Amber Malhotra

Preoperative levosimendan in ischemic mitral valve repair.

Background Levosimendan is a new calcium sensitizing drug with vasodilatory and inotropic properties, which is used for the treatment of postoperative low cardiac output syndrome and difficult weaning from cardiopulmonary bypass. Objective To evaluate the hemodynamic effects of levosimendan during and after coronary artery bypass grafting on cardiopulmonary bypass and mitral valve repair in patients with low left ventricular ejection fractions (<30%). Methods 40 patients were enrolled in this double-blind prospective randomized controlled trial. They received either levosimendan or a placebo preoperatively (n = 20) for 24 h. Clinical parameters were measured before and after administration. Any adverse events during and after drug administration and postoperative complications were evaluated. Results Patients treated with levosimendan exhibited a higher cardiac index and mean arterial pressure intraoperative and in the early postoperative period, compared to the control group. Patients treated with levosimendan required less ventilatory support (p < 0.0001) and had shorter intensive care unit (p < 0.0001) and hospital stay (p < 0.0001). Conclusions Preoperative treatment with levosimendan in patients undergoing coronary artery bypass grafting and mitral valve repair resulted in improved hemodynamics and a stable postoperative course.

Operative management of intracardiac myxomas: A single center experience

BACKGROUND Cardiac myxomas are the most common benign intracardiac tumors. We studied the clinical presentation of cardiac myxomas, their morbidity, mortality and recurrence rate following surgery at our institution over a period of four years. METHODS During August 2008 to November 2012, a total of 12023 cardiac surgeries were performed. Amongst these, 50 patients (12 males, 38 females) underwent complete removal of primary or recurrent intracardiac myxomas. Complete tumor excision with a cuff of interatrial septum followed copious saline irrigation of the cardiac chambers was performed in each case. RESULTS Forty six patients survived the surgery of which 43 are being followed up at regular intervals for development of recurrence. Myxomas constituted 0.41% of the total cardiac surgeries at our institute. Most of them were noted in the fourth decade. The commonest location was left atrium (74%) followed by right atrium (22%). Only one patient had a myxoma in the right ventricle. Forty six patients (92%) survived the surgery. CONCLUSION Cardiac myxoma excision account for a very small percentage of cardiac procedures. Immediate surgical treatment is indicated in all patients. Cardiac myxomas can be excised with a low rate of mortality and morbidity.

Is steel wire closure of sternotomy better than polyester suture closure

Introduction Median sternotomy is the preferred approach for open heart surgeries. The sternotomy incision is predominantly closed with either steel wire or polyester suture. The type of material used is primarily based on the surgeon’s choice, and both materials achieve a good result. No prospective clinical study has been undertaken to evaluate differences in the incidence of wound infection and the degree of pain associated with both techniques. Patients and methods Our randomized controlled double-blind study included 200 adults undergoing single-valve replacement. The technique of surgery, apart from the material used for sternal closure, was the same in both groups. Postoperatively, patients were analyzed for wound infection and wound pain based on the ASEPSIS score and Numeric Pain Rating Score, respectively. Results The polyester suture group had a significantly higher mean ASEPSIS score, indicating a higher incidence of wound infection, and more late wound complications. The polyester suture group also had a significantly higher mean pain score. The steel wire group had significantly higher mediastinal drain output in the first 48 h after surgery. Conclusion The use of polyester suture for sternal closure in adult patients results in increased wound infection, wound pain, and late wound complications, but lower mediastinal drain output.

Ring annuloplasty for ischemic mitral regurgitation: A single center experience

Background Ischemic mitral regurgitation associated with coronary artery disease presents a management challenge to cardiac surgeons. We report our early and midterm results of chronic ischemic mitral regurgitation treated with concomitant mitral ring annuloplasty and coronary artery bypass grafting. Methods We performed a retrospective review of the medical records of patients who underwent coronary artery bypass grafting at our institute from January 2009 to December 2011. Data were collected in 50 patients with chronic ischemic mitral regurgitation who had mitral ring annuloplasty along with coronary artery bypass grafting. Preoperative data, echocardiographic findings, operative procedure, outcome, and perioperative hemodynamics were analyzed. Early and intermediate follow-up data were also collected and analyzed. Results There were 3 (6%) early and 9 (18%) late deaths. Of the survivors, 38 (76%) had a significant reduction in left ventricular end-diastolic and end-systolic dimensions and improvement in New York Heart Association functional class. Conclusion Despite a risk of residual regurgitation, mitral ring annuloplasty combined with coronary artery bypass appears to be a good treatment option in selected patients with chronic ischemic mitral regurgitation.

