Surendra Nath Khanna

Predictors of Early Outcome After Coronary Artery Surgery in Patients with Severe Left Ventricular Dysfunction

Abstract Background: The surgical survival in patients with severe myocardial dysfunction is critically dependent on the selection of patients. The present study was undertaken to identify the prognostic factors in such patients. Methods: We analyzed the data of 176 consecutive patients (161 men, 15 women), aged 29 to 88 years (mean 58.43), with a left ventricular ejection fraction (LVEF) <30% who underwent isolated coronary artery bypass grafting. The LVEF ranged from 15% to 30% (mean 27.18%). Preoperatively, 33% had angina, 19.9% had recent myocardial infarction, and 21.6% had congestive heart failure. The mean number of grafts was 2.5/patient. The intra‐aortic balloon was used prophylactically in 20.5% of patients and therapeutically in 4.0% of patients. Results: The hospital mortality was 2.3%. The complications occurred as follows: perioperative myocardial infarction in two (1.1%), intractable ventricular arrhythmias in two (1.1%), prolonged ventilation in four (2.3%) and peritoneal dialysis in 1 (0.6%). The mean ICU and hospital stay were2.46 ± 0.76and7.57 ± 2.24days, respectively. The predictors of survival on univariate analysis were New York Heart Association (NYHA) class(x2 = 14.458, p < 0.001), recent myocardial infarction(x2 = 5.852, p = 0.016), congestive heart failure (CHF)(x2 = 5.526, p = 0.019), and left ventricular end‐systolic volume index (LVESVI)(x2 = 25.833, p < 0.001). However, on multivariate analysis, left ventricular end‐systolic volume index was the only independent left ventricular function measurement predictive of survival(x2 = 10.228, p = 0.001). Conclusion: Left ventricular end‐systolic volume index is the most important predictor of survival after coronary artery bypass surgery in patients with severe myocardial dysfunction.(J Card Surg 2003;18:101‐106)

Ascending Aortic Aneurysm Resection: 15 Years’ Experience:

Between September 1989 and June 2004, 148 consecutive patients underwent ascending aortic replacement for aneurysm or dissection. There were 130 males (88%) and 18 females (12%). Their mean age was 46.20 ± 13.36 years. Fifty-seven patients (39%) were treated for type 1 and type 2 aortic dissection, and 91 (61%) for ascending aortic aneurysm. The Bentall procedure was performed in 81 patients (55%), the Cabrol procedure in 7 (5%), separate ascending aortic replacement and aortic valve replacement or repair was carried out in 24 (16%), and ascending aortic replacement only in 36 (24%). Hospital mortality was 4.05% (6 deaths). On univariate analysis, left ventricular ejection fraction ≤ 30%, emergency surgery, contained rupture, concomitant coronary artery bypass grafting, and age ≥ 65 years were risk factors for early mortality. However, on multivariate analysis, ejection fraction ≤ 30% and contained rupture were the only factors significantly associated with early mortality. The long-term survival rates were 87.2% ± 3.7% at 5 years, 78.0% ± 5.6% at 10 years, and 60.9% ± 9.9% at 15 years. Ascending aortic resection for aneurysm or dissection can be performed with low mortality and morbidity.

Multimodality Targeted Approach in Redo Off-Pump Coronary Artery Bypass Surgery

Records of 86 patients who underwent off-pump redo coronary revascularization between December 1997 and December 2000, were analyzed. Approaches included median sternotomy (47), anterolateral thoracotomy for left anterior descending artery and diagonal targets (35), posterolateral thoracotomy for the obtuse marginal with proximal anastomosis on descending aorta (3), and a combined subxiphoid-anterior thoracotomy approach (1) for right gastroepiploic artery-to-left anterior descending artery anastomosis. The mean age was 61.82 years. There were 2 (2.3%) operative deaths. Complications included perioperative myocardial infarction in 4 patients and reexploration for bleeding in one. Blood transfusion was required in 12 patients. The mean length of hospital stay was 5 ± 2 days. A multimodality targeted approach for off-pump redo coronary artery bypass offers a less invasive but safer method of myocardial revascularization, with decreased complications, lower blood product requirement, and early hospital discharge.

