrandW,MoscaR,QuaegebeurJ.Theeffectofrepair techniqueonpostoperativeright-sidedobstructioninpatientswithtruncusarteriosus.JThoracCardiovascSurg2005;129:559-568.

15)Kalavrouziotis G, Purohit M, Giotti G, Corno A, Pozzi M.Truncusarteriosuscommunis:Earlyandmidtermresultsofearlyprimaryrepair.AnnThoracSurg2006;82:2200-2206.

16)SinzobahamvyaN,BoscheinenM,BlaschczokH,KallenbergR,Photiadis J,HaunC,HraskaV,AsfourB.Survival andreintervention after neonatal repair of truncus arteriosus with valvedconduit.EurJCardiothoracSurg2008;34:732-737.

17)Henaine R, Azarnoush K, belli E, Capderou A, RoussinR, Planche C, Serraf A. Fate of truncal valve in truncusarteriosus.AnnThoracSurg2008;85:172-178.

18)O’BrienS,JacobsJ,ClarkeD,MaruszewskiB,Jacobsm,WaltersIIIh,TechervenkovC,WelkeK,TobatoZ,StellinG,MavroudsC,HamiltonJ,GaynorJ,PuzziM,Lacour-GayetF.AccuracyofAristotlebasiccomplexityscoreforclassifyingthe mortality and morbidity potential of congenital heartsurgeryoperation.AnnThoracSurg2007;84:2027-2037.

19)VanPraaghR,andVanPraaghS.Theanatomyofcommonaortico-pulmonarytrunk(truncusarteriosuscommunis)anditsembryonicimplications.Astudyof57necropsiescases.AmJCardiol1965;16:406-425.

20)MarcellettiC,McGoonD,DanielsonG,WallaceR,MairD.Earlyandlateresultsofsurgicalrepairoftruncusarteriosus.Circulation1977;55:636-641.

21)RajasingheH,McElhinneyD,ReddyV,MoraB,HanleyF.Longtermfollowupoftruncusarteriosusrepairedininfancy:Atwenty-yearexperience.JThoracCardiovascSurg1997;113:869-879.

22)BoveP,LupinettiF,PridjianABeekmanR,CallowL,SniderA, Rosenthal A. Results of a policy of primary repair oftruncus arteriosus in the neonate. J Thorac Cardiovasc Surg 1993;105:1057-1066.

23)Heinemann M, Hanley F, Fenton K, Jonas, Mayer J, andCastanedaA.Fateof small homograft conduitsafterearlyrepair of truncus arteriosus. Ann Thorac Surg 1993; 55:1409-1412.

24)ElamiA, Laks H, and Pearl J. Truncal valve repair: Initial

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experiencewithinfantsandchildren.AnnThoracSurg1994;57:397-402.

25)Baskett R, Ross D, Nanton M, Murphy D. Factors in theearlyfailureofcropreservedhomograftpulmonaryvalvesinchildren; preserved immunogenicity? J Thorac CardiovascSurg1996;112:1170-1179.

26)BlackM,AdatiaI,andFreedomR.truncalvalverepair:initialexperience inneonates.AnnThoracSurg1998;65:1737-1740.

27)Marvoudis C, and Backer C. Surgical management ofsevere truncal insufficiency: Experience with truncal valveremodelingtechniques.AnnThoracSurg2001;72:396-400.

28)Imamura M, Drummond-Webb J, Sarris G, and Roger R.Improvingearlyandintermediateresultsoftruncusarteriosusrepair:Anewtechniqueoftruncalvalverepair.AnnThoracSurg1999;67:1142-1146.

29)McElhinneyD,ReddyM,RajasinghH,MoraB,SilvermanN, Hanley F. Trends in the management of truncal valveinsufficiency.AnnThoracSurg1998;65:517-524.

30)MelionsJ,SniderR,BoveE,SerwerG,PetersJ,LacinaS,FlorentineM,RosenthalA.Dopplerevaluationofhomograftvalvedconduitsinchildren.AmJCardiol1989;64:354-358.

31)BoveE,LupinettiF,PridjianABeekmanR,CallowL,SniderA, Rosenthal A. Results of a policy of primary repair oftruncus arteriosus in neonate. J Thorac Cardiovasc Surg 1993;105:1057-1066.

32) Chan C, Fyfe D, McKay C, Sade R, and Crawford F.Right ventricular outflow construction with cryopreservedhomograftsinpediatricpatients:Intermediate-termfollow-up

with serial echocardiographic assessment. J Am Coll Cardiol 1994;24:483-489.

33)Niwaya K, Knott-Craig C, Lane M, Chandrasekaren K,Overholt E, Elkins R. Cryopreserved homograft valves inthepulmonaryposition:Riskanalysisfor intermediate-termfailure.JThoracCardiovascSurg1999;117:141-147.

34)Reddy V, Rajasingle H, McElhinney D, Hanely F.Performanceofrightventricletopulmonaryarteryconduitsafter repairof truncusarteriosus:AcomparisonofDacron-housedporcine valvesand cryopreservedallograft.SeminThoracCardiovascSurg1995;7(3):133-138.

35)TieteA,SachwehJ,RoemerU,Kozlik-FeldmannR,ReichartB,DaebritzS.Rightventricularoutflowtractreconstructionwith the Contegra bovine jugular vein conduit: A word ofcaution.AnnThoracSurg2004;77:2151-2156.

36)Herijgers P, Ozaki S, Verbeken E Van LommelA, MeurisB,LesaffreE,DaenenW,FlamengW.Valved jugularveinsegments for right ventricular outflow tract reconstructioninyoungsheep.JThoracCardiovascSurg2002;124:798-805.

37)Kocher T, Pestaner J, Koultas T. Early complication afterrepair of truncus arteriosus with Contegra conduit. To the editor.AnnThoracSurg2006;82:1949.

38)HickeyE,McCrindleB,BlackstoneE,YehT,Pigulaf,ClarkeD, Tchervenkov C, Hawkins J, and the CHSS pulmonaryconduit working group. Jugular venous valved conduit(Contegra)matchesallograftperformance in infant truncusarteriosus repair. Eur J Cardiothorac Surg 2008; 33: 890-898.

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Graft Patency After using intra-Luminal Shunts during Off-Pump Coronary artery Bypass Grafting

A M Bassiony FRCS MD,Y M Hegazy FRCS MD,M M Mostafa MD*,M AbdelAzeem MD*,E AlKaady MD**,A Ashmawy MS**.

Address reprint request toDr A Bassiony Cardiothoracic surgery unit ,Maadi Hospital ,Cairo *Ain Shams University**IMCEmail ; : [email protected] 04/ /1010

Background ; Intraluminal Coronary Shunts (ILS) in OPCAB allow easier, safer, more accurate anastomosis and better myocardial protection by maintaining distal coronary perfusion during beating heart coronary revascularizationMethods ; retrospectively we studied 60 patients at Maadi and Ain Shams hospitals who had off pump Coronary Artery Bypass Grafting using coronary intra-Luminal Shunts ;Echo-Doppler study ,Multi-slice CT angiography after one year of surgery ,Coronary angiography preoperatively and after one year of surgery. Results: The total number of grafts was 118 grafts, 60 grafts were LIMA (50.8%) and 58 grafts (49.2%) were SVG graft .Post operatively 7 patients (11.7%) had infarction, 2 patients (3.3%) had wound infection, 1 patient (1.7%) had prolonged ventilation (> 24 hours), and 1 patient (1.7%) had per operative utilisation of intra-aortic balloon pump.By coronary angiography; 102/118 grafts (86.4%) were patent, 6 grafts (5.1%) had significant stenosis (> 50% stenosis) and 10 grafts (8.5%) were totally occluded. By CT angiography; 101 grafts (85.6%) were patent, 7 grafts (5.9%) had significant stenosis and 10 grafts (8.5%) were totally occluded. There was no significant difference between the results of coronary angiography and CT angiography (P > 0.05). By coronary angiography LIMA grafts was patent in 56/60 grafts (93.3%), 1/60 (1.7%) LIMA grafts had significant stenosis and 3/60 grafts (5%) were totally occluded. By CT angiography; 55/60 grafts (91.7%) were patent, 2/60 grafts (3.3%) had significant stenosis and 3/60 grafts (5%) were totally occluded. There was no significant difference between the results of coronary angiography and CT angiography (P > 0.05). By coronary angiography SVG grafts was patent in 46/58 grafts (79.3%), 5/58 (8.6%) SVG grafts had significant stenosis and 7/58 grafts (12.1%) were totally occluded. By CT angiography; 46/58 grafts (79.3%) were patent, 5/58 grafts (8.6%) had significant stenosis, and 7/58 grafts (12.1%) were totally occluded. There was no significant difference between the results of coronary angiography and CT angiography (P > 0.05).Conclusion: Using intra-luminal shunt during off-pump coronary artery bypass surgery is safe; it provides a relatively bloodless field; the forward flow in the shunt helps to prevent ischemia, it facilitates the construction of the anastomosis. There are data to suggest that the use of ILS is associated with mechanical endothelial injury however, this is not unique to the use of ILS . Our results showed very much accepted graft patency after one year compared to the studies looked at the graft patency one year after OPCABG using different methods to achieve bloodless field during anastomosis like snaring and

A M Bassiony FRCS et all

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bulldog. Ultimately, we believe the knowledge of superficial endothelial injury should not prevail over the benefit of allowing antegrade flow in every patient undergoing OPCAB.Multislice CT is a good modality in terms of follow up after coronary artery bypass surgery, it is non invasive , has a short examination time, needs no hospital admission and it has high sensitivity and specificity.

The renewed interest in Off-Pump Coronary Artery Bypass Grafting (OPCAB) has generated technological advances that have improved methods of coronary artery stabilization and exposure in favor of

accurate anastomosis preference.1Using Intraluminal Coronary Shunts (ILS) in OPCAB allow easier, safer, more accurate anastomosis and better myocardial protection by maintaining distal coronary perfusion.2

Experimental and clinical studies have demonstrated that shunting can prevent acute left ventricular dysfunction during beating heart coronary revascularisation and is a useful tool in patients with left ventricular dysfunction or unstable angina as well as for teaching OPCAB to residents.3 There are data to suggest that the use of ILS is associated with mechanical endothelial denudation however endothelial injury and dysfunction is not unique to the use of ILS. Although, any contact with the endothelium damages it, this may occur with snaring, use of blower, application of bulldog clamps, coronary stents, angioplasty, however, there are no data available regarding the effect of ILS usage on graft patency.4The standard invasive procedure to evaluate graft patency is selective coronary angiography, the recent introduction of a new generation of multidetector computed tomography made possible the none invasive study of grafts with excellent results in terms of visualisation and resolution.5 Multisliced Computed Tomogaphy (CT) allows for isotopic imaging with high resolution and short acquisition time.6

MethodsThis retrospective study enrolled 60 patients with

multivessel coronary artery disease who were scheduled for elective off-pump coronary artery bypass graft surgery .

All patients had angiographic evidence of critical coronary artery disease (> 70% luminal diameter narrowing in a major arterial branch).

We excluded patients with recent (< 1 month) myocardial infarction ,Previous CABG (redo surgery) ,Emergency operation,Concomitant valve lesion that require surgical intervention. ,Diffusely diseased, calcified, and small coronary vessels (diameter < 1.5 mm).

All patients included in the study were subjected to : Full history taking with special interest to determine the risk factors for CAD as hypertension, diabetes mellitus, smoking, dyslipedemia and positive family history of ischemic heart disease ,General clinical examination. ,Local cardiac examination. ,Resting twelve-leads surface ECG to localize the region of myocardial ischemia or infarction. Echo-Doppler study ,Multi-slice CT angiography after one year of surgery ,Coronary angiography preoperatively and after one year of surgery.

Surgical procedures:The studied patients were operated by two surgeons

using the same Off-Pump technique and the patient selection for this technique was based only on surgeons preference.

All procedures were performed through a median sternotomy using a standard technique. Briefly, a single 0-silk suture was inserted into the posterior pericardium midway between the inferior vena cava and the left inferior pulmonary vein. A small gauze swab was then passed between the suture and the back of the heart to protect the coronary sinus. This retraction stitch enabled anterior displacement of the cardiac apex and better visualization of the target coronary arteries during the distal anastomoses. A stabilizer (Octopus III, Medtronic, Inc, Minneapolis, Minnesota) was used during the construction of the anastomoses. To further assist good exposure of the inferior and obtuse marginal surfaces of the heart, the patient was placed in a right decubitus Trendelenburg position. The sequence of grafting was always the LAD coronary artery first, followed by the posterior descending coronary artery, and the circumflex coronary artery anastomosis.

Following exposure and stabilization of the target vessel, preparations were made for the coronary arteriotomy.

Intraluminal shunt: The coronary was opened during transient (< 1

minute) occlusion of the coronary artery and a suitably sized intraluminal shunt inserted. Shunt size was estimated before opening the coronary by examination of the external appearance of the vessel, and shunts were available in sizes ranging from 1.5 to 3.5 mm . Shunts were inserted under direct vision, proximal end


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first. Coronary anastomoses were performed using 7-0 Prolene needle size 8 (Ethicon). Proximal anastomoses were performed end to side to the ascending aorta using 6-0 prolene needle 13 mm.

CT Data Acquisition and Post-processing:All CT examinations were performed with a

64-section CT scanner (Light Speed VCT 64 – Germany) . The scanning range covered the entire heart from the level of the tracheal bifurcation to the diaphragm. An 80-mL bolus of iodixanol (Visipaque 320, mg/mL; Amersham Health, Buckinghamshire, England) followed by 30 mL of saline solution was continuously injected into an antecubital vein through an 18–20-gauge catheter with an injection rate of 5 mL/sec. Contrast agent administration was controlled by means of bolus tracking.

Data were acquired in a craniocaudal direction with a detector collimation of 32 x 0.6 mm, a section collimation of 64 x 0.6 mm by means of a z-flying focal spot, a gantry rotation time of 370 msec, a pitch of 0.24, a tube voltage of 120 kV, and a tube current of 650–780 mAs. The electrocardiogram (ECG) was digitally recorded during data acquisition and was stored with the unprocessed CT data set..

CT was successfully performed in all patients without complications. The CT protocol was well tolerated by all patients, and all were able to hold their breath during data acquisition .

Invasive Coronary Angiography (ICA) image acquisition and interpretation:

Selective ICA was performed for the patients by standard transfemoral arterial catheterization. A minimum of 8 projections were obtained (minimum of 5 views for the left coronary artery system and minimum of 3 views for the right coronary artery system). Because of differences in cardiac position, angles of projection for ICA differed slightly among study subjects. All ICA images were interpreted by an independent ICA reader blinded to all patient characteristics . Any segment deemed visually to have > 50% stenosis was quantified.

Statistical analysis: The data of each patient was collected in a special file, then it was coded and fed to the computer on a statistical package SPSS version 9.05.

ResultsThis study is a retrospective clinical trial that was

conducted in order to find out the effect of intraluminal coronary shunt on graft patency in patients undergoing elective off-pump CABG.

Sixty patients were included in the study. Their age

ranged between 36 to 67 years with a mean of 54.1 ± 9.5 years. They were 56 males (93.3%) and 4 females (6.7%). Table (1) shows the general and clinical characteristics of all the studied patients.

Parameter Total number = 60 patientsAge (mean ± SD) (years) 54.1 ± 9.5Sex distribution:MalesFemales

56 (93.3%)4 (6.7%)

Heart rate (B/min) 68.9 ± 7.7 Systolic BP (mm Hg) 127.5 ± 8.6Diastolic BP (mm Hg) 83.4 ± 9.6Height (Cm) 172.5 ± 9.6Weight (Kg) 83.6 ± 9.2Risk factors for CAD:• Hypertension• Diabetes• Dyslipidemia• +ve family history• Obesity• Smoking

36 (60%)28 (46.7%)31 (51.7%)14 (23.3%)33 (55%)40 (66.7%)

ECG findings• Anteroseptal MI• Inferior MI• Unstable angina• LBBB• Normal

14 (23.3%)12 (20%)9 (15%)6 (10%)19(31.6%)

Table (1): General characteristics of all the studied patient

Fig. (1): Risk factors for CAD among all the studied patientsHTN=HypertensionDM=Diabetes mellitusDyslipid= DyslipidemiaFH=Family History


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The mean number of grafts was 1.96 ± 0.61 , 11 patients (18.3%) had 1 graft, 40 patients (66.7%) had 2 grafts and 9 patients (15%) had 3 grafts. The total number of grafts was 118 grafts, 60 grafts were LIMA (50.8%) and 58 grafts (49.2%) were SVG graft

The mean duration of operation was 215.8 ± 40.0 minutes, the mean amount of post operative bleeding was 635.9 ± 484.7 ml. The mean RBCs transfused was 0.9 ± 1.4 unit, all patients received 500 ml of colloid, the mean volume of crystalloids transfused was 1280 ± 460 ml. The mean postoperative intubation time was 7.8 ± 6.7 hours, the mean duration of ICU stay was 2.4 ± 1.5 days and the mean duration of hospital stay was 7.36 ± 1.1 day (Table 2) .

