Multidisciplinary Cardiovascular Annals
Volume:3 Issue: 1, Feb 2011

Background. Cardiovascular operations are associated with an inherented bleeding tendency that some time leads to severe bleeding and transfusion requirement. Pharmacologic intervention to minimize post bypass bleeding and blood product transfusions has received increasing attention for both medical and economic attention. In this double-blind randomized placebo-controlled clinical trial, three groups of patients undergoing on-pump Coronary Artery Bypass Surgery(CABG), each group composed of 50 patients, were blindly randomized to receiving either low aprotinin, tranexamic acid or placebo, and then results were evaluated and compared in each group. The following variables were similar in groups and there were no statistically significant differences in these variables: Age(P=0.308), Sex(P=0.973), ypelipidemia(P=0.720), Hypertention(P=0.786), Smoking(P=0.72), Diabetes(P=0.960).The amount of drainage from chest tubes were less in aprotinin and tranexamic acid groups compared to placebo, and this was statistically important(P<0.001). There were no statistically significant differences in need for reoperation for bleeding in three groups(P=0.998). Complications following surgery in three groups were statistically the same and not significantly different (table below). All complications had a good course and all patients were discharged from hospital uneventfully. There were no mortality in any group. low dose aprotinin and tranexamic acid can significantly reduce blood loss and transfusion requirement in CABG surgery without importantly increasingmortality and morbidity.

The aim of this study was to investigate the feasibility of performing papillary muscle repositioning (PMR) for subvalvular-sparing mitral valve replacement procedures in patients with ischemic mitral regur-gitation and to determine the early and late effects of this procedure on the clinical outcome and left ventricular mechanics. We prospectively randomly allocated 50 patients with severe ischemic mitral regurgitation and left ventricle dysfunction who were candidates for coronary artery bypass graft surgery and mitral valve replacement into a total chordal-sparing mitral valve replacement group or a PMR group. Echocardiography was performed preoperatively, at discharge, and after 3 years to determine the left ventricular dimensions, shape, and function. The reduction in the left ventricle volumes and sphericity index in the PMR group was more significant than that in the other group. With regard to the left ventricular end-systolic and left ventricular end-diastolic volumes, sphericity index, and ejection fraction, the PMR group showed better results (p < 0.05), but the difference in New York Heart Association functional class after 3 years was not statistically significant between the two groups (p > 0.05). The PMR technique described herein can dramatically help ischemic patients by affecting the left ventricular shape and function more efficiently compared with the complete retention of the mitral subvalvular apparatus if the mitral valve is to be replaced.

After myocardial infarction, injured cardiomyocytes are replaced by fibrotic tissue promoting the development of heart failure. Stem cells are multipotent, undifferentiated cells capable of multiplication and differentiation. Preliminary experimental evidence suggests that stem cells derived from embryonic or adult tissues (especially bone marrow) may develop into myocardial cells. The overall clinical experience also suggests that stem cell therapy can be safely performed, if the right cell type is used in the right clinical setting. Preliminary efficacy data indicate that stem cells have the potential to enhance myocardial perfusion and/or contractile performance in patients with acute myocardial infarction, advanced coronary artery disease, and chronic heart failure. However, at the present time, the results have been mixed and inconclusive, and the mechanism of stem cell transplantation therapy remains unclear. This review discusses the controversies and problems that need to be addressed in future investigations

