Evaluation of the preoperative administration of sildenafil on operative and early postoperative outcome after mitral valve replacement in patients with pulmonary hypertension

Background: Mitral valve diseases are commonly associated with pulmonary hypertension. The aim of this study was to evaluate the effect of preoperative administration of sildenafil on the outcome after mitral valve replacement in patients with pulmonary hypertension. Methods: This prospective randomized study was carried out on 67 patients who had a mitral valve replacement and associated high systolic pulmonary artery pressure more than 50 mmHg. Patients were randomized into three groups: group A (n= 20) received preoperative sildenafil for one week, group B (n=22) received sildenafil for one month, and group C (n= 25) did not receive sildenafil. All patients had transthoracic echocardiography preoperatively, one week and one month postoperatively. Results: There was no difference in preoperative and operative variables among groups. Dobutamine support was required in 15 patients (60%) in group C vs. 6 patients (30%) in group A and 5 patients (22.5%) in group B (p= 0.012). Duration of mechanical ventilation was significantly longer in group C (389.2 ± 48.79 minutes) compared to group A and B (295.5 ± 17.01 and 281.4 ± 39.44 minutes, respectively, p<0.001). ICU stay was longer in group C (61.72 ± 13.69 hours) compared to groups A and B (53.55 ± 14.49 and 45.64 ± 13.43 hours, respectively, p=0001). The hospital stay was longer in group C (8.0 ± 1.80 days) compared to group A and B (6.05 ± 0.94 and 6.27 ± 1.24 days, respectively; p< 0.001). The transthoracic echocardiographic study one month after the operation showed that pulmonary artery systolic pressure significantly lower in groups A and B (28.30 ± 3.3 and 28.2 ± 4.98 mmHg, respectively) compared to group C (43.12 ± 4.99 mmHg) (p <0.001). There was no statistically significant difference between groups A and B regarding PASP after five days (p= 0.287) or one month (p= 0.939). Conclusion: We found that preoperative administration of oral sildenafil in patients with pulmonary hypertension undergoing mitral valve replacement may reduce pulmonary hypertension postoperatively. We could not find a difference in the administration of sildenafil for either one week or one month preoperatively.

Percutaneous drainage of delayed post-cardiac surgery pericardial effusion

Background: Pericardial effusion and tamponade are common following valve surgery. The optimal treatment of symptomatic pericardial effusions remains controversial. The objective of this study was to present our experience in non-surgical management of delayed postoperative pericardial effusion. Methods: This retrospective study was conducted on 64 patients who had delayed pericardial effusion after cardiac surgery from 2016 to 2020. Eight patients were excluded due to the presence of inaccessible posterior or clotted pericardial effusion and were managed surgically, and 56 patients had percutaneous drainage of the pericardial fluid and were included in the analysis. Results: The mean age was 46.84±11.67 years (range: 22- 68 years), and 46.43% were females. The patients had coronary artery bypass grafting (n= 9), Aortic valve replacements (n= 13), Mitral valve surgery (n= 21), double valve replacements (n= 8) and combined procedures (n= 5). All patients complained of varying degrees of exertional dyspnea. There were statistically significant differences between INR in different cardiac surgeries. Mean INR following mitral valve replacement (4.72±0.63) was significantly higher than in aortic valve replacement patients (3.32±0.34; p<0.001) and aortic valve patients (1.76±0.24; p<0.001). Fifteen patients (26.78%) had a large pericardial effusion. Successful drainage was achieved in all cases. Complications were pneumothorax (n= 2, 3.57%), recurrent effusions (n= 4, 7.14%), arrhythmias (n= 7, 12.5%), myocardial punctures (n= 2, 3.57%) and no mortality was reported. Conclusions: percutaneous drainage of postoperative pericardial effusion under radiological guidance is generally safe. Pericardial effusion is common after mitral valve surgery, which could be related to higher INR in these patients.