Rosai-Dorfman Disease of Right Atrium Mimicking Myxoma

Rosai-Dorfman disease, or sinus histiocytosis with massive lymphadenopathy, is a rare multisystemic disorder that was first reported by Rosai and Dorfman in 1969. It is a distinct histioproliferative disorder due to overproduction of histiocytes, which accumulate in lymph nodes. The cardiac involvement of this disease is extremely rare, and until now, only 18 cases have been reported. We report the case of a 53-year-old woman with right atrial mass mimicking myxoma, which the histopathologic evaluation revealed to be Rosai-Dorfman disease of the right atrium.

Repair of Tricuspid Insufficiency Following Blunt Trauma Chest - A Case Reportand Review of Literature

Tricuspid incompetence after blunt chest trauma is uncommon and is most often associated with traffic accidents. The signs of traumatic tricuspid insufficiency can be appear early or delayed, depending upon the severity of injury. We present the case of a young male who had severe tricuspid regurgitation due a blunt chest trauma in an automobile collision and underwent successful repair.

Surgical correction of Lutembacher's syndrome in a patient with severe pulmonary artery hypertension.

Lutembachers syndrome is an uncommon combination of a congenital ostium secundum atrial septal defect (ASD) with acquired mitral stenosis (MS). The incidence of this condition is very rare. The symptoms are dependent upon the size of the ASD, severity of the MS, compliance of the right ventricle and pulmonary artery hypertension. We describe a patient with Lutembachers syndrome with severe pulmonary hypertension who underwent successful surgical repair. doi: 10.1111/jocs.12340 (J Card Surg 2014;29:569–571)

Concomitant coronary bypass and below knee amputation in a diabetic patient.

A 57-year-old man presented with unstable angina and uncontrolled diabetes with diabetic foot. It was decided to perform right below knee amputation with coronary revascularization in a single stage. Right below knee amputation was carried out first. The left anterior descending artery, ramus intermedius, and second obtuse marginal branch of the circumflex were bypassed on a beating heart, using saphenous vein grafts. The patient was discharged on the 7th postoperative day after a course of antibiotics.

Management of a Patient with Unstable Angina, Left Main Coronary Artery Disease, and Respiratory Insufficiency Due to Eventration of the Diaphragm

The incidence of eventration of diaphragm before cardiac surgery is rare. We describe the management of a patient with eventration of the diaphragm who underwent a coronary artery bypass grafting (CABG) for left main coronary artery disease followed by left diaphragm plication with video‐assisted thoracic surgery (VATS) for the postoperative respiratory insufficiency. doi: 10.1111/jocs.12169 (J Card Surg 2013;28:517–519)

Early Results with Bilateral and Single Internal Mammary Artery Grafts. Are They Different

Between June 1991 and June 1996, 391 patients underwent isolated myocardial revascularization using bilateral internal mammary artery. Three hundred and sixty-five of these patients could be matched retrospectively on the basis of preoperative characteristics with 365 patients operated on during same period who had left internal mammary artery as a single or sequential graft with additional vein grafts. The cardiopulmonary bypass times and aortic cross-clamp times were similar in both groups. There were no statistically significant differences in the two groups in terms of operative mortality (0.55% versus 0.82%), perioperative myocardial infarction (2.46% versus 2.19%), low cardiac output (1.64% versus 1.09%), reexplorations (1.10% versus 1.92%), wound complications (1.10% versus 2.46%), length of stay in the intensive care unit, and total hospital stay. The incidence of respiratory, central nervous system, and renal complications showed no difference between the two groups. Logistic regression analysis showed that the number of internal mammary artery grafts was not a predictor for perioperative complications. If better long-term event-free survival is associated with the use of bilateral internal mammary artery, it should be used wherever possible.

Surgical Treatment of Aneurysms of the Ascending Aorta and Aortic Arch

Surgery for aneurysms of the aorta is a formidable challenge especially when these aneurysms involve the ascending aorta and the transverse arch. We have used the technique of cardiopulmonary bypass, profound hypothermia and total circulatory arrest with marked reduction in neurological complications. Availability of albumin coated and gelatin sealed grafts, as well as blood components, has reduced the associated bleeding problems. Ninety-six patients with aneurysms of the ascending aorta and the transverse arch were operated upon between 1983 and 1993. Patients with aneurysms of the sinus of Valsalva have not been included in this study. Syphilitic pathology was predominant in the group with late presentation of very large aneurysms. The mortality was 17.71% and was largely due to low cardiac output, prolonged ventilatory support, lung infections, and mediastinitis.