Long segment reconstruction of the diffusely diseased Left Anterior Descending Artery (LAD) with Left Internal Thoracic Artery (LITA) has been shown to be beneficial for patients that have complicated, multiple and long segment lesions in LAD. In this prospective study we analyzed the results obtained with this technique. From Feb. 2007 to Feb. 2009, 56 patients were operated by this technique. LITA was used as a patch along the opened narrow segment of LAD from 2 to 8 centimeter. Data from all patients were collected and all patients worked up for post operative complications, like post operative MI, ECG changes, NIHA class, enzymatic changes, post operative bleeding and CT-Angiography were done between 6 to 18 months after operation in some cases. 56 cases,42 male (75%)and 14 female (25%), from 43 to78 years with mean age of 59.8+_9.3 years with multiple and long segment lesions in LAD were included in this satudy. Preoperative risk factors were Hypertension (66.1%), Diabetes (57.1%), Hyperlipidemia (50%), cigarette smoking (50%), renal failure (1.8%) and positive family history (7.1%). 23 patients (41.1%) have had remote MI and 9 patients (16.1%) have had recent MI.Significant left main lesion were found in7 patients (12.5%), peripheral vascular disease in 3 patients (5.3%) and preoperative arrhythmias in 2 patients (3.6%). Mean number of grafts that were used in operations was 2.85 +_1.5 and other concomitant operations were done in 5 patients. Post operative complications were arrhythmias in 10 (17.8%), postoperative MI in 1 (1.8%), surgical bleeding in 7 (12.5%), infections in 3 (5.3%), plural effusion in 3(5.3%), tamponade in 2(3.6%), pericardial effusion in 1 (1.8%) and hemiparesia in 1 patient (1.8%). there was no mortality in these patients. Long segment and multiple lesions in LAD are difficult challenges for cardiac surgeons and in these situations; results of long-segment LAD reconstruction are very encouraging

Narcotics are the most common drugs that have been used after cardiac surgery. Everyone knows that their side effects including respiratory depression, hemodynamic instability, and nausea, vomiting and itching are dose dependent. Magnesium is both N Methyl D Aspartate (NMDA) – receptor and calcium receptor antagonist and can modify important mechanisms of nociception. The purpose of this study was to investigate the effect of magnesium sulfate on pain score and reducing narcotic requirement in coronary artery bypass surgery patients. In a randomized, double blinded, placebo-controlled trial One hundred and eighty five patients (105 male and 80 female) undergoing elective coronary artery bypass graft surgery were studied. Mean age were 58+_11 (from 24 to79 years).We enrolled them in two groups randomly. Group1 received magnesium sulfate as an IV infusion 80 mg/kg during one hour after induction and the second group received the same volume of normal saline as placebo. During the postoperative period, Morphine requirement and pain score (visual analogue scale: scaled as 0 to 10, 0=no pain and 10= worst possible pain) in 6, 12, 18, and 24 hours were recorded and documented. There were no significant differences between two groups with respect to baseline data. In MG group, only 30 patients (32%) needed to receive Morphine Sulfate, but in placebo group, 75 patients (83%) needs some doses of Morphine Sulfate (p value < 0.001); The odds ratio showed that MG could strongly prevent the needs for receiving opioid analgesics for controlling of the pain. Intra operative use of magnesium sulfate can reduce receiving opioids after (CABG) operations

Patient-controlled analgesia (PCA) has been advocated as superior to conventional controlled analgesia with less risk to patients in cardiac surgery. In this double-blinded, randomized controlled trial, we tested whether the addition of Tramadol to morphine for patient-controlled analgesia (PCA) resulted in improved analgesia efficacy and smaller morphine requirements compared with morphine PCA alone after Coronary Artery Bypass Graft (CABG) surgery in adults. Seventy patients who were randomly allocated into two groups underwent anesthesia by Total IV anesthesia, midazolam, fentanyl and atracurim and, in end of surgery each group received morphine sulfat 0.2 mg/kg after arrived in ICU, morphin PCA was started with demand (bolus) dose 1mg, lockout interval 10 minutes. The Tramadol group after separated from cardiopulmonary bypass received an intra operative initial loading dose of Tramadol (1mg/kg) and a postoperative infusion of Tramadol at 0.2 mg• kg-1• h-1. The control group received an intra operative equivalent volume of normal saline and a postoperative saline infusion (placebo). The demographic data of both groups were the same. Post-operative data were recorded in the cardiac intensive care unit at 30 min, 1 h, 2 h, 4 h, 12 h and 24 h after extubation by the same anesthesiologist, who had no knowledge of the groups, and the side-effects were also evaluated. Postoperatively, Tramadol was associated with improved subjective analgesic efficacy (P = 0.031) and there was significantly less PCA morphine use in the Tramadol group (P = 0.023). No differences between the groups were found with regard to nausea dizziness, itching, antiemetic use, sedation, or quality of recovery (all P > 0.05).We conclude that a Tramadol infusion combined with PCA morphine improves analgesia and reduces morphine requirements after cardiac surgery compared with morphine PCA alone