Routine versus selective plasma exchange before thymectomy in myasthenia gravis

Background: Prethymectomy plasma exchange may improve the outcome of surgery; however, the technique is associated with an increased risk of complications. Therefore, the objective of this study was to compare selective versus routine plasma exchange before thymectomy in patients with myasthenia gravis. Method: We conducted a prospective multi-center cohort study to compare two protocols for plasma exchange before thymectomy. We compared the routine plasma exchange in all patients undergoing thymectomy for myasthenia gravis (group I; n= 30) versus selective exchange (Group II; n= 30). Endpoints were the duration of postoperative mechanical ventilation, plasma exchange, and operative complications. Results: There was no difference in age between both groups (30± 10.1 vs. 29± 9.2 years in Group I and II, respectively; p= 0.69). There were 17 females in Group I (56.67%) vs. 16 in group II (53.33%) (p= 0.8). Comorbidities are comparable between groups. All patients preoperative pyridostigmine, and 27 patients (90%) in Group I and 26 patients (87%) in Group II received glucocorticoids. There was no difference in pulmonary function tests between groups. Plasma exchange related complications were not different between groups. Immediate extubation was achieved in 29 patients (97%) in Group II, and after 6 hours in one patient (3.33%). In Group I, 28 patients (93%) extubated immediately, and two patients were ventilated for 7-12 hours. The mean ICU stay was 1.5 days in Group I and 1.4 days in group II (p= 0.615). The mean hospital stay was 8.5 days in Group I and 9.2 days in group II (p= 0.118). There was no significant difference in pathology between groups (p= 0.137). Conclusion: Selective plasma exchange is feasible before thymectomy for myasthenia gravis. Selective plasma exchange may decrease exchange related complications without affecting the operative outcomes.

Chest Wall Tumors: A Spectrum of Different Pathologies and Outcomes of Reconstruction Techniques

Background: Chest wall resection and further reconstruction for tumors represent a challenging concept for surgeons. Thanks to the evolving reconstruction techniques, good results were obtained after extensive resection and reconstruction. Patients and methods: This prospective cohort study was conducted at our University Hospitals throughout 5 years. A total of 43 eligible cases with chest wall tumors were included. All cases were subjected to a multidisciplinary team approach, complete history taking, physical examination, radiological evaluation, and biopsy. The details of surgical techniques, complications, and follow up parameters were included. Results: The mean age of the included cases was 29.45 years. We included a total of 24 males (55.8%). Fibromatosis was the commonest encountered pathology (27.9%), followed by chondrosarcoma (25.5%), and osteosarcoma (21%). Regarding the method of reconstruction, polypropylene mesh was used in 46.5% of cases, followed by direct closure (30.2%). Ten cases were managed by Methyl Methacrylate within the proline mesh (23.3%), while superimposed muscle flap was performed in only 2 cases (4.6%). Post-operatively, bleeding was encountered in 5 cases collectively (11.6%), while wound infection occurred in 11.6% of cases. Pulmonary complications included pneumonia (2.3%) and atelectasis (11.6%). Furthermore, chest wall instability was present in (11.6%) of cases. On follow up, recurrence was diagnosed in (9.3%) of cases (n = 4). Conclusion: Surgical intervention is very effective if tailored to every patient as per team paln. A multidisciplinary team approach is extremely important especially if an extensive demolition is required. Indeed, radical wide en-bloc resection can achieve satisfactory results provided that the extent of resection is not influenced by any anticipated reconstruction problems.

Timing of Coronary Artery Bypass Grafting Surgery after Acute Myocardial Infarction

Background: Optimal timing for CABG surgery after myocardial infarction remains a matter of debate. The aim of our study was to analyze the effect of timing of CABG after acute myocardial infarction on operative mortality and morbidity. Methods: This prospective study included 60 patients who underwent isolated CABG within 30 days of acute myocardial infarction over 20 months (from the first of November 2014 till the end of June 2016) in Kasr Al-Ainy University Hospitals. Patients were divided into two groups; the early group (0 – 3 days) included 14 patients (23.3%) and the late group (4 – 30 days) included 46 patients (76.7%). The primary outcome was all-cause hospital mortality. Results: Our study included 43 males (71.7%) and 17 females (28.3%). The mean age was 58.4 ± 7.3 years. The total mortality rate was 8.3%. Patients undergoing early CABG experienced a higher mortality rate than those undergoing late CABG (21.4% vs 4.3%, P = 0.043). Also, early CABG was associated with more postoperative complications. Cardiogenic shock and early CABG were independent risk factors of mortality. Conclusion: CABG in the first 3 days after acute myocardial infarction was associated with high mortality and morbidity in comparison with late CABG. This suggests that CABG may best be deferred for more than 3 days after acute MI in non-urgent cases.

Sternal healing after bilateral internal mammary arteries use for Coronary artery bypass grafting in diabetic Patients; short-term results