Mean Number of grafts 1.96 ± 0.61

Number of grafts n (%):• 1 graft • 2 grafts• 3 grafts

11 (18.3%)40 (66.7%)

9 (15%)Type of graft (N of grafts = 118) n (%):• LIMA• SVG

60 (50.8%)58 (49.2%)

Duration of operation (min) (mean ± SD) 215.8 ± 40.0

Postoperative bleeding (ml) (mean ± SD) 635.9 ± 484.7

Red blood cell units (mean ± SD) 0.9 ± 1.4

Colloid transfused (mean ± SD) 500 ml

Crystalloid transfused (mean ± SD) 1280 ± 460Postoperative mechanical ventillation (hours) (mean ± SD) 7.8 ± 6.7

Intensive Care Unit stay (days) (mean ± SD) 2.4 ± 3.1Mean duration of hospital stay (days (mean ± SD) 7.36 ± 1.1

Table (2): Operative and Perioperative Details

during the post-operative period until discharge from hospital 7 patients (11.7%) had infarction, 2 patients (3.3%) had wound infection, 1 patient (1.7%) had prolonged ventilation (> 24 hours), and 1 patient (1.7%) had per operative utilisation of intra-aortic balloon counter pulsation. The intra-aortic balloon was put at the time of induction of anaesthesia and pulled off 24 hours after the operation. This patient had critical 3 vessel disease ejection fraction (42%). He was discharged from

hospital 10 days after the operation. There was no CNS complications in this series. The overall complication rate was in 11 patients (18.3%). Atrial fibrillation occurred in 15 patients (25%) and it became permanent AF in 2 patients (3.3%), ventricular tachycardia occurred in 7 patients (11.7%), Heart Block in 1 patient (1.7%) which required temporary pacing and the patient regained his normal sinus node function after 3 days and frequent PVCs occurred in 33 patients (55%) and out of those 33 patients only 7 patients (11.7%) required amiodarone transfusion (Table 3) .

Post-operative complications n (%): Total N = 60 patients• Infarction• Wound infection• Prolonged ventilation > 24 hours• Intra-aortic balloon

7 (11.7%)2 (3.3%)1 (1.7%)1 (1.7%)

Overall complications 11 (18.3%)

Arrhythmia:• Atrial fibrillation• Ventricular tachycardia• Heart block• Frequent PVCs

15 (25%)7 (11.7%)1 (1.7%)33 (55%)

Table (3): Post-operative complications

By coronary angiography; 102/118 grafts (86.4%) were patent, 6 grafts (5.1%) had significant stenosis (> 50% stenosis) and 10 grafts (8.5%) were totally occluded. By CT angiography; 101 grafts (85.6%) were patent, 7 grafts (5.9%) had significant stenosis and 10 grafts (8.5%) were totally occluded. There was no significant difference between the results of coronary angiography and CT angiography (P > 0.05).

By coronary angiography LIMA grafts was patent in 56/60 grafts (93.3%), 1/60 (1.7%) LIMA grafts had significant stenosis and 3/60 grafts (5%) were totally occluded. By CT angiography; 55/60 grafts (91.7%) were patent, 2/60 grafts (3.3%) had significant stenosis and 3/60 grafts (5%) were totally occluded. There was no significant difference between the results of coronary angiography and CT angiography (P > 0.05).

By coronary angiography SVG grafts was patent in 46/58 grafts (79.3%), 5/58 (8.6%) SVG grafts had significant stenosis and 7/58 grafts (12.1%) were totally occluded. By CT angiography; 46/58 grafts (79.3%) were patent, 5/58 grafts (8.6%) had significant stenosis, and 7/58


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grafts (12.1%) were totally occluded. all stenotic areas were in the proximal and middle segment of the vein graf. There was no significant difference between the results of coronary angiography and CT angiography (P > 0.05).

Also these results regarding evaluation of LIMA grafts showed it has a a sensitivity, specificity, positive predictive value and negative value of 100%, 98%, 100% and 98% respectively.

In cases of SVG, the sensitivity, specificity, positive predictive value and negative value of 100%, 100%, 100% and 100% respectively.

The diagnostic accuracy of multi-slice coronary angiography was 100% in cases of totally occluded grafts and 98% in cases of significant graft stenosis (Table 4)

Discussion :Technical advances have made the performance of

multivessel off-pump coronary artery bypass feasible. Snaring and intraluminal shunts are the techniques used for vascular control. Snaring provides a bloodless surgical field, is usually well tolerated by the patient, and is supported by years of clinical experience. Intraluminal shunts aim to achieve hemostasis at the arteriotomy site and to allow antegrade flow to provide myocardial protection. There are unresolved issues regarding whether shunts have a clinical benefit, do provide adequate flow to provide myocardial protection, and whether they cause significant endothelial damage 7. Our results demonstrated the high accuracy of multi-slice CT angiography for diagnosis of graft patency after CABG and the accuracy was maximal with saphenous vein grafts because venous bypass grafts are typically larger in diameter than the native large epicardial coronary arteries (approximately 4–10mm versus 2–5mm), and they are less subjected to cardiac motion. Accordingly, even with older generation (“non-cardiac”) CT machines, investigators examined contrast enhancement along the course of the graft to establish bypass patency. Along with the technical developments, the accuracy reported with this approach increased. However, due to the inherent limitations of non-gated scanning with relatively long acquisition times, overall diagnostic accuracy regarding bypass graft patency remained at approximately 90%, with better results for (larger) vein grafts than for the arterial grafts. It was not possible to identify potential non-occlusive highgrade bypass body stenoses, the distal anastomosis of the grafts, or the native coronary arterial run-off 8. In terms of graft

Table (4): Results of coronary angiography in comparison to the results of CT angiography on patient based analysis

ParameterCoronary angio.N = 118 grafts

CT angio.N = 118 patients

P value

N. of diseased vessels:• Patent graft• Significant stenosis (> 50%). • Totally occluded

102 (86.4%)6 (5.1%)10 (8.5%)

101 (85.6%)7 (5.9%)10 (8.5%) > 0.05

LIMA Graft: n = 60 grafts n (%):• Patent graft• Significant stenosis (> 50%). • Totally occluded

56 (93.3%)1 (1.7%)3 (5%)

55 (91.7%)2 (3.3%)3 (5%)

> 0.05

Venous Graft: n = 58 Grafts• Patent graft• Significant stenosis (> 50%). • Totally occluded

46(79.3%)5 (8.6%)7 (12.1%)

46(79.3%)5 (8.6%)7 (12.1%)

> 0.05


Figure 2 (patent LIMA and Vein grafts)

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Figure 3(stenotic vein, occluded LIMA)



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patency, our results showed 93.3% and 79.3% of the IMA and SVG respectively were patent and this is very near to the results of the following trials:-1-Ki-Bong Kim et al 9, they looked at the graft patency in

90 patients by coronary angiography after one year and the results ere 97.8%(132/135) and 67.9% (106/156) for arterial and venous conduits respectively.

2- The randomized control trial by Widimsky et al.10 reported that arterial and venous graft patency after one year was 91% and 49% respectively after off-pump coronary artery bypass surgery.

3-Kwang Rree et al 11, studied the post operative 1-year results after off-pump coronary artery bypass surgery in 833 patients by coronary angiography and they found 95.1% and 78.8% patency in arterial and venous conduits respectively.

Conclusion: Using intra-luminal shunt during off-pump

coronary artery bypass surgery is safe; it provides a relatively bloodless field; the forward flow in the shunt helps to prevent ischemia, it facilitates the construction of the anastomosis by protecting the back wall of the artery; traction on the ILS exposes the edges of the arteriotomy and it facilitates training of surgeons to perform OPCABG technique safely.

There are data to suggest that the use of ILS is associated with mechanical endothelial injury however, this is not unique to the use of ILS. Although, any contact with the endothelium can cause damage, this may occur with snaring, use of blower, application of bulldog clamps, coronary stents, and angioplasty, however, there are no data available regarding the effect of ILS usage on graft patency.

Our results showed very much accepted graft patency after one year compared to the studies looked at the graft patency one year after OPCABG using different methods to achieve bloodless field during anastomosis like snaring and bulldog. Ultimately, we believe the knowledge of superficial endothelial injury should not prevail over the benefit of allowing antegrade flow in every patient undergoing OPCAB.

Multislice CT is a good modality in terms of follow up after coronary artery bypass surgery, it is non invasive , has a short examination time, needs no hospital admission and it has high sensitivity and specificity.

References1- Koutlas TC, Elbeery JR, William JM. Myocardial

revascularisationintheelderlyusingbeatingheartcoronaryarterybypasssurgery.AnnThoracSurg2000;69:1042-7.

2- Mark Yeatman, Massino Coputo, Pradeep Narayan, etal. Intracoronary shunts reduce transient intra-operativemyocardialdysfunctionduringoff-pumpcoronaryoperations.AnnThoracicSurg2002;73:1411-7.

3-RolandG.Demaria,OlivierMalo,MichelCarrier, et al.TheMonoshunt: a new intracoronary shunt design to avoiddistal endothelial dysfunction during off-pump coronaryarterybypass.InteractiveCardiovascularandThoracicSurg2005;2:281-6.

4- Sathiakar Paul Collson, Anil Agrawal, Naresh Trehan.Controversies in the use of intraluminal shunt during off-pump coronary artery bypass grafting surgery.Ann ThracSurg2006;82:1559-66.

5- DavideDi Lazzro, Temistocle Rangi, GinoDiManici, et al.Non invasive Midterm Follow–up of Radial Artery BypassGrafts with 16-Slice Computed Tomography. Ann ThoracSurg2006;82:44-50.

6- Marc Dewely, Alexander Lembcke, Christian Enzweiler, etal. Isotropic half-millimeter angiography of coronary arterybypass grafts with 16-slice computed tomography. AnnThoracSurg2004;77:800-4.

7- Sathiakar Paul Collison, Anil Agarwal, Naresh Trehan.ControversiesintheUseofIntraluminalShuntsDuringOff-PumpCoronaryArteryBypassGraftingSurgery.AnnThoracSurg2006;82:1559-1566

8-TelloR,HartnellGG,CostelloP,EckerCP.Coronaryarterybypass graft flow: qualitative evaluation with cine single-detectorrowCTandcomparisonwithfindingsatangiography.Radiology2002;224:913–918.

9-Ki-Bong Kim, MD, Cheong Lim, MD, Cheul ,et all. Off-pump coronary artery bypass may decrease thepatency of saphenous vein grafts . Ann Thorac Surg2001;72:S1033-S1037

10-Widimsky P, Straka Z, Stros P, et al. One-year coronarybypass graft patencya randomized comparison betweenoff-pumpandon-pumpsurgeryangiographic resultsof thePRAGUE-4trial.Circulation2004;110:3418-3423.

11-KwangReeCho,DongSeopJeong,Ki-BonKim.Influenceofveingraftuseonpostoperative1-yearresultsafteroff-pumpcoronary artery bypass surgery. Eur J Cardiothorac Surg2007;32:718-723.doi:10.1016/j.ejcts.2007.08.00



One year follow-up of omental flap for management Of deep sternal wound infection

Ahmed N. Khallaf MD,Ashraf A. Esmat MD,Tarek Eltawel MD

Addrees reprint request to :Dr. Ahmed N. Khallaf MD,Department of Cardiothoracic Surgery, Cairo University


Sternal osteomyelitis after median sternotomy for cardiac surgery is associated with considerable morbidity and mortality. The ideal reconstruction after sternal debridementis still debated. From 2006 to 2009, we treated 40 patients for sternal osteomyelitis after median sternotomy for cardiac surgery. Total or partial resection of the sternum and extensive debridement were performed in all cases. The defect was covered by omental transposition. There were 4 (10%) deaths mostly due to cardiac failure. Hospital stay ranged from 19 to 40 days. Transient paradoxical movement of the anterior chest wall disappeared within one month. No recurrence was observed during 12 months of follow-up. Radical debridement along with omental flap transposition provides definitive control of the infection in cases of failure of other semi-conservative or surgical interventions. Prognosis depends on the general condition of the patient

Since the introduction of sternotomy in 1957, sternal infection has been an infrequent but challenging problem with considerable mortality and morbidity. Reported mediastinal and sternal infection rates range from 0.4% to 5%.(1,2). The ideal reconstruction after sternal debridement is still debated. Different methods have been

proposed, such as debridement and open packing with continuous antibiotic irrigation, or sternectomy with omental or muscle transposition (pectoralis, latissimus, or rectus abdominis).(3,4)

Methods:From Jan 2006 to Jan 2009, 40 patients with deep sternal wound infection

following open heart surgery were treated using sternal debridement with interposition of the omentum at the department of cardiothoracic surgery Cairo University. The procedures done for these patients are shown in the following table:

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CABG on pumpCABG off pumpDouble valve replacementRedo mitral valve replacementRedo CABGAortic valve replacementAortic valve replacement+CABG

Patients30123121

The characteristics of these patients are shown in the next table:

VariableAge range (in years)Gender (m/f)DiabetesCOPDEmergency surgeryProlonged ventilation (>12 hours)Reopening for bleeding

Patients45-6526/14

30(75%)6(15%)4(10%)2(5%)

10(25%)

4 patients came back to our hospital 1 to 2 weeks after discharge showing the clinical picture of mediastinitis in the form of fever, sternal click, with or without fistulas discharging pus. The remaining 36 patients developed sternal wound infection during their hospital stay following the initial procedure. For all patients, full laboratory investigations were done, mostly showing leucocytosis. Computed chest tomography was done also revealing sternal dehiscence, and in some patients, left side pleural collection.

Technique:Our primary intention was always to reclose the

sternum (rewiring) as it is more physiologic. However, in all these patients this was not possible due to the poor condition of the sternum, regarding the presence of severe necrosis, fractures and osteoporosis (especially in females). So we should note that the decision of omental flap was made intraoperatively, after the debridement and assessment of the remaining tissues and the feasibility of rewiring.

The omentum was delivered through an incision in the diaphragm with or without an additional laparotomy

(to facilitate omental dissection), and brought to cover the heart based on the gastroepiploic artery. Loose fixing stitches were made to fix the pedicle to the suprasternal muscles as well as on both sides. Undermining the Pectoralis major muscle on both sides was done to facilitate closure in a tension free manner. 3 suction drains were left: One in the middle line, and bilateral drains under each Pectoralis muscle to prevent Seroma formation. These drains were removed after 4 to 5 days when the drainage was minimal. The wound was closed as one layer using interrupted mattress polypropylene # 1. The mean operative time was 1.2 hours. All the patients were discharged to the ICU for a mean of 4.2 days. They were kept on NPO for the first 24 hours to prevent postoperative paralytic ileus.

Picture (1): Omental flap in place

Picture (2): Wound closure

Antibiotics were given according to the culture and sensitivity from the infected tissues. The hospital stay ranged from 19 to 40 days. The pathogens were: Staph Epidermidis in 22 patients (55%), Staph Aureus in 12 patients (30%), Pseudomonas Aeruginosa in 6 patients

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(15%), Acetanobacter in 1 patient (2.5%) and MRSA in 1 patient (2.5%).

Results: There were 4 mortalities (10%) in the early

postoperative period (1st 30 days). 3 of them occurred due to heart failure and renal and neurological complications. Only one patient died due to the severity of infection which led to a septic shock.

2 patients (5%) had wound complications in the form skin sloughing and purulent discharge.

The 1st patient was a female and was treated conservatively by frequent dressings and antibiotics with complete healing within 2 weeks.

The 2nd patient was a male with uncontrolled Diabetes which developed a very tense swelling 1 week after the procedure; exploration was done and revealed a hematoma under the omentum which was evacuated and the omentum was reapplied. This patient needed hospitalization for one month following this event, with frequent dressings and antibiotics and was completely cured. For the remaining patients, follow up was done after 1, 6 and 12 months intervals with no recurrence of infection or need for reintrevention.