Procalcitonin level for prediction of postoperative infection in cardiac surgery

Background Diagnosing infection after cardiac surgery remains difficult due to the systemic inflammatory response induced by cardiopulmonary bypass. We compared procalcitonin levels with white blood cell counts as predictors of infection after cardiac surgery. Methods We prospectively enrolled 100 consecutive adult cardiac patients. Postoperative white blood cell counts, serum procalcitonin levels, and blood cultures were examined. Result The sensitivity and specificity of white blood cell count and procalcitonin > 2 ng mL−1 were 60% and 100%, 58.8% and 42.5%, respectively. Procalcitonin > 7 ng mL−1 had 95% sensitivity and 80% specificity. Receiver-operating characteristic analysis showed a greater area under the curve for procalcitonin level (p < 0.0001) compared to white blood cell count (p = 0.31). Patients with positive blood cultures had significantly higher procalcitonin levels (51.97 ± 39.62 vs. 6.67 ± 10.73 ng mL−1), Acute Physiology and Chronic Health Evaluation-II scores (16.95 ± 3.24 vs. 13.60 ± 2.98), and intensive care unit stay (6.35 ± 3.42 vs. 4.6 ± 2.2 days). Non-survivors had significantly higher Acute Physiology and Chronic Health Evaluation-II scores (19.09 ± 1.30 vs. 13.67 ± 2.97) and procalcitonin levels (43.83 ± 52.15 vs. 12.26 ± 19.89 ng mL−1) but on logistic regression analysis, only Acute Physiology and Chronic Health Evaluation-II score was an independent risk factor for mortality. Conclusion The diagnostic accuracy of procalcitonin for bacterial infection is fairly high. Acute Physiology and Chronic Health Evaluation-II score is a better predictor of mortality and morbidity than absolute procalcitonin level. Procalcitonin > 7 ng mL−1 can prognosticate and identify the high-risk group.

Dialyzer-based cell salvage system: a superior alternative to conventional cell salvage in off-pump coronary artery bypass grafting

Objectives Our goal was to test the hypothesis that the use of a dialyzer-based cell salvage system during off-pump coronary artery bypass grafting (OPCABG) reduces requirements for homologous blood transfusions (HBT) and improves postoperative haemtochemical parameters. Methods Data were prospectively collected for 222 patients who had OPCABG using 3 different cell salvage techniques: (1) dialyzer-based cell salvage (DBCS) ( n  = 75), (2) conventional cell salvage (CCS) ( n  = 73) and (3) without cell salvage (WCS) ( n  = 74). Salvaged blood was transfused at the end of the operation. The primary outcome of the study was the amount of homologous blood transfused. Secondary outcomes were changes in haemtochemical parameters, postoperative bleeding, need for non-invasive ventilation (NIV), postoperative complications, renal dysfunction, clotting derangement, duration of intensive care unit (ICU) and hospital stay and mortality rates. Results There were no deaths. In patients with >1000 ml blood loss, there was a significant reduction in HBT in the DBCS group (300 ± 161 ml) compared with the WCS group (550 ± 85 ml) ( P  <   0.0001). Postoperative changes in haemtochemical parameters were significantly fewer in the DBCS group compared with the other 2 groups. The incidence of NIV ( P  =   0.002), renal dysfunction ( P  =   0.009) and postoperative complications ( P  =   0.003) was least in the DBCS group and highest in the WCS group. Mean ICU stays were comparable ( P  =   0.208); however, the mean hospital stay was significantly shorter in the DBCS group (6.08 ± 3.12 days) compared with the WCS group (7.54 ± 4.46 days) ( P  =   0.022). There was no significant increase in coagulopathy in any group as suggested by comparable chest tube drainage ( P  =   0.285) and comparable prothrombin time. Conclusions The use of the DBCS system in OPCABG resulted in a significant reduction in HBT, improvement in postoperative levels of haemoglobin, platelets and albumin and reduction in complications without increased risk of coagulopathy.

Single-Dose Lignocaine-Based Blood Cardioplegia in Single Valve Replacement Patients

