Ahmed Afifi

Taking Cardiac Surgery to the People

Cardiovascular disease (CVD) is currently the leading cause of mortality in the world, and it is estimated that 80 % of the disease burden is encountered in low- and middle-income countries (LMICs). While numerous wake-up calls have been issued in the recent years to face this emerging epidemic, little has been achieved. One particularly deficient area is cardiac surgery. This article aims to address the challenges and barriers to establishing cardiac surgery programs in LMICs and some of the existing efforts to overcome them, focusing on a center in Aswan, Egypt, as an example.

Surgery for TGA in Developing Countries : The End of the Beginning∗

T he last 50 years have witnessed dramatic changes in the management of transposition of the great arteries (TGA). This has transformed the disease from being almost universally fatal to being compatible with normal or near normal survival and quality of life. Unfortunately, these changes have been limited to an extremely small proportion of the global community, with a large number of children with TGA born in developing countries continuing to suffer a dismal fate.

Aortic root dynamism, geometry, and function after the remodeling operation: Clinical relevance

Objectives Valve‐conserving operations for aneurysms of the ascending aorta and root offer many advantages, and their use is steadily increasing. Optimizing the results of these operations depends on providing the best conditions for normal function and durability of the new root. Methods Multimodality imaging including 2‐dimensional echocardiography, multislice computed tomography, and cardiovascular magnetic resonance combined with image processing and computational fluid dynamics were used to define geometry, dynamism and aortic root function, before and after the remodeling operation. This was compared with 4 age‐matched controls. Results The size and shape of the ascending aorta, aortic root, and its component parts showed considerable changes postoperatively, with preservation of dynamism. The postoperative size of the aortic annulus was reduced without the use of external bands or foreign material. Importantly, the elliptical shape of the annulus was maintained and changed during the cardiac cycle (&Dgr; ellipticity index was 15% and 28% in patients 1 and 2, respectively). The “cyclic” area of the annulus changed in size (&Dgr;area: 11.3% in patient 1 and 13.1% in patient 2). Functional analysis showed preserved reservoir function of the aortic root, and computational fluid dynamics demonstrated normalized pattern of flow in the ascending aorta, sinuses of Valsalva, and distal aorta. Conclusions The remodeling operation results in near‐normal geometry of the aortic root while maintaining dynamism of the aortic root and its components. This could have very important functional implications; the influence of these effects on both early‐ and long‐term outcomes needs to be studied further.

Giant left atrial appendage aneurysm compressing the left anterior descending coronary artery

Left atrial appendage aneurysm (LAAA) is a rare congenital structural heart disease. It is often diagnosed by echocardiography; however, other imaging modalities can add to its diagnosis and its potential effects on the surrounding structures. A 16‐year‐old boy presented with dyspnea and palpitation. Transthoracic echocardiography showed a large LAAA communicating with the LA through a narrow neck with impaired left ventricular (LV) systolic function. Multidetector cardiac tomography showed that the LAAA is compressing the left anterior descending artery. The LAAA was surgically resected followed by improvement of the LV systolic function.

Giant Congenital Left Atrial Appendage Aneurysm

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 10-year-old girl presented with a 2-month history of atrial fibrillation. Chest x-ray film showed marked cardiomegaly (A) . Transthoracic echocardiography showed a giant (13 × 10 cm) saccular aneurysm

Predicting the future by looking at the past: necessary but not binding

In the complex field of cardiac surgery, risk stratification is important pre-operatively, to aid in a dispassionate prediction of outcome, and post-operatively, to allow adjustment for comparative audit. A good risk scoring system can help to put things in perspective for patients, healthcare providers, insurance companies, and, importantly, public opinion. Ranging in complexity from simple risk scores to sophisticated prediction calculators, many risk stratification models have been proposed for cardiac surgery (Table 1). In this issue of the journal, Dr Marco Ranucci and his colleagues from San Donato study the effectiveness of a simple risk score, utilizing age, creatinine, and ejection fraction (ACEF) and the addition of two parameters, namely anaemia and emergency surgery (ACEF II). The authors are to be congratulated for adding to the literature a simple risk score that surgeons can work out in their head. Their description of parsimonious may, actually, be its strength. As clinicians, we want to offer the best care for our patients and community. In the journey of climbing Mount Excellence, every effort is made to identify risks, prepare for the procedure, and then audit its outcomes. While audit of outcome is a major drive for quality, it can hinder the provision of care, especially for very sick patients. This is where risk stratification can be very helpful. As a clinician, it is important when applying a risk score to do so with an open mind, putting the patient first within his/her clinical context. It is a balancing act between patient individualization and standardization. For auditing outcomes and verifying risk assessment, surgeons and institutions have been using statistical techniques and forensic approaches. The statistical method, by means of data collection and numerical analysis, has advanced significantly in predicting surgical results. While adding a dispassionate indication of how the outcome will be, the clinical intricacies of each patient, inevitably, make this method defective. The forensic method, of reflection and explanation, is what puts statistical data in perspective to makes sense of the mathematical extrapolation. Working with the risk score proposed by the authors would exemplify statistical audit while discussion of case morbidity or mortality, individually or in series, would account for forensic audit. Various institutions have ’forensically’ audited their statistical risk scoring systems to find good correlation with prospective outcomes. In their construction, it should be identified that risk scores will remain a moving target. Components of these scores will change in size, shape, and, indeed, order of importance with time. Revision of our systems and validation of their calculations will be continuously required as we try to predict the future by looking at the past.