Discussion: Due to recent progress in cardiac surgery, an

increasing number of elderly and immunosuppressed patients with multiple risk factors are treated surgically. Therefore, despite hospital infection control and antibiotic treatment, the incidence of mediastinitis has remained constant over the years (5). In 1976, Lee and colleagues described sternal excision with wide debridement of bone cartilage and transposition of the well-vascularized omentum with primary closure (6). Banic and colleagues reported the use of latissimus dorsi as a free myocutaneous flap in cases of extensive sternectomy. Nowadays, the most commonly used muscle for sternal reconstruction is the Pectoralis major, followed by rectus abdominis and greater omentum flaps, or a combination of flaps (7,8).The omental flap easily fills the cavity after complete or partial sternal excision and obliterates the dead space. It contains large amounts of immunologically

active cells that seem to be responsible for its high anti-infective activity. Its extensive vascularization as

well as its neovascularization potential increases the blood supply, leading to a higher concentration of antibiotics at the infection site. By absorbing wound secretions, it eliminates substrates for bacterial growth. Harvesting is a rapid procedure, resulting in a short operation time, without the need for specialist knowledge, so it can be undertaken by every surgeon. Mobilizing and rotating the Pectoralis muscles centrally on the thoracoacromial vessels with direct skin closure and a myocutaneous latissimus dorsi flap are time-consuming operations that should be performed by a specialist thoracic or plastic surgeon (9). Some reports advocate laparoscopic harvesting of the omental flap rather than the traditional laparotomy(10).In our patients, the procedure was done mostly through the same incision by just delivering the omentum through a small incision in the diaphragm or by an additional small laparotomy to facilitate the omental dissection.

There are some disadvantages for the omental flap such as occurrence of ventral hernia which did not occur .No weakness, pain or restricted movement was observed due to the missing sternum at 12 months postoperatively. The analysis of risk factors did not reveal

any of statistical significance, but we have no doubt that there is a relationship between the prognosis and the patient’s general condition. It was concluded from this experience that although debridement, drainage, and primary closure can be effective in mild or early mediastinitis, in cases of failure of semi-conservative or surgical interventions or severe osteomyelitis after radical debridement, the application of omentum can be recommended as the definitive treatment.

REFERENCES:1. Shumacker HB Jr, Mandelbaum I. Continuous antibiotic

irrigation in the treatment of infection. Arch Surg 1963;86:384–7.

2. BanicA, Ris HB, Erni D, Striffeler H. Free latissimus dorsiflapforchestwallrepairaftercompleteresectionofinfectedsternum.AnnThoracSurg1995;60:1028–32.

3. Bryant LR, Spencer FC, Trinkle JK. Treatment of mediansternotomy infection by mediastinal irrigation with anantibioticsolution.AnnSurg1969;169:914–20.

4. Wettstein R, Erni D, Berdat P, Rothenfluh D, BanicA.Radical sternectomy and primary musculocutaneousflap reconstruction to control sternal osteitis. J ThoracCardiovascSurg2002;123:1185–90.

5. De Feo M, Renzulli A, Ismeno G, Gregorio R,Della CorteA, Utili R, et al. Variables predicting adverse outcome inpatients with deep sternal wound infection. Ann Thorac


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Surg2001;71:324–31.6.LeeABJr,SchimertG,ShaktinS,SeigelJH.Totalexcision

of the sternum and thoracic pedicle transposition of the greater omentum; useful strategies in managing severe mediastinal infection followingopenheartsurgery.Surgery1976;80:433–6.

7.SchroeyersP,WellensF,DegrieckI,DeGeestR,VanPraetF,Vermeulen Y, et al. Aggressive primary treatment forpoststernotomy acute mediastinitis: our experience withomentalandmuscleflaps.surgery.EurJCardiothoracSurg2001;20:743–6.

8. Francel TJ, Kouchoukos NT.A rational approach to wound

difficulties after sternotomy: reconstruction and long-termresults.AnnThoracSurg2001;72:1419–29.

9. Fuchs U, Zittermann A, Stuettgen B, Groening A, MinamiK,KoerferR.Clinicaloutcomeofpatientswithdeepsternalwound infection managed by vacuum-assisted closurecompared to conventional therapy with open packing: aretrospectiveanalysis.

AnnThoracSurg2005;79:526–31.10. Puma F, Fedeli C, Ottavi P, Porcaro G, Battista Fonsi

G,Pardini A, et al. Laparoscopic omental flap for thetreatment of major sternal wound infection after cardiacsurgery.JThoracCardiovascSurg2003;126:1998–2002.


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Plication of paralysed diaphragm after congenital cardiac surgeries

Mohamed Fouad Ismail, MD,A.B. Said Mahmoud MD


Dr. Mohamed Fouad Ismail

Division of cardiothoracic surgery,

cardiovascular department, King

Faisal Specialist Hospital and

Research center, Jeddah, KSA

E-mail: [email protected]

Codex : 04/139/1010

Background: Diaphragm plication has been used since 1954 for the treatment of hemidiaphragm paresis. It is now the standard treatment of diaphragm paresis (DP) for children aged less than 1 year. Methods: We performed a retrospective review for all patients who required diaphragm plication after congenital cardiac surgery from June 2002 to June 2009. Results: Sixteen patients (9 males and 7 females) with a median age of 2.75 months (range 15 days- 36 months). Modified Blalock-Taussig shunt (m BTS) was the most common procedure associated with DP (43.7%). Left sided DP need plication was reported in 11 patients (68.7%) and right sided was 5 patients (31.3%). All patients were successfully extubated and the median time of mechanical ventilation after plication was 4 days (range, 1–14 days).Conclusion: Diaphragmatic plication is an effective procedure in management of postoperative diaphragmatic paralysis. We recommended early intervention for plication once diagnosis was confirmed.

Te most common cause of unilateral DP in infants is injury of one of the phrenic nerves during operations for congenital heart disease. Most of injuries were temporary (84%) but initially associated with considerable morbidity. Before modern management, mortality after DP was 20-25%; the high rate was

due mainly to underlying cardiac conditions (1). Diaphragm plication (DP) has been used since 1954 for the treatment of hemidiaphragm paresis (2). It is now the standard treatment of diaphragm paresis for children aged less than 1 year (3). The exact incidence of diaphragmatic paralysis after cardiac surgery in the pediatric age group is unknown. The reported incidence varies from 0.3% in retrospective studies (4) up to 12.8 % in prospective studies (5). If the patient is ventilated, the diagnosis may be considered difficult to be confirmed in the intensive care unit (ICU) situation.

The aim of this retrospective study was conducted to review our experience with diaphragmatic plication.

Methods:We performed a retrospective review including all patients who underwent

diaphragm plication from January 2002 to January 2009. The diagnosis was suspected if the patient could not be weaned from mechanical ventilation, elevation of the diaphragm was noted on the postoperative chest X-ray or paradoxical movement of the epigastrium during spontaneous ventilation. Fluoroscopy and/or ultrasound studies were used to confirm the diagnosis in all cases. Hospital mortality was defined as mortality happened during one month of the procedure or during the same admission.

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Our technique for plication was performed in accordance with that described by Schwartz and Filler (6). All of our diaphragm plications were performed through a thoracotomy at the seventh or the eighth intercostal space. Multiple parallel rows of interrupted 2-0 pledgetted monofilament sutures placed in an anterior-to-posterior orientation. The plication sutures were taken primarily in the membranous area of the diaphragm with the intention of bringing the diaphragm down to a point that is 1 to 2 interspaces below its usual level.

Statistical analysis was performed with SPSS statistical program (SPSS 15 Inc., Chicago, IL, USA). The Shapiro-Wilk normality test was used to assess normal distribution. Continuous variables with normal distribution were reported as the mean ± the standard error. Continuous data without normal distribution were reported as the median with ranges. Categorical data were presented as number and/or frequency.

ResultsSixteen patients (9 males and 7 females) with a

median age of 2.75 months (range, 15 days- 36 months) had diaphragmatic plication after a congenital cardiac procedure from January 2002 to January 2009. The diagnoses and operations resulting in DP are listed in (Table 1). Ultrasound examination was used to diagnose DP in 14 patients (87%) and/or fluoroscopy in 12 patients (75%). Modified BTS was the most common procedure associated with DP (43.7%). Left sided DP needed plication was reported in 11 patients (68.7%) and right sided was 5 patients (31.3%). No cases with bilateral DP were reported. The median time between the primary surgery and diaphragm plication was 13 days (range 3–27 days). The median ventilation period before plication was 6 days (range 2- 55 days), 6 of these patients (37%) had failed extubation and re-intubated again. Nasal continuous positive airway pressure (CPAP) was applied for 5 of our patients (31%) after extubation and before plication. All patients were successfully extubated following plication and the median time of mechanical ventilation after plication was 4 days (range, 1–14 days); 12 patients (75%) were extubated within 4 days post plication. All our patients were discharged with a median hospital stay of 36 days (range, 11–80 days), and ICU stay of 31 days (range, 8– 65). Their was no mortality recorded in our study after plication.

Table 1. Patient diagnosis, surgical procedure and plication side

Diagnosis Age (months) Procedure Time to plication (days) Plication to extubation (days) Paralysis side 1 TA/PA 36 TCPC 20 4 Left 2 PA/VSD 25 Redo- mBTS 3 4 Left 3 PA/MA/ Cortri-atriatum 1.5 mBTS, resection of Cortri-atriatum 7 3 Right 4 DORV/AVSD 2.5 mBTS 55 3 Right 5 TA/PA 9 Redo- mBTS 27 8 Left 6 TOF/DCRV 14 Repair 18 4 Left 7 TOF 1.5 mBTS 5 1 Left 8 DORV 12 Rastelli 12 2 Right 9 AP WINDOW 1.7 Repair 21 5 Left 10 MS/CoA 3 Repair 13 3 Left 11 Right coronary artery to right atrium fistula 0.5 Repair 13 4 Left 12 d-TGA 1.5 ASO 18 7 Right 13 d-TGA/IAA 1 ASO, arch repair 9 1 Left 14 TOF/ absent PV 4 Repair 20 14 Left 15 VSD,/CoA 4 Repair 12 3 Right 16 DORV/MA/ IAA 1 PAB, Arch repair 14 4 Left

TA/PA, pulmonary atresia /tricuspid atresia; TCPC, total cavo-pulmonary connection; PA/VSD, pulmonary atresia/ventricular septal defect; mBTS, modified Blalock Tausig shunt; MA, mitral atresia; DORV/AVSD, double outlet right ventricle/atrioventricular canal defect; TOF/DCRV; tetralogy of Fallot/ double chamber right ventricle; AP window, aorto-pulmonary window; MS/CoA, Mitral stenosis/ coarctation of aorta; d-TGA, dextro-transposition of the great arteries ; ASO, arterial switch operation; IAA, interrupted aortic arch; CoA, coarctation of aorta; PV, pulmonary valve; PAB, pulmonary artery banding.

6 (range, 3-11) Mechanical Ventilation before plication (days) 6 (range, 2-55) Mechanical Ventilation after plication (days) 4 (range, 1-14) ICU stay (days) 31 (range, 8-65) Hospital stay (days) 36 (range, 11-80)

DiscussionIn this study, we reported 16 patients who had

DP after repair of congenital heart disease. This DP population represented 0.7% of all pediatric patients (n= 2345) operated during the period of the study. Reports of the prevalence of DP after cardiac operations in children vary from 0.3 % (4) to 12.8% (5). This prevalence of DP, in our study, might be under estimated due to the retrospective nature of our study. The higher prevalence noted in prospective versus retrospective studies have many explanations, including increased surveillance in prospective studies to detect asymptomatic cases by routinely performing percutaneous phrenic nerve stimulation to confirm the diagnosis of abnormal phrenic


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nerve latency (7). Many children with abnormal phrenic nerve latency do not have clinical symptoms, which are often the criteria prompting investigation and detection in retrospective series and some prospective series (8). In our series, the median age of our patients 2.75 months (range, 15 days- 36 months) with only 2 patients (12.5%) were more than 2 years. Our results were similar to that reported by van Onna and colleagues (14) median 66 days (range 1 day–17 years). Tonz and colleagues (13) studied the clinical outcomes of 25 patients with DP after pediatric cardiac surgery, noting that no patient older than 2 years required plication whereas 7 of 9 patients aged less than 1 year required a procedure, while Baker and colleagues (4) in their study had a median age of 6.81 months (range 0.27–63 months).

According to Chan and colleagues (9) DP is frequently under diagnosed. If the child is asymptomatic the diagnosis may be missed, while if the child is ventilated the diagnosis may not be considered, or is difficult to confirm in the ICU setting.

Phrenic nerve injury is less well tolerated in infants and small children than in older children.(4, 6, 10-12) Several factors contribute to make younger children more vulnerable to respiratory complication including 1) underdeveloped intercostal musculature, 2) greater chest wall compliance, 3) horizontal rib cage orientation because of increased supine positioning, and 4) mediastinal hypermobility (3). Infants prefer or are placed in a recumbent position, and this reduces the vital capacity and, due to the small caliber of the infant bronchial tree, facilitates retention of secretions and bronchial obstructive debris. The marked cranial displacement of the flaccid diaphragm in the supine position and a mediastinal shift to the nonaffected side result in a significant reduction of the functional residual capacity of the affected and normal lung. This results in alveolar collapse and formation of atelectasis, which not only compromise arterial oxygen saturation but increase pulmonary vascular resistance (13).

Several cardiac procedures have been reported to be associated with increased risk of DP. In our study, the surgical procedure that was most often associated with an increased risk of DP was m BTS (43.7%). Similar observation was reported by others (5, 8, 10-13, 15). De Leeuw and colleagues (8) showed that the highest prevalence of phrenic injury occurred during operations for systemic venous to pulmonary artery connection, pulmonary arterioplasty, and m BTS. Similarly, Joho-

Arreola and colleagues (15) reported that the most common operations resulting in phrenic nerve injury were m BTS, and arterial switch procedures.

The cause of DP in our study is unclear. However, several factors have been proposed. The use of cold solutions within the pericardium has been associated with DP (16). Ice slush seems to be a greater risk factor than other cold solutions. Internal jugular vein cannulation is also identified as a possible causative factor (14). Eagerness to obtain a large patch of pericardium especially in arterial switch and Atrio-ventricular canal defect for subsequent intraoperative patching may also result in injury (11). Previous cardiothoracic operations have been reported to increase the risk (4, 10). The higher risk related to repeat operations is most likely related to technical difficulties in dissection caused by fibrous adhesions surrounding the phrenic nerve. The use of electrocautery in the direct vicinity of the phrenic nerve has also been reported as a risk factor (11, 13).

In our study most of our patients either had ultrasound examination (87%, n= 14) and/or fluoroscopy (75%, n= 12). Some authors described the use of direct percutaneous stimulation of the phrenic nerve and it may be considered as the most accurate diagnosis, and can be applied to patients on full ventilation (7, 17). This technique was not used in our study and we agree with other authors (5) that this technique may be painful, especially in infants, and the presence of jugular venous cannulae may make direct stimulation technically difficult. Kunovsky et al (5) found that this approach offers little practical advantage over prompt ultrasound detection in the presence of any difficulty in withdrawing ventilatory support. Ultrasound approach is technically straightforward, involves no patient discomfort or inconvenience and is readily repeatable. In addition, ultrasound examination allows patients with DP to be subdivided into those with absent diaphragmatic movement and those with paradoxical movement.

Optimal management of DP in children who have undergone cardiac surgery remains controversial and consists of prolonged ventilation with training or diaphragmatic plication. Some authors (5, 10, 18) report that optimal management involves an anticipatory approach with long-term ventilatory support. It worth while to mention that in our study 12 patients (75%) were extubated within 4 days post plication. The patient who had prolonged ventilation (55 days) was easily extubated after 3 days. It seemed to be that diaphragmatic plication


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was an effective technique that led to extubation after failure of conservative management.

Tonz et al (13), advocate plication of the diaphragm for the following reasons: First, plication allows earlier extubation and reduces the hazards of prolonged mechanical ventilation that associate with substantial morbidity and extended hospital stay with extremely costly intensive care. Further delay implies multiple and unsuccessful attempts at weaning from the ventilator allowing a potential for increase in pulmonary infection rate and with a substantial mortality (14). Second, plication of the diaphragm does not interfere with return of normal function. Stone et al (4) demonstrated return of normal diaphragmatic function in all their patients (examined 1 to 7 years after plication). Third, plication is a safe procedure, with a low morbidity rate. The pronounced negative psychological effects of this period on both parents and other family members should not be underestimated (14).

Although most authors (4-6, 11-13) agree on the role of diaphragmatic plication, there is controversy regarding the optimal timing of the plication, however most of them argue that it would be best to withhold diaphragmatic plication for 2 to 3 weeks in anticipation of potential spontaneous recovery of phrenic nerve function.