Pericardial effusion resulting in cardiac tamponade is uncommon after open heart surgery and is associated with significant morbidity and mortality. In a clinical randomized trial 80 patients that have undergone CABG, were divided in two groups, posterior pericardectomy group and control group. Both groups were evaluated after operation by TEE and clinical parameters for early and late postoperative pericardial effusion. In this study 45% of control group and 5% in study group developed postoperative pericardial effusion, also the incidence of late pericardial effusion was 10% in study group and 57% in control group. Age, Gender, Smoking, Diabetes Mellitus and the Number of grafts didn’t have any effect on the incidence of pericardial effusion. Posterior pericardiotomy as a safe and simple procedure can significantly reduce the incidence of early and late pericardial effusion

This study was undertaken to examine clinical and echocardiographic outcomes of aortic valve–sparing operations to treat aortic root aneurysms. From May 1988 to December 2007, a total of 228 patients underwent reimplantation of the aortic valve, and 61 underwent remodeling of the aortic root. Patients were followed up prospectively and had echocardiographic evaluation of valve function. Mean follow-up was 7.28 ± 4.33 years. There were 5 operative and 26 late deaths. Survival at 12 years was 82.9 ± 3.7% and similar between types of operations. Age and aortic dissection were independent predictors of mortality. Seven patients have had reoperations on the aortic valve: 6 for aortic insufficiency and 1 for endocarditis. Five of these patients had undergone remodeling of the aortic root. Freedoms from reoperation at 12 years were 94.3% ± 2.6% among all patients, 90.4% ± 4.7% after remodeling, and 97.4% ± 2.2% after reimplantation (P =. 09). Postoperatively, moderate aortic insufficiency developed in 14 patients (8 remodeling and 6 reimplantation) and severe aortic insufficiency in 5 (3 remodeling and 2 reimplantation). The remaining patients had mild, trace, or no aortic insufficiency. Freedoms from moderate or severe aortic insufficiency at 12 years were 86.8% ± 3.8% among all patients, 82.6% ± 6.2% after remodeling, and 91.0% ± 3.8% after reimplantation (P =. 035). Only age—by 5-year increments—was an independent predictor of postoperative aortic insufficiency. Aortic valve–sparing operations provide excellent patient survival and stable aortic valve function, particularly after reimplantation of the aortic valve.

A case of thorombosis of the superior vena cava (SVC) was complicated by unilateral chylothorax. Removal of the SVC clot and repairing its stenosis with geor-tex patch led to the prompt resolution of the chylothorax. Chylothorax is an uncommon result of obstruction of the SVC. The most reported cause is the placement of the central venous catheters.(1-6) We describe a case of chylothorax after atrial septal defect(ASD) repair with single pericardial patch.

We present a one-year old male infant with heart murmurs discovered at birth. Transthoracic echocardiography revealed a perimembranous ventricular septal defect (VSD) as well as multiple cardiac masses. Pediatric cardiologists recommended closure of the VSD and biopsy of the uncertain cardiac masses. The VSD was repaired, and one of the masses was excised and sent for histopathological examination. Here, we discuss a case of multiple rhabdomyomas in an infant whose associated finding was congenital heart disease, rather than tuberous sclerosis. He was discharged in good clinical condition and his parents were given instructions to have routine followup visits for the evaluation of the possible regression of the remaining masses.