Background: Bilateral internal mammary artery (BIMA) use may improve long-term outcomes after coronary artery bypass grafting (CABG); however, the risk of infection is high. Skeletonization of the internal mammary may decrease the risk of infection, especially in patients with diabetes. Our study aimed at evaluation of sternal healing in diabetic patients with different techniques of bilateral internal mammary artery harvesting. Methods: This prospective randomized study included 200 diabetic patients who underwent CABG using BIMA between 2017 and 2019. We divided patients into two groups; Group A had skeletonization of both internal mammary arteries, and Group B had pedicled left mammary and skeletonized right mammary. Patients were observed for three months, post-operatively for any sternal wound problems. Results: There was no significant difference regarding the baseline variables. Type I diabetes mellitus was present in 25% in group A (n= 24) and 13.64% in group B (n= 12) (p= 0.324). There was no difference in harvest time between groups (83 ±4 vs. 81 ±3 minutes in group A vs. B, respectively. P= 0.1). The mean number of grafts was 3± 0.5 in Group A and 3± 0.6 in Group B (p= 0.8). Postoperative drainage was 402.9 ± 174.1 ml in Group A vs. 387.2 ± 153.6 ml in Group B (p= 0.474). The duration of ICU stay did not differ significantly between groups (2± 0.7 in Group A vs. 2± 0.5 in Group B; p= 0.8). Deep sternal wound infection occurred in 4.17% in group A (n= 4) and 4.55% in group B (n= 4) (p= 0.705). Superficial wound infection occurred in eight patients in group A (8.33%) and eight patients in group B (9.1%) (p= 0.59). No patient had sternal dehiscence in group A vs. four patients in group B (4.55%) (p= 0.39). Conclusion: We did not find differences between bilateral mammary artery harvest with skeletonization of both arteries versus skeletonization of the right mammary only on sternal healing nor wound infection in diabetic patients undergoing CABG. A larger study is recommended.

Skeletonized versus pedicled left internal mammary artery harvesting and risk of sternal wound infection after coronary artery bypass surgery

Background: The left internal mammary artery (LIMA) is the gold standard conduit for coronary artery bypass grafting (CABG). There are two harvesting methods, either pedicled or skeletonized. The choice of any technique must consider its complication profile, especially sternal wound infections (SWI). This study aims to evaluate and compare the occurrence of SWI after pedicled and skeletonized LIMA harvesting techniques for CABG. Methods: This prospective observational study included 300 patients who had CABG between 2016 and 2019. We included patients who had pedicled LIMA (n=200) in group 1 and who had skeletonized LIMA (n=100) in group 2. All patients completed a follow-up period of 3 months after CABG. The evaluation during follow-up included: sternal instability, signs of wound infection, temperature, the microbiological study of wound discharge, and chest computed tomography scan. Results: There was no significant differences in age (p = 0.20), male to female ratio (p = 0.43), body mass index (p = 0.12), NYHA I/II (p = 0.50), diabetes mellitus (p = 0.28), ejection fraction (p= 0.14), and EuroSCORE II (p= 0.09) between groups. No significant difference in cardiopulmonary bypass time (p = 0.24), and cross-clamp time (p= 0.19) between groups. There was a significant increase in the total operating time in skeletonized LIMA group (212.77±75.25 min vs. 190.78±55 minutes, p= 0.004). Skeletonized LIMA was significantly associated lower incidence of SWI than that with pedicled LIMA (4% vs 15.5%, p= 0.003), and non-significantly lower incidence of deep SWI (1% vs 4.5%, p= 0.11). The risk factors for SWI in patients who had pedicled IMA were obesity (OR: 13.06, 95%CI: 3.98-42.89), diabetes mellitus (OR: 10.51, 95%CI: 2.35-46.84), and excessive diathermy (OR: 12.62, 95%CI: 3.93-40.54). Conclusion: Obesity, diabetes, and the use of excessive diathermy for hemostasis may increase the risk of sternal wound infection with pedicled LIMA harvest compared to skeletonized LIMA in patients undergoing CABG.

Beating-heart versus conventional mitral valve replacement; a randomized clinical trial

Background: Various methods have been developed to overcome the deleterious effects of ischemia/ reperfusion injury that occurs after cardioplegic arrest. The aim of the study was to assess the safety, efficacy, and applicability of the beating-heart mitral valve replacement (MVR) compared to the conventional MVR. Methods: Forty patients scheduled for mitral valve replacement were randomly assigned into two groups, conventional MVR as the control group (n= 20) and beating-heart MVR with continuous antegrade coronary perfusion as the study group (n=20). Three patients in the beating-heart group were converted to the conventional technique because of the blood-flooded field and excluded from the analysis. Results: The preoperative clinical and echocardiographic variables were comparable between both groups. There was no significant difference between both groups regarding cardiopulmonary bypass time (79.4± 14 vs. 75.7± 10.9 minutes; p= 0.398) and total operative time (200± 55.6 vs. 183.9± 67.5 min; p= 0.458) in the conventional and beating-heart group, respectively. Serum troponin I level was significantly higher in the conventional MVR group 6 hours postoperatively (4.9±4 vs. 2.7±1.2 ng/ml; p= 0.036), while there was no significant difference between both groups regarding total CK and CK-MB (p= 0.565 & 0.597 respectively). Eight patients (44%) in the conventional MVR group needed inotropic support compared to 3 patients (19%) in the beating-heart MVR group (P = 0.11). There was no operative mortality or major morbidity in both groups. At 6-months follow-up, there was no difference in NYHA class (1.3±0.3 vs. 1.2±0.3; p= 0.336) and the ejection fraction (60.0±6.3 vs. 63.2±6 %; p= 0.139) in the conventional vs. beating-heart group. Conclusion: Beating-heart MVR is a safe alternative to the conventional method with comparable outcomes. There is a relatively blood-filled field compared to the conventional technique.

