Mohamed F. Ibrahim

Survival and Quality of Life After Cardiac Surgery Complicated by Prolonged Intensive Care

Abstract  Aim: To determine survival, factors determining survival and evaluate quality of life (QOL) after 1 year, in patients who had prolonged intensive care unit (ICU) stay after cardiac surgery. Methods: In the year 2001, 804 patients underwent various cardiac procedures utilising cardiopulmonary bypass (CPB). Eighty‐nine consecutive patients requiring ICU stay of ≥5 days constituted the study group, majority of these suffered from multiorgan failure (>2 organ systems). Survival was determined in the study group after 1 year. Patients with an uncomplicated postoperative course were matched to the survivors in the study group with respect to age, gender, type of surgery, risk scores, and duration of follow‐up and constituted the control group. The, Short Form Health Survey was used to assess QOL at the end of 1 year in these patients. QOL was compared between the study group and the control group and to that of general population. Results: Seventy percent of the patients in the study group suffered from failure of at least three organ systems. Mean ICU stay was 13 ± 3 days (median nine, maximum 53). At the end of 1 year the mortality in the study group was 34%. The independent predictors of mortality were: preoperative cardiac support, lower ejection fraction, higher Parsonnet score, higher Euroscore, pulmonary complications, renal failure necessitating hemofiltration, CNS complications, and failure of three or more organ systems. The QOL was lower in the study group than the control group in all eight dimensions measured (significant in five p < 0.05): Physical function, Role physical, Vitality, Mental health, General health, and Bodily pain. Conclusion: One year mortality in patients with prolonged ICU stay after cardiac surgery remains high. Identification of risk factors will help to reduce the mortality with help of regular follow up. The QOL remains low in all dimensions especially those measuring physical aspects and pain.

Acute Type A Aortic Dissection at Seven Weeks of Gestation in a Marfan Patient: Case Report

Abstract  A 34‐year‐old Marfan patient at the seventh week of pregnancy presented with acute type A aortic dissection and severe aortic regurgitation. The aortic valve and ascending aorta were replaced successfully using circulatory arrest and deep hypothermia. At 35 weeks of gestation, the patient underwent a cesarean section and delivered a healthy baby. To our knowledge, this case is the first to report a favorable fetal outcome following surgical repair of acute dissection in the first trimester of pregnancy.

Coronary fistula between the left anterior descending coronary artery and the pulmonary artery: Two case reports

Coronary artery fistulae are rare congenital or acquired connections between the coronary vessels and the cardiac chambers or other vascular structures. We present two consecutive cases of coronary fistulae between the proximal left anterior descending artery (LAD) and the main pulmonary artery. Both cases where admitted with history of acute coronary syndromes and had multivessel coronary disease along with coronary pulmonary fistulae. The two cases were managed by coronary artery bypass grafting (CABG) and repair of the fistulae.

Asymptomatic metastatic osteosarcoma to the right ventricle: Case report and review of the literature.

Metastatic cardiac tumors are far more common than primary tumors, and benign primary cardiac tumors are common than malignant tumors. We report a 22-year-old Saudi woman with right femur osteosarcoma who was found to have a large right ventricular mass by transthoracic and transesophageal echocardiography. Diagnosis was highly suggestive by cardiac magnetic resonance imaging (MRI) and fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) scan. We performed a review of the literature for metastatic osteosarcoma of the right ventricle.

Comparison of Clinical Outcomes among Patients Undergoing Coronary Artery Bypass Grafting (CABG) with or without Prior Percutaneous Coronary Intervention (PCI)

Background: There are increasing number of patients who are referred for coronary artery bypass grafting (CABG) after prior percutaneous coronary intervention (PCI). The intent here is to characterize the risk, if any, that is associated with PCI experience prior to CABG. Methodology and patients: 2358 consecutive patients underwent coronary artery bypass grafting between January 2008 to December 2013 at two tertiary cardiac centers in Middle East (one center in Egypt and one in Saudi Arabia) divided in 2 groups: 1st group-492 patients with Prior PCI to CABG (PPCABG), and the 2nd group-1866 patients underwent CABG without previous PCI (Native Vessel CABG-NVCABG). We chose the 2 groups with similar cardiac morbidities and extra cardiac co-morbidities. Results: Except for emergency cases, clopidogrel, statin use and the distribution of NYHA classification, the two groups were similar in terms of baseline demographic and pre-operative characteristics. Summarized intra-operative and post-operative data showed that PPCABG group had significantly higher cross clamp time, total bypass time, higher incidence of post-operative complications such as bleeding, renal impairment than NVCABG and also significant higher in-hospital mortality rate in PPCABG group than NVCABG group. Conclusion: Future re-interventions after PCI are common and both extent of disease and re-stenosis of stents are responsible for re-intervention. PCI prior to CABG increases morbidity post operatively and seem to have an independent factor in increasing mortality. So, in the best interest of the patient, proper consensus among cardiologists and cardiac surgeons must be reached before subjecting to PCI, especially in cases of multivessel coronary artery disease.

Hybrid Approach to Repair Type A Aortic Dissection: Combined Endovascular Superior Mesenteric Artery Stenting and Bentall Procedure

A Stanford Type A aortic dissection is a life-threatening surgical emergency that requires emergent surgery. The mortality after repair is high especially if the aortic dissection is complicated by visceral or peripheral malperfusion. We describe a case of a male patient who presented with an aortic dissection involving the ascending aorta, aortic arch, descending thoracic aorta, and the abdominal aorta down to the iliac bifurcation. The dissection also involved the visceral and renal arteries with evidence of superior mesenteric artery (SMA) occlusion. Successful outcome was achieved by endovascular stenting of the patients SMA, followed by a Bentall procedure. To the best of our knowledge this is the first case report in the English literature of SMA stenting followed by a Bentall procedure to treat acute Type A aortic dissection complicated by SMA occlusion.

Surgical repair and outcome of large mycotic pseudoaneurysm of the ascending aorta originating at saphenous vein graft take off

Mycotic pseudoaneurysm of the ascending aorta is a rare but potentially lifethreatening complication following cardiac surgery. We experienced a rare case of early post-operative pseudomonas mediastinitis with large pseudo-aneurysm of ascending aorta originating at the venous graft take off site following a recent coronary artery bypass grafting (CABG) operation. To the best of our knowledge, this is the first case report that describes mycotic pseudoaneurysm originating at aorto-saphenous anastmosis after CABG in a non-immunosuppressed patient.

Mycotic Pseudoaneurysm of the Proximal Saphenous Vein Graft

A 55-year-old male who underwent coronary artery bypass grafting (CABG) with left internal mammary artery (LIMA) graft to left anterior descending artery (LAD) and saphenous vein graft (SVG) to D1 and RCA was readmitted with a deep lower sternal wound Figure 1. (A) Chest X-ray showing airspace opacity in the midzone of the left lung; arrow is pointing to the opacity. (B) CT chest post IV contrast showing enhancing vascular aneurysm in the anterior mediastinum at retrosternal region; arrow is pointing to the pseudoaneurysm