In 1978, Schwartz and Filler (6) described their surgical technique of plication and published results on 6 infants. Five of the infants were eventually capable of maintaining adequate ventilation without support. Shoemaker and colleagues, 1981 (1) subsequently published results of 7 patients undergoing diaphragm plication after operations for congenital heart disease. Watanabe and colleagues, 1987 (10) published a retrospective study in 1987 showing that phrenic nerve injury was diagnosed in 125 children (1.6%) undergoing pediatric cardiac surgery. Only 12 of the 125 patients from their series underwent diaphragm plication with no mortality.

Awareness of the detailed anatomical course of the phrenic nerve and the differences between right and left side is essential for the cardiac surgeon (14). The anatomical course of the phrenic nerve in the mediastinum is of paramount importance. On the right, the phrenic nerve lies on the lateral aspect of the superior vena cava superiorly, crosses just anterior to the right pulmonary artery (in proximity to the right lobe of thymus) and

pulmonary veins and then is intimately related to the pericardium until it reaches the diaphragm. On the left, it is closely related to the internal mammary branch of the left subclavian artery and then passes over the surface of the left lobe of thymus before crossing the left pulmonary artery towards the pericardium and the apex of the left ventricle (11).

Anatomically, it has been expected the right phrenic nerve to be more vulnerable and this has been suggested by other authors (12). In our study, the majority of phrenic nerve injuries requiring diaphragm plication occurred on the left side with a ratio near 2 to 1 in favor of a left side. Hamilton and colleuges (5) had almost the same results. This high incidence of left-sided injuries may be related to extensive thymic resections in primary cases or the mobilization required for arch reconstructions. On the other hand, left side injury may be related to the combined mechanical compressive effects of the heart and the diaphragm.

In our study median interval from the primary operation to plication is 13 days (range 3-27 days), which is similar to that reported van Onna and colleuges (14) who had a median interval of 14 days (range, 2-44 days). De Leeuw et al (8) had a median interval of 21 days (range 6 days–11.2 months) while Baker et al (3), had a median interval of 10 days (range 1-84 days).

We could extubate our patients with a median interval of 4 days after plication (range 1-14), which almost equal to that of van Onna et al (14), who had median interval of 4 (range 1-60 days). Serraf and colleuges (19) had a mean interval of 3.3 ± 2.5 days while Baker et al, had a median interval of 2 days (range 0-21 days).

Study limitationsThe limitations of our study include the fact that we

only reviewed patients with DP who required plication. Therefore, we do not have data on the true incidence of DP given that some patients did well without intervention.

Conclusion:Diaphragmatic plication is an effective procedure

in management of postoperative diaphragmatic paralysis. Patients could be extubated earlier which may decrease ICU and hospital stay. We recommended early intervention for plication once diagnosis was confirmed. Randomized clinical trials are needed to determine the role and optimal timing of diaphragmatic plication.


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References1- Shoemaker R, Palmer G, Brown JW, King H: Aggressive

treatmentofacquiredphrenicnerveparalysisininfantsandsmallchildren.AnnThoracSurg.1981;32:251-259.

2- Large SR, Heywood LJ, Flower CD, Cory-Pearce R,Wallwork J,EnglishTAH: Incidenceandetiology of raisedhemidiaphragm after cardiopulmonary bypass. Thorax.1985;40:444-447.

3-BakerCJ,BoulomV,ReemtsenBL,RollinsRC,VaughnA.,Starnes and Wells WJ: Quantitative return of diaphragmfunction over time Hemidiaphragm. J Thorac CardiovascSurg.2008;135:56-61.

4-StoneKS,BrownJW,CanalDF,andKingH:Long-termfateofthediaphragmsurgicallyplicatedduringinfancyandearlychildhood.AnnThoracSurg.1987;44:62-65.

5-KunovskyP,GibsonA,PollockJCS,StejskalL,HoustonA,JamiesonMPG:Managementofpostoperativeparalysisofdiaphragm in infants and children. Eur J Cardiothorac Surge. 1993;7:342–346.

6- Schwartz MZ, and Filler RM: Plication of the diaphragmfor symptomatic phrenic nerve paralysis. J Pediatr Surg.1978;13:259-63.

7-RossRussellRI,HelpsBA,Dicks-MireauxCN,andHelmsPJ:EarlyassessmentofdiaphragmaticdysfunctioninchildrenintheITU:chestradiologyandphrenicnervestimulation.EurRespJ.1993;6:1336–1339.

8- De Leeuw M, Williams JM, Freedom RM, Williams WG,Shemie SD, and McCrindle BW: Impact of diaphragmaticparalysisaftercardiothoracicsurgeryinchildren.JThoracCardiovascSurg.1999;118:510-517.

9-ChanCK,LokeJ,VirgultoJA,MohseninV,FerrrantiR,andLammertse T: Bilateral diaphragmatic paralysis; clinicalspectrum, prognosis, and diagnostic approach.Arch PhysMedRehabil.1988;69:976–979.

10-WatanabeT,TruslerGA,WilliamsWG,EdmondsJF,Coles

JG,andHosokawaY:Phrenicnerveparalysisafterpediatriccardiacsurgery.JCardiovascSurg1987;94:383–388.

11-HamiltonJRL,TocewiczK,ElliotMJ,deLevalM,andStarkJ:Paralyseddiaphragmaftercardiacsurgeryinchildren:valueofplication.EurJCardiothoracSurg.1990;4:487-491.

12-MickellJJ,OhKS,SieversRD,GalvisAG,FrickerFJ,andMathewsRA:Clinicalimplicationofpost-operativeunilateralphrenic nerve paralysis. J ThoracCardiovasc Surg. 1978;76:297-304.

13-TonzM,vonSegesserLK,MihaljevicT,ArbenzU,StaufferUG, and Turina MI: Clinical implications of phrenic nerveinjuryafterpediatric

surgery.JPediatrSurg.1996;31:1265-1267.14-vanOnnaIEW,MetzR,JekelL,WoolleySR,andvandeWal

HJCM:Post cardiac surgery phrenic nervepalsy: valueofplicationandpotentialforrecovery.EurJCardiothoracSurg.1998;14:179-184.

15-Joho-ArreolaAL,BauersfeldU,StaufferUG,BaenzigerO,and Bernet V: Incidence and treatment of diaphragmaticparalysisaftercardiacsurgeryinchildren.EurJCardiothoracSurg.2005;27:53-57.

16- Marco JD, Hahn JW, and Barner HB: Topical cardiachypothermiaandphrenicnerveinjury.AnThoracSurg.1977;23:235–237.

17-MokQ,Ross-Russell R,MulveyD, and Shinebourne EA:Phrenic nerve injury in infants and children undergoingcardiacsurgery.BrHeartJ.1991;65:287-292.

18- Raine J, Samuals MP, Mok Q, Shinebourne EA, andSouthhallDP:Negativeextrathoracicpressureventilationforphrenicnervepalsyafterpaediatriccardiacsurgery.BrHeartJ.1992;67:308-311.

19- Serraf A, Planche C, Lacour Cayet F, Bruniaux J, NottinR,andBinetJP:Postcardiacsurgeryphrenicnervepalsypediatric patients.Eur JCardiothoracSurg.1990;4:421–424.


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Chylothorax after surgery for congenital heart disease in children: a retrospective observational study

Alaa Basiouni S MDSameh Ibrahim MD

Addrees reprint request to :Dr. Alaa Basiouni Said Mahmoud.King Faisal Specialist Hospital and Research Center.Cardiothoracic surgery dept. MBC J 16P.O.Box 40047Jeddah 21499 Saudi [email protected] Codex : 05/127/1010

Background: Chylothorax in children after pediatric cardiac surgery heart is a clinical challenge. This study reviews our experience in the management of chylothorax following surgical repair of congenital heart disease in children.Methods: A retrospective analysis of 40 patients with a median age of 10 months (range, 1-120 months) who developed chylothorax after congenital heart surgery (July 2007 through January 2010). Data were collected regarding demographics, surgical procedures, characteristics of chylous drainage and its management. The responses of patients to different lines of treatment were recorded.Results: There was no hospital death. All patients were treated by Fat-free diet or medium chain triglyceride (MCT)-enriched diet mainly Monogen. Steroids were used adjunctively in seven patients (17.5%). Somatostatin analogous (octreotide) was used adjunctively in five patients (12.5%), and in two patients (5%) steroids and octreotide were used adjunctively. The median duration of chest tube drainage was 9.5 days (range, 4-34 days). The median amount of chest tube drainage /kg/day was 17mL (range, 6.6 to 70 mL). All patients responded to medical treatment except one case required further thoracic duct ligation. The use of octreotide and steroids therapy significantly reduced the amount of chest tube drainage. None developed major side effects from steroids or octreotide. At median follow up of 7 months (range, 1-24 months) after hospital discharge, no recurrence of chylothorax was observed.Conclusions: Conservative therapy of chylothorax after surgical repair of congenital heart disease remains the standard approach. Steroids and or octreotide can be used with an acceptable success with no recurrence or mortality.

Chylothorax can occur after any surgery performed in the vicinity of the thoracic duct including surgical repair of congenital heart disease. The incidence of chylothorax following cardiothoracic surgery has increased from 0.6–1.5% up to 6.6% over the past 20 years (1-9). This increase almost certainly reflects

the increased complexity of cardiac surgery with a higher incidence of chylothorax observed following the Fontan procedure, bidirectional Glenn shunt and tetralogy of Fallot repair (5,7). The consequences of a persistent chylous leak may be serious, including nutritional depletion with lipid and protein loss, compromise of immune system from the loss of immune proteins and lymphocytes, electrolyte and weight loss (1-5). Chylothorax also may lead to increased hospital stay and mortality. Diagnosis of chylothorax relies on the presence of chylomicrons, triglyceride level above 1.1 mmol/L, and an absolute white blood cell counts above 1,000 cells/mm3, with a lymphocyte fraction above 80% in the pleural fluid(6,7,10). One of the challenges of managing this complication, especially in neonates and small infants, is to maintain fluid,

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electrolyte, and nutritional homeostasis while trying to eliminate the lymphatic leak using therapies that are often lengthy. Nutritional support and strategies to limit the volume and duration of chylous loss provide the key to limit complications of chylothorax. A somatostatin analog (octreotide) and steroids have been used in addition to nutritional modifications with acceptable successes rate (11-16).

The aim of this study was to review our experience and current approach in the management of chylothorax in children following surgical repair of congenital heart surgery. It also aimed at evaluation of the effects of fat-free diet, steroids and octreotide in its treatment.

Methods:This is a retrospective analysis of all pediatric

patients who developed chylothorax after surgical repair of congenital heart disease (July 2007 through January 2010) in our hospital. The demographic, operative, intensive care unit, dieticians’ records, and ward data were collected. Serial data from the hospital stay were recorded including dietary intake, laboratory investigations, medications and chest tube drainage. Interval between surgery and chylothorax diagnosis were recorded. Diagnostic criteria for chylothorax were applied as reported in the literature (6, 7, 10). Namely, triglyceride level above 1.1mmol/L and an absolute white blood cell counts above 1,000 cells/mm3, with a lymphocyte fraction above 80%.

Patients were divided into 4 groups according to the line of treatment. Group (1); was treated by only dietary modification using fat-free diet and or monogen(Scientific hospital supplies, Liverpool, England); group (2); was treated with dietary modification and octreotide, group (3); treated was with dietary modification and steroids, and group (4); was treated with dietary modification and both steroids and octreotide.

Chest tube drainage was determined from the daily charts. The duration and the amount of drainage/kg/day were calculated for every patient. For the purpose of the study, the duration of chylothorax was considered from the date of surgery until chest tube removal regardless when the chemical diagnosis of pleural fluid was obtained.

Resolution of chylothorax was defined as chest tube drainage of less than 5 mL/kg/day

Hospital death was defined as death occurring from the intraoperative period up to 30 days after surgery. Outpatients’ charts were accessed to determine patient status with regard to recurrent effusions. Recurrences were defined as re-accumulation of chylothorax after initial chylothorax resolution and hospital discharge.

Statistical analysis :Statistical analysis was performed with SPSS

statistical program (SPSS 15 Inc., Chicago, Illinois). Data were presented as mean or median with ranges or percentages as appropriate. Differences in categorical variables were analyzed by means of the χ2 analysis, and differences in continuous variables were analyzed by Student t tests. The Fisher exact test was also used where appropriate. Differences were considered to be statistically significant when p value was less than 0.05.

Results:Patients Demographics

Patients’ characteristics and procedures are listed in Table1. During the period of the study, 40 patients were identified to have postoperative chylothorax from a total of 755 congenital heart surgeries, giving an incidence of 5.2%. There were 21 females and 19 males. The median age at repair was 10 months (range, 1-120 months) and the median weight was 6 kg (range 2.9-37.5 kg). Thirteen patients (32.5%) had single-ventricle morphology and redo surgeries were done in 11 (27.5%) patients (10 single ventricle and one biventricular repair). Surgical procedures preceding the occurrence of chylothorax included tetralogy of Fallot repair in 8 patients (20%), complete atrioventricular canal repair in 8 patients (20%), Extra cardiac Fontan procedure in 5 (12.5%) Bidirectional Glenn shunt in 5 (12.5%), arterial switch repair in 3 (7.5%), total anomalies pulmonary venous drainage in two (5%), Blalock-Taussig shunt in 3, ventricular septal defect in 3 (7.5%), ventricular septal defect status post pulmonary artery banding in one (2.5%), and Rastelli operation in 2 (5%).

Operative data:Surgical approach was by median sternotomy in all

cases. Our hospital preference is to remove the thymus gland for exposure in all patients. Both pleurae were opened routinely and drained at the end of the operation. The chest was usually drained through one or two Silastic Blake drain (Ethicon, Inc) with a single pleur-evac system. The median cardiopulmonary bypass time was 105 minutes (range, 50-261 minutes) and the median aortic cross clamp time was 82 minutes (range, 30-163 minute).


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Variable n=40Median age at repair (months) Male/femaleMedian weight at repair (kg)Cardiac anatomy (No. %)Single ventricle anatomyBiventricular anatomyRedo surgeriesOperation (No. %)Complete atrioventricular canal repair Tetrology of Fallot repair Fontan Bidirectional Glenn Blalock-Taussig shunt Ventricular septal defect repairVentricular septal defect, S/P pulmonary artery bandingTotal anomalies pulmonary venous connection repair Arterial switch repair Rastelli operation

10 months (range, 1-120)19/216 kg (range, 2.9-37.5)

13 (32.5%)27 (67.5%)11 (27.5%)

8 (20%)8 (20%)5 (12.5%)5 (12.5%)3 (7.5%)3 (7.5%)1 (2.5%)

2 (5%)3 (7.5%)

2 (5%)

Table 1. Patients’ characteristics and procedures

Diagnosis of chylothorax:The diagnosis of chylothorax was suspected when

persistent chest tube drainage occurred or the drainage from the chest tube became cloudy in orally fed patients regardless of the volume. Diagnosis was confirmed based on biochemical and microscopic analyses of the pleural fluid for each patient. Diagnosis of chylothorax was confirmed from laboratory testing of the fluid collected in the chest tube. All patients had at least one of the 4 previuosly mentioned parameters used for its diagnosis. The median triglyceride content in the pleural fluid was 1.4 mmol/L (range, 0.3-10.3 mmol/L). Six patients (15 %) had triglyceride level less than 1.1 mmol/L. thirty-two patients (80%) had white blood cell counts above 1000 cells/mm3with a percentage of lymphocytes above 80 % in 27 of them.

Management of chylothorax after diagnosis:During the period of this study, there was

no standardized protocol for the management of

postoperative chylothorax. All patients were treated initially with dietary modification beginning with fat-free or Monogen with subsequent nothing by mouth and total parenteral nutrition. In addition to fat-free diet, diuresis and after load reduction by Angiotensin converting enzyme (ACE) inhibitors were maximized to lower ventricular end-diastolic pressure. Supplement of concentrated albumin, electrolytes were also added as required. If chest tube drainage continued for more than 7-10 days octreotide or steroids were induced. There was no fixed protocol for the use of octreotide and steroids. Dosing and duration of these drugs were based on the surgeon preference. Twenty-six patients (65%) were treated only with fat-free and or Monogen diet (group 1), octreotide was used adjunctively in 5 (12.5%) patients (group 2), steroids were used adjunctively in 7 (17.5%) patients (group 3), and in two patients (5%) both octreotide and steroids were used adjunctively (group 4).

Chylothorax fluid characteristics for the whole series (Table 2)

There was no hospital mortality. For the whole group, median time to diagnosis of chylothorax was 3 days (range, 1-7 days) after surgery, the median amount of chest tube drainage/kg/day was 17 mL (range, 6.6-70 mL), and the median duration of chest tube drainage was 9.5 days ( range 4-34 days).

