Adequate pain control after cardiac surgery is essential. Paravertebral block is a simple technique and avoids the potential complications of epidural catheters. The objective of this study is to ...compare the effect of ultrasound-guided bilateral thoracic paravertebral block with thoracic epidural block on pain control after cardiac surgery.
Between March 2016 and 2017, 145 patients who had cardiac surgery through median sternotomy were randomized by stratified blocked randomization into two groups. Group I (
= 70 patients) had bilateral ultrasound-guided thoracic paravertebral block and Group II (
= 75 patients) had thoracic epidural analgesia. The primary end point was the postoperative visual analogue scale (VAS). The duration of mechanical ventilation, intensive care unit (ICU), and hospital stay were the secondary end points. The study design is a randomized parallel superiority clinical trial.
Both groups had similar preoperative and operative characteristics. No significant difference in VAS measured immediately after endotracheal extubation then after 12, 24, and 48 hours between groups (
= 0.45). Pain score significantly declined with the repeated measures (
< 0.001) and the decline was not related to the treatment group. Postoperative pain was significantly related to diabetes mellitus (
= 0.039). Six patients in group I (8.5%) required an additional dose of morphine versus three patients (4%) in group II (
= 0.30). Patients in group I had significantly shorter ICU stay (
= 0.005) and lower incidence of urinary retention (
= 0.04) and vomiting (
= 0.018). No difference was found in operative complications between groups.
This randomized parallel controlled trial demonstrates that ultrasound-guided paravertebral block is safe and effective method for relieving post-cardiac surgery sternotomy pain compared with thoracic epidural analgesia but not superior to it.
Current classifications of cor triatriatum sinister (CTS) do not address the associated heart defects or single ventricle pathology. Therefore, these classifications are not prognostic ...classifications and only describe the anatomy and the pulmonary venous drainage. The proposed classification considered the associated congenital cardiac lesions and the single ventricle pathology, therefore, it could have prognostic value. Future multicenter studies are required to measure the performance of this classification and its prognostic value in patients with CTS.
Cellular injury is not avoidable with current cardioplegic solutions. The effect of adenosine on reducing cardiac injury post-surgery is controversial. The objective of the current study is to ...evaluate the effect of fast cardioplegic arrest induced by adenosine on high sensitive cardiac troponin I after heart valve surgery.
Forty-five (45) patients with rheumatic heart diseases underwent heart valve surgery using conventional approach through median sternotomy. They were classified into two groups, group I (n=21) patients received 0.25mg/kg adenosine into the aortic root just after aortic cross-clamping and before infusion of the cold hyperkalaemic crystalloid cardioplegia via antegrade route and group II (n=24) who received cold crystalloid hyperkalaemic cardioplegia without adenosine. Cardiac troponin I was measured preoperatively and on postoperative days 0, 3 and 7.
There was no significant difference between both groups in the demographic, preoperative and operative data. Adenosine significantly reduced arrest time. Postoperative high sensitive cardiac troponin I increased significantly in both groups compared to the preoperative levels and the rise continued till postoperative day 3. Troponin levels were significantly lower in the adenosine group compared to the control at all measurements. The clinical outcomes were non-significant different between groups.
Using adenosine in inducing fast cardioplegic arrest in heart valve surgery after aortic cross clamp and prior to infusion of the cold cardioplegia had significantly decreased postoperative cardiac troponin levels which was used as a proxy for cellular injury compared to the control group.
Immunoglobulin G4 Thymic Tumor Arafat, Amr A; Torky, Mohammad A; Elhamshary, Mustafa ...
The Annals of thoracic surgery,
10/2019, Volume:
108, Issue:
4
Journal Article
Peer reviewed
Open access
Thymic immunoglobulin G4 (IgG4) is a rare entity that can mimic anterior mediastinal tumors. Preoperative diagnosis is essential to prevent unnecessary surgery. Little is known about disease ...presentation, diagnosis, and response to therapy. A 40-year-old man presented with retrosternal chest pain. A roentgenogram showed an anterior mediastinal mass. Intraoperatively, dense adhesions to the phrenic nerve, aorta, and pulmonary artery deemed the tumor unresectable. Thymic IgG4 disease was diagnosed on the basis of tissue biopsy. The patient's postoperative serum IgG4 level was elevated, and no other organ was affected. The patient responded to prednisolone therapy, and after 18 months of follow-up, there was no recurrence or involvement of other organs.