CTS Trials Network: A paradigm shift in the surgical treatment of moderate ischemic mitral regurgitation?

The Cardiothoracic Surgery Trials Network has reported results of the one-year follow up of their randomized trial “Surgical Treatment of Moderate Ischemic Mitral Regurgitation”. They studied 301 patients with moderate ischemic mitral regurgitation (IMR) undergoing coronary artery bypass grafting (CABG) with or without mitral repair with the primary end-point of change in left ventricular end-diastolic volume index (LVEDVI) at one year and multiple clinical and echocardiographic secondary endpoints. Although their results were against repairing the mitral valve, the debate on surgical management of moderate IMR remains unsettled.

The RIME trial: Are we closer to the answer of when to repair ischemic mitral regurgitation?

BACKGROUND The development of mitral valve regurgitation as a result of left ventricular remodelling following myocardial infarction carries adverse implications on survival and quality of life (QOL). There is uncertainty whether mitral valve repair at the time of surgical revascularization improves survival and quality of life and enhances left ventricular reverse remodelling in patients with moderate ischemic mitral regurgitation (IMR). The Randomized Ischemic Mitral Evaluation (RIME) trial investigators tried to address this issue by studying whether repairing moderate IMR at the time of surgical revascularization can lead to more favourable outcomes compared with surgical revascularization only. Results of this multicentre, randomized, controlled trial were recently published in Circulation. 1 RIME was conducted in 6 centres in the UK and one in Poland. Out of 172 patients referred for CABG with moderate IMR, the RIME investigators randomized 73 eligible patients to receive either CABG alone (CABG group; n ¼ 39 patients) or CABG with mitral valve repair (Repair group; n ¼ 34 patients) The primary end-point was oxygen consumption at maximal exercise (VO2Max) measured by cardiopulmonary exercise testing, as an objective measure of functional capacity, at one year. The secondary end-points were left ventricular end-systolic volume indexed to body surface area (LVESVI) and mitral regurgitation volume as well as plasma B-type natriuretic peptide (BNP). All measurement were performed before enrollment and at one year postoperatively. Moderate IMR was defined by echocardiographically derived quantitative measures – namely regurgitant orifice area, regurgitant volume and vena contracta width – as per the ACC/AHA/ASE Valvular Heart Disease Guidelines. Patients were considered eligible if they met any of the above criteria whether at rest or during exercise. 2 Patients were excluded if they had ejection fraction ,30%, structural mitral valve disease (including papillary muscle rupture), significant aortic valve disease, previous or active endocarditis, previous cardiac surgery, unstable angina, symptoms of advanced heart failure or cardiogenic shock or significant comorbidities like liver or renal impairment and chronic obstructive airway disease. All CABG procedures utilized the left internal mammary artery to graft the left anterior descending coronary artery All technically graftable, significantly narrowed coronary arteries were addressed. Mitral repair was performed using a complete annuloplasty ring with the aim of achieving a leaflet coaptation length of at least 8mm and no or trace mitral regurgitation at the end of the operation. Both groups received similar number of grafts but the repair group expectedly had longer bypass and cross clamp times compared to the CABG group. The trial met all its end points with high statistical significance at the proposed follow up period of one year. The primary end point of change in peak oxygen consumption (Peak VO2) showed significant improvement at 1 year. The Peak VO2 in the repair group increased by 22% (from 14.8 ^ 3.2 to 18.1 ^ 2.9mL/kg/min) while the CABG group only increased by 5% (from 15.1 ^ 3.3 to

Surgery for TGA in Developing Countries

T he last 50 years have witnessed dramatic changes in the management of transposition of the great arteries (TGA). This has transformed the disease from being almost universally fatal to being compatible with normal or near normal survival and quality of life. Unfortunately, these changes have been limited to an extremely small proportion of the global community, with a large number of children with TGA born in developing countries continuing to suffer a dismal fate.

Original InvestigationEditorial CommentSurgery for TGA in Developing Countries: The End of the Beginning∗

T he last 50 years have witnessed dramatic changes in the management of transposition of the great arteries (TGA). This has transformed the disease from being almost universally fatal to being compatible with normal or near normal survival and quality of life. Unfortunately, these changes have been limited to an extremely small proportion of the global community, with a large number of children with TGA born in developing countries continuing to suffer a dismal fate.