Outcomes of chylothorax Management in the 4 groups (table3)

All patients except one (2.5%) responded to conservative therapy with resolution of chylothorax. This patient was a 2 year old boy with double outlet right ventricle with hypoplastic right ventricle who had a redo sternotomy and bidirectional Glenn shunt status post Blalock-Taussig shunt. Postoperatively, his mean chest tube drainage was 17ml/kg/day. Monogen was started for 10 days, followed by steroids for 5 days. However, the chest tube drainage did not improve. It was planned to keep him nothing by mouth and to start total parenteral nutrition. After two days the plan was changed because of the non compliance of the mother who kept on giving the patient milk formula. At the end, right thoracotomy and supra-diaphragmatic ligation of the thoracic duct on the 23rd day postoperatively was performed. The chest tube was removed on the 6th day post duct ligation.

Twenty six patients (65%) responded to lone fat-free diet and or Monogen. The median chest tube drainage was 16.6 ml/kg/day in group 1, 11.5 in group 2 and 10.9


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Variable

Median Time to diagnose chylothorax (days)Median Triglyceride level (mmol/L) Triglyceride more than 1.1 mmol/LWhite blood cells count above 1000 cells/mm3 (n=40) Lymphocytes above 80% (n=32)Median amount of chest tube drainage/ kg/day (mL)Median duration of chest tube drainage (days)Median ICU stay for the whole series (days)Median hospital stay for the whole series (days)Lines of treatment of chylothorax (No. %)Group 1 (Dietary modification) Group 2 (Dietary modification + steroids)Group 3 (Dietary modification + octreotide) Group 4 (Dietary modification + steroids+octreotide)

3 (range, 1-7)1.4 (range, 3-10.3)34 (85%)32 (80%)27 (84%)17 (range, 6.6-70)9.5 (range, 4-34)4 ( range, 2-47)15 (range, 8-60)

26 (65%)7 (17.5%)5 (12.55%)2 (5%)

Table 2. Characteristics of Chylothorax and chest tube drainage and hospital stay.Dietary modification= fat-free and or Monogen

LoneFat-Free

n=26

Fat-Free +Octreotide

n=5

Fat-Free + Steroids

n=7

Fat-Free+Steroids+Octreotide

n=2

Time to diagnose chylothorax (days) 3 6 5 5

Mean Chest tube drainage/kg (ml)/day in the 1st week

22.2 19.5 21 23.7

Mean Chest tube drainage/kg (ml)/day after 1st week

14.6 18.5 17.9 16.2

Mean duration of chest tube drainage (days) after the start of each treatment

18 14.5 13 15.5

ICU Stay 8.9 4.7 7 5

Hospital stay 21.3 27 30 25

Failure 0 0 1 0

Recurrence 0 0 0 0

Table 3. Results of the 4 groups.


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in group 3 and 16.2 in the group 4. The median duration of chest tube drainage was 18, 14.5, 13 and 15.5 days in the 4 groups respectively. The hospital stay was significantly longer in the groups 2, 3 and 4 (21, 27 and 30 days than in group 1(21.3 days) with p values of 0.04, 0.02 and 0.04 respectively

It was noted that the use of octreotide and steroids had a positive impact on reducing the amount of chest tube drainage/day (Figures 1 and 2). In the octreotide group, the mean indexed daily drainage was decreased from 18.6 to 10.1 ml/kg/day with p value of 0.03. Similarly the use of steroids decreased the mean indexed daily drainage from 16.2 to 10.1 ml/kg/day with p value of 0.02.

Figure (1): Octreotide use on day 18 postoperatively, patient’s weight 24 kg

Figure (2): Steroids use on day 15 postoperatively patient’s weight 37.5 kg.

Chest tube managementOur hospital preference has been to place chest

tube to suction during the medical management phase. Suction was turned off for 24 hours before chest tube removal. Chest X-ray was done in all patients before removal of chest tube to exclude residual collection in the pleural cavity.

Follow-upFollow-up was available for all cases except 2

patients who were living outside the country. In all patients, Parents were instructed to stay on the MCT-enriched diet for 4-6 weeks. At the time of follow up, most of the patients were switched to a normal diet appropriate for their age. There was no reaccumulation of chylous effusion (by Chest X-ray) in any patient during a median follow up of 7 months (range, 1-24 months).

Discussion: Incidence and etiology of chylothorax

Chylothorax after pediatric cardiac surgery is not uncommon with a reported incidence of 0.6% to 6.6% and can cause significant morbidity and mortality (1-9).

We are reporting here 40 cases out 755 cases of pediatric cardiac surgeries in our tertiary centre with an incidence of 5.2%. The chylothorax incidence rate of 5.2% for a 30 months period in our study is higher than in previous older studies reporting incidence less than 2 % (1-4). This change likely reflects differences in the characteristics of patients, types of surgical procedures and time frame of these studies.

Chylothorax after surgery for congenital heart disease may be attributed to disruption of accessory small lymphatic channels, direct thoracic duct injury, and elevated pressure in the upper body systemic veins exceeding that in the thoracic duct (16). In our study, all patients had undergone sternotomy, and surgical manipulation was remote from the course of the thoracic duct. The high incidence of chylothorax in our study is not clear but may be due to our practice of removal of the thymus gland for better exposure which might lead to chyle leaking from its remnant. Injury to small lymphatic vessels around the ascending aorta, superior vena cava, or the pulmonary artery trunk and its branches, can occur leading to lymph leakage. Another explanation may be due to the common variation in the lymphatic pathways may render them vulnerable to injury during extensive dissection especially in redo surgery, 11 patients (27.5%) in our study. The high central systemic venous pressure can result in obstruction to the flow of lymph into the venous system, leading to dilatation and possibly rupture of small thoracic duct branches with subsequent lymphatic leak into the pleural cavity(2).

In particular, the Fontan, bidirectional Glenn shunt and right ventricular dysfunction after repair of tetralogy of Fallot are associated with a high risk of developing high


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central venous pressure. In our study, these operations were performed in 45 % of our patients.

Diagnosis of chylothoraxDiagnostic criteria for pediatric chylothorax

have been defined by many authors (6,7,10, 17, 18). Our practice is to send for chyle study if the nature of fluid is suspicious (large amount, milky). We used the criteria of triglyceride concentration above 1.1 mmol/L, total white blood cell counts above 1,000 cells/mm3, with a percentage of lymphocytes above 80% (6,7,10). Cholesterol level is not applicable in neonates and infants as dietary fat used in their formula consists mainly of triglycerides and almost no cholesterol, and the presence of cholesterol in the effusion is not expected (10). In our study, 85% of the patient samples had triglyceride levels more than 1.1 mmol/L. Poor enteral nutrition at the time of sending samples may explain the low triglyceride level in the rest of the patients.

Management of chylothoraxTreatment of chylothorax has historically proceeded

in a stepwise fashion once adequate drainage has been established (7). The primary aim is to drain the pleural effusion and stop or decrease the thoracic lymph flow to allow the thoracic duct branches to heal. The first line conservative therapy is based on decreasing lymph flow by nutritional modification in the form of fat-free (19) or low-fat, preferably MCT-enriched diets as Monogen (6). If chyle production does not decrease with dietary restriction, a period of gut rest and total parenteral nutrition is imposed. Pharmacologic therapy may most commonly octreotide (11-15) or steroids (20-21) may provide a medical option with a high success rate reported in several studies. If this conservative treatment fails, the next step will be surgical intervention in the form of pleurodesis (22), ligation of the thoracic duct (23) or pleuroperitoneal shunt (24).

In our study the first step of management was keeping chest tube on suction. Continuous suction drainage helps to relieve the pressure of chyle on the lungs, re-expands the partially collapsed lungs, obliterates the pleural space, and permits an accurate measurement of chyle production.

Our approach was to start with Monogen for young babies and fat-free diets for older infants and children. In a week to 10 days, if the chest tube drainage trend is still high, going up or not decreasing to about 5 ml/kg/day,

we start another line of management, either steroids 1-2 mg/kg/day on 2 divided doses or octreotide (5-10 mcg/kg/h) intravenously for 5-10 days with gut protection for steroids with proton pump inhibitor and blood pressure monitoring for octreotide.

The role of MCT-enriched diet in chylothoraxIn our study, most patients (26 of 40, 65%)

had successful resolution of their drainage with only using fat-free diet and Monogen. MCT-enriched diet constitutes little to chylomicrons formation and so should minimize the volume of lymph flow along the thoracic duct allowing time for healing of the thoracic duct branches. The MCT diets have met with variable success in the treatment of chylothorax. This is may be because any oral enteral feeding increases lymph flow (25), and intestinal triglycerides are derived from both endogenous and exogenous sources (26). Our practice is to avoid total parenteral nutrition and long term central lines, as much as possible, for 4 reasons. The first reason is there is always a concern about thrombus formation especially after bidirectional Glenn and Fontan procedures. The second reason is that chylothorax is an annoying problem for patients and parents. It is difficult for the patient and the parents to keep patient on nothing by mouth for 1-2 weeks especially in children. The compliance of the patient and the parents is usually poor. The third reason is that enteral feeding will protect gut barrier function through the provision of luminal nutrients. The fourth reason is that no difference in clinical outcome has been reported between patients receiving an MCT-enriched diet when compared with parenteral nutrition (1,4, 7).

The role of octreotide in chylothoraxIn our study, octreotide was used in 5 patients

(12.5%) and had a positive impact on reducing chest tube drainage with final resolution of chylothorax. Octreotide was safe and only minor side effects were documented in the files in the form of transient abdominal distension and loose stool. However, during administration of octreotide, regular monitoring of liver function, blood glucose and thyroid function test is recommended (15).

Octreotide is the synthetic analog of somatostatin with a longer half-life and is available for use either intravenously or subcutaneously (27). Since the first reports of its use in the 1990 (27,28), somatostatin and octreotide have been recommended for the treatment of chylothorax prior to surgical interventions for prolonged chylous drainage not responding to conservative


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nutritional management (11-16). The optimal timing of initiating octreotide in addition to dietary measures has not been clearly defined yet. The mechanism of action of octreotide in the reduction of chylothorax is not well understood although it may occur via the reduction of the gastrointestinal blood flow, lymphatic flow and inhibiting intestinal motility. It has been also proposed that lymphatic vessels may contain somatostatin receptors that respond by reducing lymph production (29) or reduce absorption of triglycerides from the gut (30). Octreotide is usually commenced at 0.5mcg/kg/h and gradually increased to a maximum dose at 10 mcg/kg/h (15). In the majority of studies, the treatment effect of octreotide was evident by 5–6 days, with the median duration of therapy reported from 10–18 days (11-16). If the treatment is not successful, the infusion should be gradually reduced over a 3-day period (15).

The role of steroids in Chylothorax In our study, steroids were used in 7 patients

(17.5%) and also had a positive impact on reducing chest tube drainage with final resolution of chylothorax in six out of them. Success with steroid therapy has been reported in case reports of chronic pleural effusion following the Fontan procedure and in association with specific medical conditions (20,21). Although there is no sufficient evidence to support the use of steroids in the routine management of post-operative chylothorax, they have been used with no clear mechanism to explain how this may resolve a lymphatic leak and no definitive guidelines for dosing exist. However, endogenous glycocorticosteroids are known to reduce the quantity of protein in the tissues with increasing the degradation rate of extrahepatic proteins. Amino acids that are released will increase hepatic protein synthesis. The increased of the plasma’s osmotic pressure causes the immediate shift of the fluids from the interstitial tissue to the blood, reducing the volume of lymph (31).

Failure of conservative treatment and hospital mortality

We encountered only one failure (2.5%) of the conservative treatment. One out of the 7 patients who were treated with fat-free diet and steroids continued to have high amount of chest tube drainage. Hyperalimentation could not be continued due to lack of compliance. He had a successful thoracic duct ligation with complete resolution of chylothorax. No mortality related to chylothorax in our study probably due to early diagnosis and aggressive treatment and better patient characteristics than other reports (23,28).

Recurrence of chylothoraxWe did not encounter any recurrence in our study.

This may be due to the relatively short follow up duration (median of 7 months). However the longest follow-up was 24 months with no reccurence.

Conclusions:Based on our results, in the absence of

contraindications to enteral feeding, an initial trial of enteral feeding using fat-free diet and or Monogen and if the response is not appropriate octreotide and or steroids can be used safely. Controlled randomized clinical trials should be conducted to evaluate whether earlier introduction with steroids or octreotide can reduce hospital duration and improve prognosis of chylothorax following pediatric heart surgery.

Limitations:This is a retrospective study with a relatively small

number of patients. There are some significant differences in the complexity of operations and treatment regimens. Follow-up was relatively short. There was no standard fixed protocol for the management of each patient in this series.

References1.AllenE,VanHeeckerenD,SpectorM,BlumerJ.Management

of nutritional and infectious complications of postoperative chylothoraxinchildren.JPediatrSurg1991;26:1169–1174.

2.LeCoultreC,Oberhansli I,MossazA,BugmannP,FaiduttiB,BelliD.Postoperativechylothoraxinchildren:Differencesbetween vascular and traumatic origin. J. Pediatr. Surg.1991;26:519–23.

3.BondS,GuzzettaP,SynderM,RandolphJ.Managementofpediatricpostoperativechylothorax.AnnThoracSurg2001;72:193-1960.

4. Nguyen D, Shum-Tim O, Dobell A, Tchervenkov C. Themanagement of chylothorax/chylopericardium followingpediatriccardiacsurgery:a10-yearexperience.JCardSurg1995;10:302–308.

5.BeghettiM,LaScalaG,BelliD,BugmannP,KalangosA,LeCoultreC.Etiologyandmanagementofpediatricchylothorax.JPediatr2000;136:653-658.

6.CormackB,WilsonN,FinucaneK,WestC.UseofMonogenfor pediatric postoperative chylothorax. Ann Thorac Surg2004;77:301–305.

7. Chan E, Russell J, Williams W, Van Arsdell G, Coles J,McCrindleB.Postoperativechylothoraxaftercardiothoracicsurgeryinchildren.AnnThoracSurg2005;80:1864–1870.

8. Cannizzaro V, Frey B, Bernet-Buettiker V. The role ofSomatostatin in the treatment of persistent chylothorax inchildren.EurJCardiothoracSurg2006;30:49–53.


Tho

raci

c


Thoracic

9. Milonakis M, Chatzis A, Giannopoulos N, Contrafouris C,BobosD,KirvassilisG,SarrisG.Etiologyandmanagementofchylothoraxfollowingpediatricheartsurgery.JCardSurg2009;24:369-373.

10. Buttiker V, Fanconi S, Burger R. Chylothorax in children:Guidelinesfordiagnosisandmanagement.Chest1999;116:682-687.

11.PratapU,SlavikZ,OfeoV,OnuzoO,FranklinR.Octreotidetotreatpostoperativechylothoraxaftercardiacoperationsinchildren.AnnThoracSurg2001;72:1740-1742.

12. Cheung Y, Leung M, Yip M. Octreotide for treatment ofpostoperativechylothorax.JPediatr2001;139:157-159.

13.MilkroulisD,DidilisV,BitzikasG,BougioukasG.Octreotideinthetreatmentofchylothorax.Chest2002;121:2079-2080.

14.Rosti L,BiniR,ChessaM,ButeraG,DragoM,CarminatiM. The effectiveness of octreotide in the treatment ofpostoperativechylothorax.EurJPediatr2002;161:149-151.

15. Lim K, Kim S, Huh J, Kang I, Lee H, Jun T, Park P.SomatostatinforPostoperativeChylothoraxafterSurgeryforChildrenwithCongenitalHeartDisease.JKoreanMedSci2005;20:947-51.

16.ChanS,LauW,WongW,ChengL,ChauA,andCheungY.ChylothoraxinChildrenafterCongenitalHeartSurgery.AnnThoracSurg2006;82:1650–1656.

17. Staats B, Ellefson R, Budah L The lipoprotein profile ofchylous and nonchylous pleural effusion.Mayo clinicProc1980;55:700-704.

18. Straaten Van H, Gerards L, Krediet T. Chylothorax in theneonatalperiod.EurJPediatr1993;152:2-5.

19.Gershanik J, JonsonH,RiopelD.Dietarymanagement ofneonatalchylothorax.Pediatrics1994:53:15:400-403.

20.RothmanA,MayerJ,FreedM.treatmentofchronicpleuraleffusionsaftertheFontanprocedurewithprednisolone.Amj

Cardiol1987;60:408-409.21.PatsourasD,ArgiriO,SiderisD.SpontaneousChylothorax

in a Patient with Noonan Syndrome: Treatment withPrednizone.HellenicJCardiol2002;43:170-173.