Objective Myocardial protection is the most important in cardiac surgery. We compared our modified single-dose long-acting lignocaine-based blood cardioplegia with short-acting St Thomas 1 blood cardioplegia in patients undergoing single valve replacement. Methods A total of 110 patients who underwent single (aortic or mitral) valve replacement surgery were enrolled. Patients were divided in two groups based on the cardioplegia solution used. In group 1 (56 patients), long-acting lignocaine based-blood cardioplegia solution was administered as a single dose while in group 2 (54 patients), standard St Thomas IB (short-acting blood-based cardioplegia solution) was administered and repeated every 20 minutes. All the patients were compared for preoperative baseline parameters, intraoperative and all the postoperative parameters. Results We did not find any statistically significant difference in preoperative baseline parameters. Cardiopulmonary bypass time were 73.8±16.5 and 76.4±16.9 minutes (P=0.43) and cross clamp time were 58.9±10.3 and 66.3±11.2 minutes (P=0.23) in group 1 and group 2, respectively. Mean of maximum inotrope score was 6.3±2.52 and 6.1±2.13 (P=0.65) in group 1 and group 2, respectively. We also did not find any statistically significant difference in creatine-phosphokinase-MB (CPK-MB), Troponin-I levels, lactate level and cardiac functions postoperatively. Conclusion This study proves the safety and efficacy of long-acting lignocaine-based single-dose blood cardioplegia compared to the standard short-acting multi-dose blood cardioplegia in patients requiring the single valve replacement. Further studies need to be undertaken to establish this non-inferiority in situations of complex cardiac procedures especially in compromised patients.

Normokalemic nondepolarizing long-acting blood cardioplegia

Objective Blood cardioplegia, the gold-standard cardioprotective strategy, requires frequent dosing, resulting in hyperkalemia-induced myocardial edema. The aim of our study was to compare the efficacy and safety of a long-acting blood-based cardioplegia with physiological potassium levels versus the well-established cold blood St. Thomas’ Hospital no. 1 cardioplegia solution in multivalve surgeries. Methods One hundred patients undergoing simultaneous elective aortic and mitral valve replacement ± tricuspid valve repair were randomized in two groups. In group 1, adenosine 12 mg was given via the aortic root after crossclamping, followed by a single dose of long-acting solution at 14℃ (30 mLċkg−1); in group 2, an initial 30 mLċkg−1 of St. Thomas’ cardioplegia at 14℃ was administered, followed by 15 mLċkg−1 every 20 min. Duration of cardiopulmonary bypass, inotropic score, arrhythmias, ventilation time, and the levels of interleukin-6, creatinine kinase-MB, and troponin I were compared. Results Mean cardiopulmonary bypass and crossclamp times were 134.04 ± 36.12 vs. 154.34 ± 34.26 (p = 0.004) and 110.37 ± 24.80 vs. 132.48 ± 31.68 min (p = 0.002), respectively, in the long-acting and St. Thomas’ groups. Cardiac index, creatinine kinase-MB and troponin I levels were comparable. Interleukin-6 levels post-bypass were 61.72 ± 15.33 and 75.44 ± 31.78 pgċmL−1 (p = 0.007) in the long-acting and St. Thomas’ cardioplegia groups, respectively. Conclusions Single-dose long-acting cardioplegia gives a cardioprotective effect comparable to repeated doses of the well-established St. Thomas’ Hospital no. 1 cold blood cardioplegia.

Ruptured intracardiac hydatid cyst presenting as acute coronary syndrome

Hydatid disease is a parasitic infection caused by the larvae of Echinococcus granulosus, which is still endemic in many developing countries. Cardiac involvement is rare but potentially very serious on account of various clinical presentations and nonspecific symptoms that occasionally mimic acute coronary syndrome. We describe a case of ruptured left ventricular hydatid cyst presenting as acute inferolateral myocardial infarction with electrocardiographic changes. Because coronary angiography revealed normal coronary arteries, the final diagnosis was made on the basis of echocardiography and magnetic resonance imaging. On-pump surgical resection followed by albendazole therapy yielded an excellent outcome.

Clinical and hemodynamic study of tilting disc heart valve: Single-center study

Background The TTK Chitra heart valve has been developed and widely used in India. This study aimed to evaluate its hemodynamics, complications, and event-free survival in comparison with other commonly used prosthetic valves. The role of color Doppler echocardiography in the follow-up of patients with prosthetic valves was also studied. Patients and methods Two hundred patients underwent 249 valve replacements (122 mitral, 29 aortic, 49 both). Total follow-up was 451 patient-years. Results There were 18 late deaths (3.98% ± 0.92% per patient-year). One mitral valve replacement patient (0.36% ± 0.36% per patient-year) developed valve thrombosis. Two aortic valve replacement patients (2.74% ± 1.91% per patient-year), 2 double-valve replacement patients (1.95% ± 1.36% per patient-year) and 3 mitral valve replacement patients (1.08% ± 0.62% per patient-year) developed embolic complications. Freedom from all valve related mortality and morbidity at 4 years was 86% ± 4% for mitral valve replacement, 56% ± 10% for double-valve replacement, and 89% ± 6% for aortic valve replacement. The average peak gradient, mean gradient, and average peak velocity for the aortic and mitral positions were found to be comparable to those of other commonly used valves. Conclusion The performance of this valve in terms of hemodynamic complications, mortality, and morbidity is comparable to other valves in common use. Hemodynamic gradients are more reproducible than effective orifice area, hence more beneficial for follow-up.