Purpose: We compared the composite outcome of tricuspid valve (TV) reintervention or heart failure (HF) admission in patients who underwent tricuspid valve replacement (TVR) with tissue vs. ...mechanical valves.Patients and Methods: The study included 159 patients who underwent TVR from 2009 to 2019. We grouped the patients according to the valve’s type into tissue valve group (n = 139) and mechanical valve group (n = 20).Results: The mean age of patients was 52.4 ± 12.8 years, and 117 patients were females (73.6%). Hospital mortality occurred in 20 patients (12.6%); all of them were in the tissue valve group. The composite outcome of reintervention and HF readmission occurred in 8 patients with mechanical valves (40%) vs. 24 patients with tissue valves (17.3%), (P = 0.018). Predictors of reintervention and HF admission were female (subdistributional hazard ratio SHR: 1.38–34.3, P = 0.019), stroke (SHR: 1.25–8.76, P = 0.016), hypertension (SHR: 1.13–5.36, P = 0.024), and mechanical valves (SHR: 1.6–10.7, P = 0.003). In post hoc analysis, the difference in the composite outcome was derived from the difference in the reintervention rate that was higher in mechanical valves. Survival did not differ significantly between groups (P = 0.12).Conclusion: Mechanical TVs have a higher rate of composite outcome of reintervention or HF readmission than tissue TVs that are related mainly to higher rate of reintervention.
Abstract
Data on mitral valve replacement (MVR) in young children is still limited. Our objective was to evaluate MVR in children below 5 years and identify factors affecting the outcomes. This ...retrospective study included 29 patients who had MVR from 2002 to 2020. We grouped the patients into two groups according to their age: age ≤ 24 months (n = 18) and > 24 months (n = 11). Primary cardiac diagnoses were Shone complex (n = 7; 24%), isolated congenital mitral valve abnormality (n = 11; 38%), and complete atrioventricular septal defect (n = 3; 10%). The median age was 19 month (25th–75th percentile: 11–32) and 59% were females (n = 17). The hemodynamic lesions were mitral regurgitation in 66%, mitral stenosis in 10%, and combined mitral stenosis and regurgitation in 24% of the patients. St. Jude mitral valve was the most common valve implanted (n = 19, 66%), followed by CarboMedics in 21% of the patients (n = 6). The mitral valve was implanted in the supra-annular position in 6 cases (21%). Preoperative and operative data were comparable between both groups. There was no association between valve size and position with postoperative heart block (P > 0.99, for both). The median follow-up duration was 19.4 months (8.6–102.5). Nine patients had mitral valve reoperation, six had MVR, and three had clot removal from the mitral valve. There was no effect for age group on reoperation (SHR 0.89 (95% CI 0.27–2.87), P = 0.84). Valve size significantly affected reoperation (SHR 0.39 (95% CI 0.18–0.87), P = 0.02). The supra-annular position was associated with an increased risk of reoperation (SHR 3.1 (95% CI 1.003–9.4), P = 0.049). There was no difference in survival according to the age (Log-rank P = 0.57) or valve size (Log-rank P = 0.66). Mitral valve replacement in children is associated with low morbidity and mortality. The risk of reoperation could be affected by the valve size and position rather than the age.
Background
The aorta is rarely affected by autoimmune vasculitis, which can lead to aortic dilatation requiring surgery. Autoimmune aortitis may affect one aortic segment or the entire aorta, and in ...some cases, the aorta may be affected at different time intervals. Because of the rarity of the disease and the limited cases described in the literature, management of autoimmune aortitis is still controversial. We aimed to review the current literature evidence regarding these controversial aspects for the management of autoimmune aortitis and give recommendations based on this evidence.