22. Rubin J, Moore H, Ellison R. Chylothorax: Therapeuticalternatives.AmSurg1977;43:292–297.

23.NathD,SavlaJ,KhemaniR,NussbaumD,GreeneC,WellsW. Thoracic duct ligation for persistent chylothorax afterpediatriccardiothoracicsurgery.AnnThoracSurg2009;88:246-252.

24. Wolff A, Silen M, Kokoska E, Rodgers B. Treatment ofrefractory chylothorax with externalized pleuroperitonealshuntsinchildren.AnnThoracSurg1999;68:1053-1057.

25.RobinsonC.Themanagementofchylothorax.AnnThoracSurg1985;39:90-95.

26.ShiauY,PopperD,ReedM,OmstetterC,CapuszziD,LevineG.Intestinaltriglyceridesarederivedfrombothendogenousandexogenoussources.AmJPhysiol1985;248:164-169.

27. Lamberts S, Vander Ley A, De Herder W, Hofland L.Octreotide.NEnglJMed1966;334:246-254.

28.RimensbergerPC,Muller-SchenkerB,KalangosA,BeghettiM.Treatmentofapersistentpostoperativechylothoraxwithsomatostatin.Ann.Thorac.Surg1998;66:253–254.

29. Scarpignato C, Pelosini I. Somatostatin for uppergastrointestinal hemorrhage and pancreatic surgery. Areviewof itspharmacologyandsafety.Digestion1999;60(Suppl.3):1–16.

30.HenglG,PragerJ,PointnerH.Theinfluenceofsomatostatinontheabsorptionoftriglyceridesinpartiallygastrectomizedsubjects.Acta.Hepatogastroenterol.1979;26:392–395.

31.GuytonAC:Textbook ofMedical Physiology. Philadelphia,Pa:WBSaundersCo;1991,p769.QuotedfromPatsourasetal.,reference(21).


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Effectiveness of BioGlue In The TreatmentOf Alveolar Air Leak

Mahmoud Abd-Rabo, MD

Addrees reprint request to :DR. Mahmoud Abd-RaboLecturer of Cardiothoracic Surgery Faculty of Medicine Zigzag University


Background: The occurrence of intraoperative air leaks is an unavoidable complication during pulmonary surgeries. The use of tissue glue has been advocated to reduce this post pulmonary resection alveolar air leak. The aim of this study is to evaluate the effectiveness and sealing capacity of BioGlue (CryoLife Europa Ltd, Hampshire United Kingdom) for the closure of alveolar air leaks following pulmonary resections and to determine its effect on time to chest drain removal and duration of hospitalization. Methods: a prospective randomized study enrolled in King Fahad Specialist Hospital ,AL Qassim Region, KSA, between Jan. 2006 and Jun. 2010, 109 patients showing moderate – severe intraoperative air leaks after pulmonary lobectomy –bilobectomy (30%) or minor resection (segmentectomy –wedge resection ) (70%) have been assigned to receive one of the following management strategies : stapling (48patients –standard control group(SCG) ) or stapling plus BioGlue sealant (32 patients -stapling BioGlue group (SBG) ) or suture plus BioGlue sealant (29patients -suture BioGlue group (sBG) ). To assess the effectiveness of the sealant the following date were compared: number of patients with air leak cessation intra operatively, number of patients without air leaks at 24 h and 48 h, duration of air leaks , length of hospital stay, and complications of the BioGlue. Results: indications for surgery were malignancy (21 %), infective disease (17.5%), pulmonary infiltration (biopsy) (27.5%), and bullectomy (34 %). No adverse event related to the sealant application occurred. Intraoperative air leak cessation rate was lower in the SCG than SBG and sBG (48 % vs. 26% and 28% respectively, < 0.001). Air leaks rate at 24 h and 48 h was significantly lower in both BioGlue group (21.6 % and 22.4 % vs. 42.3%, p=0.001 at 24 h and 22.9% and 23.5% vs. 41.6%, p=0.006 at 48 h). Duration of air leak was significantly shorter in BioGlue groups (p=0.01). The hospital stay was shorter in BioGlue groups mean: 5.8 ±1.4 days’ and 5.7 ± 1.4 days and 5.7 ± 1.3 days ±1.3 days vs. 7.3 ± 2.1 days) but this difference did not reach statistical difference. Conclusion: this study proved the application of BioGlue is safe and effective in reducing the alveolar air leak after lung surgery, chest drainage time and hospital stay. Also application of sealant has the same result with stapler or suture techniques .

In contrast to the rare large-airway bronchopleural fistulas after lung resection, peripheral or alveolar air leaks (AAL) are very common, often prolong hospital stay, increase utilization of resources, and on occasion result in significant morbidity (1). Various adjuncts have been used in attempts to reduce AAL. The question addressed was whether

the intraoperative use of surgical adhesives in patients undergoing lung resection would reduce the incidence and length of postoperative air leaks (2).

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Prolonged alveolar air leak (AAL) after thoracotomy is generally defined as an air leak that lasts more than 7 days (3). AAL prevalence is greater than 15%, and it may result in serious complications including longer duration of intercostals drainage and increased immobility with associated risks of infection, empyema, and thromboemboli (4, 5).These complications may lead to greater postoperative pain and longer hospital stays with increased associated costs (6).

Standard methods for intraoperative control of air leaks include suture and stapling, but have the disadvantage of causing further trauma to lung tissue. Various attempts have been made to prevent or reduce the incidence of postthoracotomy AAL including additional surgical techniques, postoperative water seal drainage, and surgically applied sealants (7).

There are trials of using fibrin based sealant (8,9,10,11,12,13), or glutaradehyde –based sealant, or fleece- bound sealing [TachoSeal] (14) or collagen patches coated with human fibrinogen and thrombin [TachoComb] (15,16)or gelatin – poly (L-Glutamic Acid ) [Hydrogel Glue] (17,18) or autologous fibrin sealant [Vivostat] (19,20) or lung staple-line reinforcement [ FORE seal] (21) or tautologies tissue engineered cell sheets(22).

BioGlue (CryoLife Europa Ltd, Hampshire, United Kingdom) surgical adhesive is a topically applied mixture of bovine serum albumin and glutaradehyde. In North America, it is approved for use as an adjunct to standard methods of hemostasis in open surgical repair of large vessels. It also has European approval for use in a wide range of soft tissue repairs (7). However randomized studies in this setting are rare and the results are disappointing with no clear evidence supporting the choice of an ideal technique (3).

The aim of this study is to evaluate the effectiveness and sealing capacity of BioGlue (CryoLife Europa Ltd, Hampshire United Kingdom) for the closure of alveolar air leaks following pulmonary resections and to determine its effect on time to chest drain removal and duration of hospitalization.

METHODS: A prospective randomized study conducted in King

Fahad Specialist Hospital, AL Qassim Region, KSA, between Jan. 2006 and Jun. 2010. The study population included patients older than 18 years undergoing

lobectomy (including bilobectomy, or minor resections including (segmentectomy and wedge resections). Patients having immune system disorders, previous lung surgery, previous chemotherapy, emergency operation, pregnancy, breast feeding or hypersensitivity to any component of the investigational product were excluded.. Informed consent was obtained from each patient included in the trial before the operation.

Lung r sections were performed through a lateral muscle sparing thoracotomy. Division of incomplete fissures was performed by stapling devices (Gastro-Intestinal anastomosis 75 or 80 mm) reinforced by pleural flap in stapler groups (SCG and SBG). Bronchial stump suture were performed by Thoraco-Abdominal (TA) 30 mm stapler in stapler groups (SCG and SBG).

Alveolar air leaks were evaluated intraoperatively by submersion of the resection site in saline and were graded according to the Macchiarini scale as 0 (no bubbles), 1 (single bubbles), 2 (stream of bubbles), 3 (coalescent bubbles). Patients with grade 1 or 2 air leaks were randomised to TachoSilW or standard treatment. Grade 3 patients received standard treatment until the air leak was downgraded to grade 1 or 2 at which point they were randomised. Patients with grade 0 leakage were excluded.

Patients with moderate to severe air leaks have been randomly allocated to one of the two following management strategies:-Standard control: routine methods of closing leaks including staple [standard control group (SCG)] and- Standard control plus BioGlue: application of BioGlue on air leaks sites as an addition to the standard method (suture/staple) [BioGlue groups (BG)].

o Stapler with BioGlue groups (SBG) o Sutures with BioGlue groups (sBG) i.e., without

use of staple Randomization, on the basis of the use of close

envelopes containing notes reading either ‘A’ for BioGlue or ‘B’ for conventional treatment, was performed intraoperatively

BioGlue and Application BioGlue surgical adhesive is a topically applied

mixture of bovine serum albumin and glutaradehyde. It is supplied in a prefilled cartridge and stored below 25°C. The components of the product are mixed within a double-helix applicator attached to a syringe. Polymerization with tissues occurs immediately on application, and bonding strength is reached within 2 minutes.Evidence of incomplete resorption of BioGlue has been identified at 2 years (23).

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After the first attempt to close air leaks was performed according to the indications of each group, a second submersion test was performed to assess if the procedure was effective in closing parenchyma. In patients of the SCGthe persistence or absence of the air leak was then registered without further interventions. In patients included in the BioGlue group in whom air tightness was not achieved, reapplication of the sealant was performed and a third test for air tightness was conducted. The volume of Coseal applied in each patient ranged from 4 to 8 ml, depending on the extension of the surface area to be treated, the number of applications and the number of air leak sites. Chest tubes have been regularly assessed for air leaks and fluids drainage at 24 and 48 h postoperatively by highly specialized nurses.

Postoperative measurements of volume were made in the morning of postoperative days 1 and 2.In patients with persistent air leakage (>7 days) regular measurements were performed every second day.

Efficacy parameters: The primary efficacy endpoints of the study

were postoperative quantification of air leakage on postoperative days 1 and 2. Other efficacy measurements included mean time to chest drain removal and mean time to hospital discharge.

Statistics: The statistical method used was the t-test for

independent samples. A P value <0.05 was considered to be significant.

RESULTS: During 4.5 years period between Jan. 2006 and

Jun. 2010, 109 patients were included in the study with mean age of 27±13 with 68 (62%) male and 41 (38%)female, 49%of patients were smoking and the mean of body weight was 26±11kg (Table, 1).

Variants SCG (48) SBG (32) sBG (29)Age (years) 26±13 28±12 27±13Male (%) 62% (30) 64% (20) 62% (18)Female 38% (18) 34% (12) 38% (11)

Body mass index (kgm⁄m2)

27.4±5.3 25.8±4.9 26.2±4.3

Smoking (%) 43.7% (21) 46.7% (15) 44.8% (13)

Table 1 demographic data of the patients

Most of our patients had bullous diseases 34%, lung infiltrate in 27.5%, while malignancy cases and infective diseases were low (21% and 17.5% respectively). So, wedge resection was very high in our series (62%) ,segmentectomy ,lobectomy ,and bilobectomy were low (8%,22% and 8% respectively) (table 2&3).

Types of diseases, n (%) SCG SBG sBG

Bullous diseases 16 (33%) 11 (34%) 10 (34%)

Lung infiltrate 13 (27%) 9 (28%) 8 (27%)Malignancy(Primary or secondary) 10 (21%) 7 (22%) 6 (21%)

Infective diseases 9 (19%) 5 (16%) 5 (18%)

Table 2: types of diseases in the three groups

Types of surgery, n (%) SCG SBG sBG

Wedge resection 31 (64%) 20(62%) 17 (59%)

segmentectomy 4 (8%) 3(9%) 2( 7%)

Lobectomy 10 (21%) 7(22%) 7 (24%)

Bilobectomy 3 (7%) 3 (7%) 3 (10%)

Table 3 :types of surgical procedur

The severity of air leaks were mild in 77%, moderate in 19% and sever in 4%. And after initial maneuver to stop the air leak surgically or by use of stapler and BioGlue, cessation of intra operative air leak was 48%, 26%and 28% for SCG, SBG, and sBG respectively. The air leak rate became significantly lower in SBG and sBG rather than SCG group in the first 24 hours (17%, 21% and 42 % respectively), also at 48 hours (6%, 9% and 36%respectively) (table 4).

The duration of air leak in SBG and sBG was significantly low 1.7± 0.8 and 1.8±0.9 days, than SCG group (4.1±1.6 days). Also, the time to chest drain was lower in both SBG and sBG (3.8 and 3.9 days) than the SCG (5.2 days). This was reflecting on the hospital stay time which was significantly

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lower in both BioGlue groups (5.8 ±1.4 and 5.7±1.3 days)(Table 4).

Complication as continues air leak, fever, infection, continues pleural drain and non specific complication were low and with no statistical difference between the two groups) (table 5).

Complication,n (%) SCG SBG sBG

Continuous air leak 5(10%) 1(3%) 2(7%)

Fever 2(4%) 2(6%) 3(10%)

Infection 1(2%) 0(0%) 1(4%)

Continuous pleural drain 7(14%) 5(15%) 5(17%)

Non specific complications 4(8%) 2(6%) 1(4%)

Table 5: complications

DISCUSSION Postoperative air leakage is a common problem

following lung resection (3). It remains a major cause of morbidity after lung resection. It leads to prolonged chest tube drainage time associated with pain and immobilization, and consequently puts the patient at an increased risk for development of infections and pneumonia. The resulting prolonged hospital stay has its clear negative economical consequences (4).

Although the routine use of surgical staplers for

division of parenchymal areas has improved the primary sealing of resection lines itself, a number of potential sources for air leakage do remain. Especially the hilar region after lobectomy, stitch holes after suturing, as well as other lacerated or decorticated lung surface areas are among them. Even when complete airtight sealing is achieved at the end of an operation, air leaks can develop at any point of time during the postoperative course. Deriving from there, a need for an effective tool for prevention of lately developing air leaks is given (6).

For this reason increasing requirements for new sealant products to be used as an adjuvant to surgical technique has stimulated active industrial research and clinical experimentation in this setting (7).

Fibrin glue has been the most studied option over the last two decades, unfortunately with unsatisfactory results. The randomized trials conducted by Wong and Goldstraw (9) and by Fleisher and colleagues (8) have demonstrated no difference in the incidence of postoperative air leaks, in the duration of chest-drain and in hospitalization.

Most trials looked at three primary outcomes: air leak duration, length of time of intercostal drainage, length of hospital stay. Seven trials use fibrin-based sealants, three trials use polyethylene-glycol-based sealants, and one trial uses a glutaraldehyde-based sealant (4).

Six trials found a significant reduction in the duration

Air leak SCG SBG sBG

Severity of air leak, n (%)Mild ModerateSevere

36 (75%)8 (17%)4 (8%)

25 (78%)7 (22%)0 (0%)

23 (79%)6 (21%)0 (0%)

Intra operative cessation of air leak 48% 26% 28%

Air leak rate at 24 hours 42% 17% 21%

Air leak rate at 48 hour 36% 6% 9%

Duration of air leak (days) 4.1± 1.6 (2-6) 1.7± 0.8(0-3) 1.8 ± 0.9( 0-3)

Time to chest tube removal (days) 5.2 (4-6) 3.8 (3-4) 3.9 ( 3-4)

Hospital stay time(days) 7.3 ± 2.1(7-10) 5.8± 1.4 (5-7) 5.7± 1.3 (5-7)

Table 4: severity ,duration and cessation of air leak in three groups . Time to chest tube removal and hospital stay time

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of air leak after use of a sealant as compared to controls (2,5, ,7,11,15,20), however, three trials found the difference to be non-significant (8,9,26).

The aim of this study was to examine the management of AAL, of all degrees of severity, using BioGlue in a prospective, randomized, controlled manner; in a clinically relevant scenario in which an air leak persists after all conventional techniques have been exhausted. Patients having immune system disorders, previous lung surgery, previous chemotherapy, emergency operation, pregnancy, breast feeding or hypersensitivity to any component of the investigational product were excluded. Almost all patients underwent resection of pulmonary tissue to some degree. The intra-operative air leak grading system was simple, pragmatic, and easily reproducible. It worked well and allowed easy inter-surgeon communication.

Our prospective randomized study of total 109 patients with mean age 27± 13 were classified into three groups stapling (48patients –standard control group(SCG))or stapling plus BioGlue sealant (32 patients -stapling BioGlue group (SBG))or suture plus BioGlue sealant (29patients -suture BioGlue group (sBG) ). Bullous diseases were significantly high in our series (34%) while infective diseases were low, and malignancy represented 21%. Wedge resection was done for the most of our patients (62%), lobectomy in (22%) while bilobectomy and segmentectomy were the lowest; this due to that bullous diseases were common in our area.