Antegrade Intermittent Cold Cardioplegia in Comparison to Antegrade Intermittent Warm Cardioplegia in Heart Valve Surgery

Background: The cardioplegic arrest is essential for motionless and bloodless heart valve surgery. The objective of this work was to compare antegrade cold versus warm blood cardioplegia during valve surgery. Methods: This randomized controlled study included 100 patients who had mitral valve surgery. Patients were randomly assigned into two groups; the warm cardioplegic group (n= 50) and the cold cardioplegic group (n= 50). Study endpoints were creatine kinase myocardial band, lactate dehydrogenase, and troponin levels. Results: There was no significant difference in age and sex between groups (p= 0.51 and 0.56, respectively). Cardiopulmonary bypass was significantly longer in the cold group (85.66 ± 22.9 vs. 72.34 ± 25.09 minutes; P= 0.01); however, there was no difference in ischemic time (p= 0.32). The number of DC shocks given for each patient is less in the warm group with a median of 1.5 (range 1-3 times), while in the cold group, the median was 2 (range 2-4 times); p= 0.02. The amount of blood loss was significantly lower among the warm group (645.4 ± 464.93 ml vs. 404 ± 252.7 P< 0.01). warm group had significantly lower postoperative CK (532.78 ± 249.08 vs. 638.14 ± 344.01 IU/L; P< 0.01), CK-MB (78.64 ± 34.58 vs. 103.18 ± 82.11; P< 0.0.01), LDH level (805.3 ± 322.71 vs. 1060.88 ± 500.94 mg/dl; P< 0.01) and (0.4148 ± 0.226 vs. 0.6404 ± 0.411 ng/ml; P< 0.01). Conclusion: Antegrade warm blood cardioplegia may provide better myocardial protection during valve surgery compared to the cold cardioplegia. A larger study is recommended.

Single versus bilateral chordo-papillary apparatus preservation in mitral valve replacement: a hemodynamic study

Background: It has been postulated that disruption of the mitral valve apparatus at the time of mitral valve replacement (MVR) is a risk factor for postoperative ventricular dysfunction. The aim of this study was to evaluate the effect of single versus bilateral chordo-papillary preservation on the left ventricular function in comparison to no preservation. Methods: This study was conducted from 2015 to 2018 on sixty patients who had MVR. The patients were classified into group I included 20 patients who underwent MVR with complete excision of the subvalvular chordae and tips of papillary muscles, group II: included 20 patients who underwent MVR with preservation of posterior chordo-papillary apparatus, and group III: included 20 patients who underwent MVR with preservation of both posterior and anterior chordo-papillary apparatus. Results: There were 20 males (33.3%), and the mean age was 48.76± 8.91 years. Patients in group III were significantly older (37.15 ±4.92, 39.8 ± 5.49, and 57.25 ± 6.93 years in groups I, II, and III, respectively; p< 0.001). The left ventricular end-diastolic (5.40 ±0.34, 4.96 ± 0.43, and 4.44 ± 0.55 mm in group I, II and III, respectively, p<0.001) and end-systolic diameter (4.33 ±0.48, 3.58 ±0.43 and 3.20 ±0.43 mm in group I, II and III; respectively, p<0.001) were significantly reduced in partial and complete preservation groups after 6 months. Left ventricular ejection fraction improved in the bilateral preservation and partial preservation groups after 6 months (45.32 ±9.78, 56.79 ±10.14, and 56.60 ±11.68 % in groups I, II and III respectively, p<0.001). Mechanical ventilation was significantly longer in group I (24.10 ± 6.6, 16.80 ± 5.97, and 15.80 ± 5.24 hours in groups I, II and III, respectively, p<0.001) and the duration of ICU stay was significantly longer in group I (78.65 ± 15.32, 65.40 ± 14.21, and 60.20 ± 12.58 hours in groups I, II and III, respectively, p<0.001). Conclusion: Preservation of the annulo-papillary continuity may preserve left ventricular geometry and performance. Total preservation of chordae could be superior to partial preservation with better left ventricular remodeling and improvement in the left ventricular functions.