Main text
Immunosuppressants are generally indicated in vasculitis to halt the progression of the disease; however, its role after the occurrence of aortic dilatation is debatable since further aortic dilatation would eventually occur because of the weakness of the arterial wall. In patients with a localized ascending aortic dilatation who required surgery, the optimal approach for the distal aorta is not known. If the probability of disease progression is high, it is not known whether the patients would benefit from postoperative immunosuppressants or further distal aortic intervention may be required. The risk of rupture of the weakened aortic wall was not established, and it is debatable at which diameter should these patients have surgery. In patients with previous ascending surgery for autoimmune aortitis, the endovascular management of the distal aortic disease has not been studied. The inflammatory process may extend to affect the aortic valve or the coronary vessels, which may require special attention during the procedure.
Conclusion
Patients with diagnosed autoimmune aortitis are prone to the development of the distal aortic disease, and endovascular intervention is feasible in those patients. Patients with concomitant aortic valve can be managed with the aortic valve-sparing procedure, and preoperative screening for coronary disease is recommended. Immunosuppressants should be used early before aortic dilatation, and its role postoperatively is controversial.
BACKGROUND:
COVID-19 infection affects the quality of the medical services globally. The pandemic required changes to medical services in several institutions. We established a virtual clinic for ...anticoagulation management during the pandemic using the Whatsapp application.
OBJECTIVES:
Compare anticoagulation management quality in virtual versus in-person clinics.
DESIGN:
A retrospective crossover study
SETTINGS:
Specialized cardiac care center
PATIENTS AND METHODS:
The study included patients who presented to Prince Sultan Cardiac Center in Riyadh for anticoagulation management during the pandemic from March 2020 to January 2021. We compared time in therapeutic range (TTR) in the same patients during virtual and in-person clinics. All international normalized ratio (INR) measures during the virtual clinic visits and prior ten INR measures from the in-person clinic were recorded. Patients who had no prior follow-up in the in-person clinic were excluded.
MAIN OUTCOME MEASURE:
TTR calculated using the Rosendaal method.
SAMPLE SIZE:
192 patients
RESULTS:
The mean age was 58.6 (16.6) years and 116 (60.4%) were males. Patients were diagnosed with atrial fibrillation (n=101, 52.6%), mechanical mitral valve (n=88, 45.8%), mechanical aortic valve (n=79, 41%), left ventricular thrombus (n=5, 2.6%) and venous thromboembolism (n=8, 4.2%). Riyadh residents represented 56.7% of the study population (n=93). The median (IQR) percent TTR was 54.6 (27.3) in the in-person clinic versus 50.0 (33.3) (
P
=.07).
CONCLUSION:
Virtual clinic results were comparable to in-person clinics for anticoagulation management during the COVID-19 pandemic.
LIMITATIONS:
Number of INR measures during the virtual clinic visits, retrospective nature and single-center experience.
CONFLICT OF INTEREST:
None.
There is no consensus regarding mitral valve management during surgical ventricular restoration (SVR) for ischemic cardiomyopathy. We compared the impact of SVR with mitral valve repair (MVr) vs ...replacement (MVR) on postoperative outcomes and long-term survival in ischemic cardiomyopathy and mitral regurgitation patients. This study included 112 patients who underwent SVR from 2009 to 2018 with MVr (n = 75) or MVR (n = 37). Patients who had MVR had higher Euro SCORE II, dyspnea class, a lower ejection fraction, higher pulmonary artery systolic pressure, higher grade of preoperative mitral and tricuspid regurgitation, and higher end-diastolic and end-systolic diameters. Intra-aortic balloon pump was more commonly used in patients with MVR. Hospital mortality occurred in 7 (9.33%) patients in the MVr group vs 3 (8.11%) in the MVR group (P > .99). Freedom from rehospitalization at 1, 5, and 7 years was 87%, 76%, and 70% in the MVr group and 83%, 61%, and 52% in the MVR group (P = .191). Survival at 1, 5, and 7 years was 88%, 78%, and 74% in the MVr group and 88%, 56%, and 56% in the MVR group (P = .027). Adjusted survival did not differ between groups.
MVr or MVR are valid options in patients undergoing SVR, with good long-term outcomes.
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