In this series, mild intraoperative air leak was significantly high p =0.001 while severe air leaks represented (4%) of our cases .Cessation of intraoperative air leak was significantly high in (SCG) p =0.001and low in (SBG) and (sBG) with no significant difference between both groups and it is related to meticulous surgical technique rather than types of surgical technique. Air leak was low in (SBG) and (sBG) within 24 hours and 48 hours with no significant difference between both groups while it was significantly high in (SCG) p =0.001, air leak was significantly low in BioGlue groups.

In our study, duration of air leak was significantly reduced in both BioGlue groups [(SBG) & (sBG)] p =0.001 with no significant difference between them while it was significant prolongation of post operative air leak in (SCG) p =0.001.

Time of chest tube removal in our study, was early in BioGlue groups and significantly reduced p =0.001in comparing to (SCG).Only two trials found a significant

reduction in the time of intercostal drainage compared to controls (7,15), two trials found the difference to be non-significant (8, 9).

Hospital stay was significantly low in BioGlue groups [(SBG) and (sBG)] p =0.001.and significantly high in (SCG), no statistical difference of post operative complications in three groups, in our study. while,only two trials found length of hospital stay to be significantly shorter in groups treated with sealant compared to their controls (7, 26),whilst five trials found a non significant difference (2, 5, 9, 11, 20).

While In Droghetti et al.,study , there were no significant differences in the 3 clinical outcome measures of duration of air leak, time to intercostal drain removal, and length of hospital stay in those patients receiving BioGlue or Vivostat (1).

The use of electrocautery dissection and collagen patches coated with human fibrinogen and thrombin (TachoSil, Nycomed, Vienna, Austria) for aerostasis to complete interlobar fissures seems to be safe and effective in reducing alveolar air leaks and procedure costs (1). This come with our results , both showed advantages in terms of hospitalization and cost benefits, further multicentric studies are required to clarify that these differences are statistically significant.

Historically, there has been considerable difficulty in establishing a clear message on the effectiveness of surgical sealants in preventing air leaks.(1,3,4,6). For a sealant to be shown to be effective, its application should lead to a reduction in the incidence and duration of air leak, as demonstrated in this trial. This prospective, randomized study is the one in which the sealant (BioGlue) succeeds in the reduction of air leak and demonstrates a reduction in drainage time with subsequent reduced hospital stay. The study suggests that the systematic use of BioGlue in the treatment of AAL after thoracotomy may be warranted in adult thoracic surgical procedures, with the exception of pneumonectomy and decortication, when an air leak remains after all other steps to control it have failed. In this context, our study makes a positive contribution to the information available to surgeons.

In conclusion, the application of BioGlue in this randomized study proved safe and effective in reducing air leaks occurring after lung resections and in shortening the duration of air leak with a trend towards a shorter

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time to chest drain removal and postoperative hospital stay. Also application of sealant has the same result with stapler or suture techniques

REFERENCES 1-DroghettiA , SchiaviniA, ,MurianaP, FolloniA,PicaroneM,

BonadimanC,SturaniC,PaladiniR,MurianaG: prospectiverandomized trial comparing completion technique of fissuresforlobectomy:StaplerversusprecisiondissectionandsealantThoracCardiovascSurg2008;136:383-391

2-PorteHL,JanyT,AkkadR,ContiM,GilletPA,GuidatA,WurtzAJ:Randomized controlled trial of a synthetic sealant forpreventingalveolarairleaksafterlobectomy.AnnThoracSurg2001;71:1618–1622.

3-D’AndrilliA,AndreettiC,IbrahimM,MariaA,VenutaF,MansmannU,AngeloRendinaE:AprospectiverandomizedstudytoassesstheefficacyofasurgicalsealanttotreatairleaksinlungsurgeryEur J Cardiothorac Surg 2009;35:817-821. doi:10.1016/j.ejcts.2009.01.027

4 - Tambiah J, Rawlins R, Robb D and Treasure T: Can tissueadhesives and glues significantly reduce the incidence andlength of postoperative air leaks in patients having lungresections? Interact CardioVasc Thorac Surg 2007;6:529-533; originally published online Apr 25,2007;DOI: 10.1510/icvts.2007.153080

5 -Wain JC, Kaiser LR, Johnstone DW, Yang SC, Wright CD,Friedberg JS,Feins RH, Heitmiller RF, Mathisen DJ, SelwynMR:Trial of a novel synthetic sealant in preventing air leaksafter lung resection. Ann Thorac Surg 2001;71:1623–1628;discussion2001;1628–1639.

6-BelcherE,DusmetE,JordanS,LadasG,LimE,GoldstrawP:Aprospective, randomized trialcomparingBioGlueandVivostatforthe control of alveolar air leak J Thorac Cardiovasc Surg2010;140:32-38

7- Tansley P, Al-Mulhim F, Lim E, Ladas G, Goldstraw P.prospective,randomized,controlledtrialoftheeffectivenessofBioGlueintreatingalveolarairleaks.JThoracCardiovascSurg2006;132:105—12.

8-FleisherAG,EvansA,KG,NelemsB,FinleyRJ:Effectofroutinefibringlueuseonthedurationofairleaksafterlobectomy.AnnThoracSurg1990;49:133–4.

9-Wong K.,Goldstraw P: Effect of fibrin glue in reduction ofpost thoracotomy alveolar air leak Ann. Thoracic Surg.1997,64:979-981

10- Patricia A. Thistlethwaite, James D. Luketich, Peter F.Ferson,Robert J.Keenan,and Stuart W. Jamieson:AblationofPersistentAir LeaksAfterThoracicProceduresWithFibrinSealant(AnnThoracSurg1999;67:575–7)

11- FabianT,JohnA. Federico, andRonald B. Ponn: FibrinGluein Pulmonary Resection:A Prospective,Randomized, BlindedStudy(AnnThoracSurg2003;75:1587–92).

12-KawamuraaM,GikaaM,IzumiaY,HorinouchiaH,ShinyabN,MukaicM,KobayashiaK:Thesealingeffectoffibringlueagainstalveolarairleakageevaluatedupto48h;comparisonbetweendifferent methods of application Eur. J. CardioThoracoc Surg.

2005,28:39-4213-MoserC,OpitzW.ZhaiV.RoussonE.W.RussiW,WederD

.Lardinois:Autologous fibrin sealant reduces the incidence ofprolongedairleakanddurationofchesttubedrainageafterlungvolume reduction surgery: A prospective randomized blindedstudyThoracCardiovascSurg2008;136:843-849

14-AneggU,LindenmannJ,MatzV,SmolleJ,MaierA,Smolle-JüttnerF:Efficiencyoffleece-boundsealing(TachoSil®)ofairleaksinlungsurgery:aprospectiverandomisedtrialEurJCardiothoracSurg2007;31:198-202.doi:10.1016/j.ejcts.2006.11.033

15- Lang G, Csekeo¨, Stamatis G, Lampl L, Hagman L, MihaiMartaG,MuellerMR,KlepetkoW:Efficacyandsafetyoftopicalapplication of human fibribogen/thrombin-coated collagenpatch(TachoComb)fortreatmentofairleakageafterstandardlobectomy.EurJCardiothoracSurg2004;25:160—6.

16-FeitoaB,AnaM,LongchamptcE,AzorinaJ:ExperimentalstudyontheinvivobehaviourofanewcollagenglueinlungsurgeryEuropeanJournalofCardio-thoracicSurgery17(2000)8±13

17- Otani Y, Tabata Y, and Ikada Y: Sealing Effect of RapidlyCurableGelatin-Poly(L-GlutamicAcid)HydrogelGlueonLungAirLeak(AnnThoracSurg1999;67:922–6)

18-Araki M, Tao H, N Nakajima N, Sugai H, SatoNT, HyonNS,Takeshi Nagayasu, Nakamura T,:Development of newbiodegradablehydrogelglueforpreventingalveolarairleakageJThoracCardiovascSurg2007;134:1241-1248

19-KjaergardH,Pedersen J,KrasnikM,UllaS.FoghW,FleronH,and. Eugene Griffin H :Prevention of Air Leakage bySprayingVivostat Fibrin Sealant After Lung ResectioninPigs*Chest2000;117;1124-1127

20-BelboulA,Dernevik L,AljassimO,SkrbicB,RådbergGandDonald:Theeffectofautologousfibrinsealant (Vivostat®)onmorbidityafterpulmonarylobectomy:aprospectiverandomised,blindedstudyRoberts.EurJCardiothoracSurg2004;26:1187-1191

21-ThomasP ,MassardG, PorteH , Doddoli C , DucrocqX ,Conti M : A new bioabsorbable sleeve for lung staple-linereinforcement(FOREsealTM):reportofathree-centerphaseIIclinicaltrial.EurJCardiothoracSurg2006;29:880-885.

22- Kanzaki M, Yamato M,Yang J,Sekine H,Takagi R, Isaka T,OkanoT,OnukiTKanzakiM,YamatoM,YangM,SekineH,TakagiR, IsakaT ,OkanoT,TOnukiT: Functional closureofvisceralpleuraldefectsbyautologoustissueengineeredcellsheets.EurJCardiothoracSurg2008;34:864-869.

23- Raanani E, Latter DA, Errett LE, Bonneau DB, Leclerc Y,Salasidis GC: Use of “BioGlue” in aortic surgical repair.AnnThoracSurg.2001;72:638-40.

24- US Food and Drug Administration–New Device Approvals(CryoLife BioGlue SurgicalAdhesive).Accessed on January14,2006athttp://www.fda.gov/cdrh/mda/docs/P010003.pdf

25-HistoryofBioGlue.AccessedonJanuary14,2006athttp://www.cryolife.com/products/bioglue_historynew.htm

26-AllenMS,WoodDE,HawkinsonRW,HarpoleDH,McKennaRJ,WalshGL,etal:Prospectiverandomizedstudyevaluatingabiodegradablepolymericsealantforsealingintraoperativeairleaksthatoccurduringpulmonaryresection.AnnThoracSurg.2004;77:1792-801.

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Osteomyelitis Of The Ribs As A Missed Late Post Cabg Ischaemic Chest Wall Complication

Ashraf El-Sebaie Mohammed, M.D.*and Mustafa El-Saban, M.D**.

* Department of surgery ,plastic surgery unit, Cairo University** Department of Cardio thoracic surgery, Cairo Universitye-mail: [email protected] : 05/128/1010

Background: Chronic osteomyelitis of the ribs is usually a missed problem that should be suspected in post CABG patients with chronic chest wall pain late postoperatively. As any osteomyelitis pathology it is started with infection early postoperative together with ischaemia of antero-lateral chest wall after single or double IMA harvesting for CABG operation. Methods: Twenty patients had osteomyelitis of the anterior or antero-lateral chest wall were managed, 12 patients were males while 8 were females. Their ages ranged from 48 to 70 years. Chronic dull aching chest wall pain that shows intermittent exacerbation associated with erythema of overlying skin and tenderness and may be bony crepitus with discharging pre sternal sinus or sinuses. Confirmation of the diagnosis is done by sinogram, C.T scanning and radio-isotopic bone scanning.Results : The most affected ribs are the 5th to the 9th ribs of the left side antero-lateral parts only never exceeded the mid axillary line because of the left IMA harvesting in most of cases.Surgical excision of the affected ribs is done intra-periosteally where the eroded diseased ribs are removed after their staining by methylene blue with hydrogen peroxide not to miss any affected part. All patients showed marked improvement with good rapid healing of the surgical wounds. The distressing pain disappears completely after complete removal of the diseased ribs. Conclusion: Chronic osteomyelitis of the ribs is usually a missed problem that should be suspected in post CABG patients specially if diabetics who had wound problem early postoperative.

The incidence of mediastinal and chest wall infection after cardiac surgery has been reported to range from (0.39% to 8.4%) Greater than 90% of osteomyelitis in this region has bacterial and mycobacterial causation, with staphylococcal species predominating. Fungal species are rare causes of chronic

infection of the ribs and sternum but have been increasingly recognized as important pathogens. (1)

Both diabetes and obesity are important associations of ischaemic heart disease and are commonly present in patients undergoing CABG surgery. The major risk factor for mediastinitis after CABG is obesity.

Obesity as a risk factor was discussed by Bitkover et al., (2) the etiology relates to increased postoperative mechanical loads, facilitated bacterial contamination, and failure to adjust antibiotic doses to body mass, an error that leads to inappropriately low tissue antibiotic concentrations. Another risk factor was COPD, which was associated with more than threefold increased

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risk of postoperative mediastinitis, possibly as a result of frequent coughing, which might contribute to wound dehiscence and thereby facilitate bacterial infection. (3)

Patients with COPD also experience more frequent respiratory infections and prolonged weaning from artificial ventilation. (4)

Bone wax is frequently used as a haemostatic agent to prevent oozing from cancellous bone of the cut edges of median sternotomy. Although bacterial infection in this setting is infrequent, its occurrence is associated with increased morbidity and mortality. Robicsek et al1981 have commented on the infection promoting role of bone wax. (5) Another study has suggested that bone wax augments infection. (6)

Blood transfusion has been identified as an independent risk factor. Blood transfusion is associated with impaired immunocompetence, (7) all patients had received blood transfusion. Re-exploration for haemorrhage has been reported as an important risk factor. (8)

The internal mammary artery (IMA) is isolated from the chest wall as a pedicle, together with the vein, muscle, fat and accompanying endothoracic fascia. Cautery is used to separate the pedicle from the chest wall. Cauterization damages the blood supply to the sternum, impedes sternal wound healing and exposes the sternum to the risks of early dehiscence and infection, especially, if both IMAs are harvested. IMA is the primary source of blood supply to the sternum. There is frequently a substantial degree of ischaemic necrosis of the bone on the side of the IMA graft. The risk is particularly great in the elderly and the diabetic patients. (9)

For sternal-intercostal, perforating-intercostal, and sternal-perforating branches to function as collaterals after ITA harvesting, the common trunk of origin must remain intact. Based on morphologic data, we recommend ligating the common trunk as close as possible to the ITA; in this way, collateral blood flow to the sternum remains intact. (10)

Aim of the work:In this work we described how to suspect the

presence of rib osteomyelitis in post CABG surgery patients, how to prove its presence and we described a new simple method of complete removal of the diseased

ribs to end the problem of persistent pre-sternal scar sinus and chronic persistent chest wall pain.

MethodsPopulation, age and gender

Twenty patients had osteomyelitis of the anterior or antero-lateral chest wall were managed at the cardio-thoracic surgery department, Cairo university hospitals during the period between July 2007 till July 2010. 12 patients were males while 8 were females. Their ages ranged from 48 to 70 years (with a mean age of 57 years) at the time of diagnosis. All the patients’ data are shown in (table 1).

Presenting complaintPresenting complaint: all the patients in our

study presented complaining of intractable chest wall pain during the late post CABG period (8-18 months post operative). The pain in 80% of cases was limited to the left side mainly anterior and lateral chest wall but it never extends beyond the mid-axillary lines. Sometimes pain is bilateral in cases of bilateral internal mammary harvesting. The pain is exaggerated at night, with localized tenderness and may be bony crepitus (or egg-shell crackling) sensation. Pain is usually associated with erythema of the overlying skin (Figure 1) with or without intermittent sinus discharge (most patients were operated upon for such discharge (wire removal, part of pacemaker tube removal, refreshing of the bone edges) at least twice for sinus debridement and closure, with no use.

Figure1 : showing the redness which denotes the underlying pathology with remissions and exacerbationsA: a case of 52 years old male post 9 months with marked erythema around median sternotomy wound with marked tenderness over left costal margin. B: a case of 58 years old male post 16 months with bilateral erythema around median pre-sternal wound with marked bilateral tenderness.

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Patient evaluation& investigations: Clinical evaluation of the patients included careful

history, physical examination followed by plain chest x-ray, chest C.T. scanning, sinogram and bone scanning. As shown in (Figure 2).

*Technique of intra-operative injection of methylene blue and hydrogen peroxide:

The idea is to stain all the cavities inside through the skin sinus by using a blunt plastic part of a cannula without its metal trocar. Then 10-15 ml of the solution is injected within the sinus tell the syringe is injected. The stained hydrogen peroxide will push itself through possible cavities and stains it. (Figure. 3)

Surgical technique: Skin incision is made according to the site of the

lesion. If the tenderness is located on the anterior chest wall at a certain site over a specific rib , the skin incision is made vertically over the mid-portion of the sternum including any skin sinus if any) and extended laterally over the involved rib ( if more than one rib is involved ,the incision is done over the rib in the middle of the lesion). A flap of skin and subcutaneous tissue is elevated over the anterior chest wall. The involved rib (or ribs) is apparent beneath the pectoralis major muscle. The muscle is split along its direction of the fibers. Then the whole tissues down to periosteum are incised , the osteomyelitic rib appears (Figure 4) eroded ,irregular, dull ,floating,

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Figure 2 : A: sinogram showing 2 left sided tracts.B: bone scan showing activity of the left costal margin in anterior view in the bone phase.C: C-T with contrast showing the eroded ribs on both sides with periosteal thickening in 63 years old female.


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Patient no

sex age Post CABG time Site & side Extent of rib affection known postoperatively

1 F 47 12 months antero-lateral ribs Left side 4-6 ribs2 M 52 9 months antero-lateral ribs Left side 6-9 ribs3 M 61 13months antero-lateral ribs Left side 5-8 ribs4 M 62 17 months antero-lateral ribs Left side 7-10 ribs5 F 48 10 months antero-lateral ribs Left side 4-8ribs6 F 54 8 months antero-lateral ribs Left side 4-8 ribs7 F 63 12 months antero-lateral ribs both sides 6-9ribs8 M 62 10 months antero-lateral ribs Both sides 5-9 ribs9 M 51 11 months antero-lateral ribs Left side 6-8 ribs10 M 55 15months antero-lateral ribs Left side 4-6 ribs11 F 49 14 months antero-lateral ribs Left side 6-7ribs12 M 67 13months antero-lateral ribs Left side 6-9 ribs13 M 70 12 months antero-lateral ribs Left side 4-6 ribs14 F 61 9 months antero-lateral ribs Left side 6-8 ribs15 F 48 17 months antero-lateral ribs Left side 5-9 ribs16 F 65 8 months antero-lateral ribs Left side 4-8 ribs17 M 58 16 months antero-lateral ribs Both sides 6-9ribs18 M 59 12 months antero-lateral ribs Both sides 5-9 ribs19 M 63 12months antero-lateral ribs Left side 6-8 ribs20 M 65 18 months antero-lateral ribs left side 5-9ribs

Table 1 : demographic data of all the patients affected by rib osteomyelitTable 1 : Demographic data, patient characteristics, clinical and operative details.)

Figure 3 : showing the injected sinuses with methylene blue and hydrogen peroxideA= injected two median sternotomy sinuses post 12 months in a 47 years old female patient.B= exposure of the diseased ribs following the staining of tissues.C= the diseased ribs appears stained eroded and floating (easily separated from surrounding periosteum (intra-periosteal excision).

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does not bleed on nippling by bone nippler and is stained by methylene blue so we proceed in removal of diseased parts till reaching normal ribs ( smooth surface, shiny ,regular, not stained, inseparable from periosteum and can easily bleeds on nippling.

. If the staining is near the sternum a portion of the sternum medially is removed to ensure complete removal of the diseased parts (usually this part is underlying the skin sinus) .

After total removal the periosteum and overlying muscles are closed over a suction drain for (3-7) days. And skin is sutured. No flaps were needed in any of our cases.

The removed ribs and parts of bones or cartilage are photographed and sent for histo-pathological examination to prove the pathology. (All the steps of the technique are shown in full details in (Figure 5).

Results:The twenty patients were operated upon for

coronary artery by-pass grafting (CABG) from a period ranged from 8 to 18 months; this was the time of our intervention. They all start complaining of discharging sinus or sinuses in the early postoperative period (as early as 3rd week), as all of them have median sternotomy wound problems like wound infection, partial or complete wound dehiscence, collection and discharge, maceration of wound edges or even necrosis of part of skin. (In our opinion it is a part of ischemic changes that occur after taking the left internal mammary artery for coronary by-

pass). From now the osteomyelitis pathology is started (very low grade infection in presence of ischemia of chest wall post CABG) with remissions and exacerbations till chronicity is established.

100 % of the studied patients were diabetics for 10-21 years, all of them were insulin dependent (Type 1) at the time of surgery. They all complained of frequent attacks of uncontrolled diabetes usually with the exacerbations.

They complained of persistent chest wall dull pain which may show acute exacerbation ( acute inflammation on top of chronic osteomyelitis) with redness, tenderness, edema of overlying skin, all associated with general constitutional manifestations ( fever , headache, malaise, anorexia).

All our patients had an immediate postoperative improvement; the suction drainage is usually left till complete cessation of blood and serum discharge usually by the 3rd -5th days after surgery.

None of the patients need any form of soft tissue coverage of any defect, as the soft tissues over affected ribs are closed directly over suction drain (there is no tissue loss).

Four patients (20%) only complained of bilateral rib osteomyelitis and (80%) had left sided pathology affecting mainly from the 6th till the 9th ribs in more than 60 % of cases. The affection never exceeded the mid-axillary line. The least number of affected ribs was 2 while the maximum number was 5 ribs in each side.

When the pain from surgical trauma disappears, patients were able to do bending, ipsi-lateral and contra-lateral tilt successfully, usually by the end of the 2nd week after surgery.

Figure 4: A case of bilateral rib osteomyelitis removed (ribs are dull eroded irregular and fragmented


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Figure 5: male patient 62 years old A: marking the sinus site to be injected and the most tender points on the left costal margin over 7th, 8th, 9th&10th ribs.B: after methylene blue and hydrogen peroxide injection, excision of scar around the sinus opening, then the tract is followed till reaching the affected ribs.C: exposure of the lateral side over the tender ribs, the dye is noticed.D: the whole tract is exposed deep to the muscle layer of lower chest and upper abdomen.E: the soft tissues over the affected ribs will be oedematous and thickened, after incising it the affected rib is revealed.F: the affected rib is eroded, dull, irregular, may be broken and easily separable from surroundings.G: the wound after removal of all affected ribsH: the removed osteomyelitic parts of the affected ribs stained with methylene blue.

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About wound problems, there was no incidence of wound infection in our study. Moreover the redness or erythematous skin noted over the affected area of active osteomyelitis (2ry infected or acute exacerbation of chronic osteomyelitis) showed rapid improvement then complete disappearance as in (figure 6). The hospital stay ranged from 3-5 days to ensure removal of suction drain, parenteral antibiotic complete course and starting wound healing process.

Figure 6: the improvement of the erythema of the overlying skin of osteomyelitic ribsA: preoperative photo showing the redness.B: 3 wks postoperatively showing the disappearance of the erythematous skin.

Discussion:The incidence of mediastinal and chest wall

infections after cardiac surgery has been reported to range from 0.39% to 8.4%. (1) Diabetes, obesity, COPD, Bone wax usage and Blood transfusion are important associations of infections in patients underwent CABG surgery. ( 3) (4) (5) (6) (7) (8)

In our study, all the twenty patients suffered early post CABG from wound infection and discharge which necessitates prolonged hospital stay and antibiotic therapy in 100% of cases and 40 % of them needed re-exploration of the wound for debridement or drainage and rewiring and 20% of them needed flap coverage by omental flap to fill the retrosternal cavity to avoid recollection.

70 % of the patients were diabetics for 10-21 years all of them were insulin dependent (Type 1) at the time of surgery. They all complained of frequent attacks of uncontrolled diabetes usually with the exacerbations. 20 % only were obese with BMI above 35 kg/m2. COPD was found in 60 % of cases. Bone wax was used in all our patients, and all of them had received blood transfusion during CABG.

There is frequently a substantial degree of ischaemia and mat be ischaemic necrosis of the bone on the side of the IMA graft. The risk is particularly great in the elderly and the diabetic patients. Excessive cauterization during IMA harvesting damages the blood supply to the sternum, impedes sternal wound healing and exposes the sternum to the risks of early dehiscence and infection, especially, if both IMAs are harvested as the IMA is the primary source of blood supply to the sternum. (10)

No previous studies concentrate on the pathogenesis of osteomyelitis of the ribs in post CABG patients. In our opinion the pathogenesis may be explained by the occurrence of early infection on top of ischemia of the chest wall, the ischaemia will allow for the chronicity and the spread of the infecting organisms through different tissue planes.

The multiple ischaemic planes leading to multiple rib affection which was seen in all our patients. The presence of multiple sinuses allow for more affection, with more liability for spreading to other ribs. Even recurrent attacks of exacerbation of primary focus may spread to other healthy sites. The infection usually spreads from sternotomy site or focus around stainless steel wires, focus

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around pacemaker wire or even a subcutaneous infection. Reaching the ischemic costo-chondral junctions and ribs, so the chronic osteomyelitis is started.

All the removed ribs from our patients which were sent for histo-pathological diagnosis were proved to be osteomyelitic (100%).

The proper diagnosis of post CABG rib osteomyelitis should be based on proper history taking (elderly diabetics ,above 50 years , with early post CABG wound problems and chronic severe chest wall pain with attacks of remissions and exacerbations) , clinical examination ( looking for chest wall sinuses , erythema and tenderness of the overlying skin of the painful site and may be bony crepitus) and investigations (sinography, C-T scanning and bone scan).

In our technique, using the methylene blue and hydrogen peroxide to stain the involved planes and affected ribs, when injected through openings of chest wall sinus (es), we found it very beneficial in staining unexpected sites which were pathological and were not clinically suspicious.

Reconstruction was not needed in all our patients as there were no soft tissue losses after intra-periosteal excision of the involved ribs.

Conclusion:Chronic osteomyelitis of the ribs is usually a

missed problem that should be suspected in post CABG patients specially if diabetics who had wound problem early postoperative. Chronic dull aching chest wall pain that shows intermittent exacerbation associated with erythema of overlying skin and tenderness and may be crepitus with discharging pre sternal sinus or sinuses. Confirmation of the diagnosis is done by sinogram, C.T scanning and radio-isotopic bone scanning.

Surgical excision of the affected ribs is done intra-periosteally where the eroded diseased ribs are removed after their staining by methylene blue not to miss any affected part. All patients showed marked improvement with good rapid healing of the surgical wounds.

References:1- Bishara J, Gartman-Israel D, Weinberger M, et al.:

Osteomyelitisoftheribsintheantibioticera.ScandJInfecDis;32:222–223.2000

2- BitkoverCY,GardlundB:Mediastinitisafter cardiovascularoperations:acase-controlstudyofriskfactors.Ann.Thorac.Surg.,65:36-40.1998.

3- WoutersR.,WellensF.,VanermenH,DeGeestR,DegrieckI,DeMeerleerF:Sternitisandmediastinitisafter coronaryartery bypass grafting.Analysis of risk factors. Text HeartInst.J.,21:183-188,1994.

4- Baskett RJ, MacDougall CE, Ross DB: Is mediastinitis apreventable complication?A 10-year review.Ann. Thorac.Surg.,67:462-465,1999.

5- Robicsek F., Masters R.N., Littman L., Born G.V. : Theembolization of bonewax from sternotomy incisions.Ann.Thorac.Surg.;31:357-359,1981.

6- JohnsonP.andFrommD.:Effectsofbonewaxonbacterialclearance.Surgery;89:206-209,1981

7- Raudat C.W., Pagel J., Woodhall D., Wojtanowski M.,BergenR.V.:Earlyinterventionandaggressivemanagementof infected median sternotomy incision: A review of 2242open-heartprocedures.TheAmericanSurgeon;63:238-242,1997.

8- OttinoG.,DePaulisR.,PansiniS.,RoccaG.,TalloneM.V.,ComoglioC.,etal.:Majorsternalwoundinfectionafteropenheartsurgery:Amultivariateanalysisofriskfactorsin2,579consecutive operative procedures. Ann. Thorac. Surg.; 44:173-179,1987.

9- RandR.P.,CochranR.P.,AzizS.,BradleyH.O.,AllenD.M.,Verrier E.D., et al.: Prospective trial of catheter irrigationandmuscleflaps forsternalwound infection.Ann.Thorac.Surg.;65:1046-1049,1998.

10-BerdajsD.,ZündG.,TurinaM.I.,GenoniM.:Bloodsupplyofthesternumanditsimportanceininternalthoracicarteryharvesting.Ann.Thorac.Surg.Jun;81(6):2155-9,2006.



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Anomalous right coronary artery ostium encountered during aortic valve

replacement surgeryR Jeffrey , MDY Hegazy, MDS Mac Angnus

correspondance to :DR.Y.Hegazy

Cardiothoracic Surgery Unit , ARI ,

Aberdeen , UK

Email : [email protected]

Case report

We experienced a case with anomalous right coronary ostium origin during aortic valve surgery. The anomalous artery was injured inadvertly during the routine aortotomy transverse incision for aortic valve replacement , a saphenous vein graft segment was interposed between the ascending aorta and the separated injured coronary artery as management of the problem.Origin of the right coronary artery from the left sinus of valsalva is a rare congenital anomaly of less than 1% (1), classified by most of the pathologists as minor and of no importance (2) , but unpredicted association of coronary artery anomaly with acquired heart disease may create a problem in patients undergoing aortic valve replacement(3).

A 58 years old gentleman was admitted to the hospital with history of progressive dyspnea and echocardiographic findings revealing bicuspid aortic valve with extensive calcification and severe aortic stenosis with peak systolic gradient of 83 mmhg .Preoperative coronary angiogram showed a dominant

right coronary artery with anomalous origin and mid segment lesion . An elective Aortic Valve replacement operation was performed under moderate hypothermic cardiopulmonary bypass . Cardiac arrest was achieved by antegrade and subsequent retrograde blood cardioplegic solution delivery.The left coronary artery arose normally from the left posterior coronary sinus of valsalva . The right coronary artery could not be seen in the right sinus of valsalva although the artery was known to have an anomalous origin, it was not anticipated to amarise so posterialy as the pre opangio auggested it was only displaced toward the P A. and was iatrogenically transected during the aortotomy transverse incision as it passed between the aorta and the pulmonary artery instead of originating from the aorta under the atrial appendage (fig1).after the aortic valve was replaced with a Medtronic Hancock II porcine tissue valve size 23 mm, the transacted ostium of the right coronary artery was stitched securely in the line of the aortotomy closure .while the proximal segment of the right coronary artery was carefully explored and mobilized free from the aortic wall and anastomosed to a reversed saphenous vein graft segment (3cm) the proximal end of which was anastomosed to the ascending aorta.with 6/0 prolene suture successfully (fig.2) .The postoperative course of the patient was uneventful and he was discharged home.

Comment :Anomalous coronary arteries are usually an incidental findings during

conventional coronary angiography 0.17-2% (5) when cardiac surgeons are aware of such abnormality they can avoid injury of any aberrent artery by altering the operative strategy whether by changing the location of aortotomy incision or sometimes by changing the type of the valve used. The orifice of the coronary arteries should be generally explored to avoid iatrogenic operative


Case report

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R Jeffrey et all

morbidity specially in patients with small aortic root or bicuspid valves . Intraoperatively the course of the anomalous coronary artery could be defined by placing a probe gently in the abnormally located ostium delineating the course of the abnormal artery (fig 1)

Fig.(1) a probe placed in the located cut right coronary artery delineating the abnormal course of the vessel.

Fig.(2) a saphenous vein graft segment interposed between the ascending aorta and the separated injured coronary artery

In summary routine coronary angiography is very important prior to aortic surgery . the use of transesophageal echocardiography is also reasonable to demonstrate the relationship of the anomalous right coronary artery with the aortic root. (1).operative consideration of adequate mobilization of the injured vessel and saphenous vein interposition graft usage(4) are very important to ensure tension free anastomosis and avoid kinking (5).

References(1)KaanInanM.D.,AlperUcakM.D.,BurakOnanM.D.,Burak

TamtekinM.D.,VeyselTemizkanM.D.,AhmetTuranYilmazM.D.

Posterior Root Enlargement for Aortic Valve ReplacementAssociated with Unexpected Anomalous Right Coronary

ArteryJournalofCardiacSurgery2010;25;(1),92–95,(2)Berkeley Brandt,JamesMartins,Melvin Marcus . Anomalous

origin of the right coronary artery from the left sinus ofvalsalva.

NEngJMed1983;309:596-598(3)SurajitDanandAndrewJ.Hodge.Anomalous right coronary ostium cleft sinus of valsalva.

omplicating aortic valve replacement . TheAsiaPacificHeart JournalVolume6, Issue2,September

1997,127(4)YoshioMisawa, ,TsutomuSaito,Shin-ichiOkiandKatsuo

Fuse.Management of anomalous right coronary arteries

encounteredduringaorticvalvesurgery .humanpathology1992;23(10):1182-1184

(5)Shah AS, Milano CA, Lucke JP. Anomalous origin of the rightcoronary artery from the left coronary sinus: case report andreviewofsurgicaltreatments.CardiovascSurg2000;8:284–6

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