Journal of Cardiovascular and Thoracic Research
Volume:6 Issue: 3, Oct 2014

In this review we addressed the various analgesic techniques in cardiac surgery, especially regional methods such as thoracic epidural anesthesia (TEA). There are many techniques available for management of postoperative pain after cardiac operation including intravenous administration of analgesic drugs, infiltration of local anesthetics, nerve blocks, and neuroaxial techniques. Although there are many evidences declaring the benefits of neuroaxial blockade in improving postoperative well-being and quality of care in these patients, some studies have revealed limited effect of TEA on overall morbidity and mortality after cardiac surgery. On the other hand, some investigators have raised the concern about epidural hematoma in altered coagulation and risks of infection and local anesthetics toxicity during and after cardiac procedures. In present review, we tried to discuss the most recent arguments in the field of this controversial issue. The final conclusion about either using regional anesthesia in cardiac surgery or not has been assigned to the readers.

Massive thromboembolic intraoperative pulmonary embolism (IOPE)is rare butcarries a great degree of morbidity and mortality. This is the first study to formally assess the utility of various tools for the diagnosis of these events and the impact of each tool on mortality. Due to both the infrequent occurrence of these events and the high mortality of massive IOPE, it was cost-prohibitive to prospectively randomize patient patients to study commonly used diagnostic tools. Hence,a descriptive review of all reported cases in the literature was performed. This review yielded146 cases for past 4 decades. Following a careful review of these cases, the alerting monitor for the occurrence of IOPE was recorded. Furthermore, we recorded the confirming diagnostic tool and the outcome of these patients. We compared4 monitoring tools: (1) end-tidal carbon dioxide; (2) central catheter pressures; (3) echocardiography; and (4) standard monitoring of vital signs. Pre-event use of transesophageal echocardiographyhad no survival benefit. End-tidal carbon dioxide changes as an alerting tool were associated with improved survival compared to changes in vital signs (P<0.0001). Signs of right heart strain were associated with greater mortality, but direct thrombus visualization was not. Echocardiography appears to be useful for diagnosis of massive IOPE. Compared with hemodynamic collapse, end-tidal carbon dioxide decline as the presenting sign of massive IOPE may be associated with a better prognosis because it may represent earlier detection of IOPE and allow for more time to intervene.

Percutaneous subclavian vein catheterization is one of the most common invasive procedures performed in cardiac surgery. The aim of this study was to compare left and right subclavian vein catheter placement via the infraclavicular approach in patients who undergo coronary artery bypass graft (CABG) surgery. This prospective, randomized clinical trial was performed in193 patients. The technique applied for cannulation was infraclavicular approach for both the right and the left sides. Subclavian vein of other side was attempted only when catheterization at initial side was unsuccessful at two attempts. The success and complication rates were compared for the two sides. On193 patients, catheterization attempts were performed. 177 catheterizations (91.7%) were successful during the first attempt, 105 (92.1%) on the right side and 72 (91.1%) on the left side. There was no significant difference between success rate and side of catheterization. Malposition of the catheter tip on the right side (9.6%) was significantly more than the left side (0%) (P= 0.003). The differences in other complications on two sides were statistically insignificant. Compared with the right side, insertion of the cannula on the left side resulted in fewer catheter tip misplacements. Incidence of cannulation failure and other complications were similar on both sides.

Serum uric acid (SUA) is considered a marker for natural progression of chronic heart failure (CHF) mediated cardiovascular remodelling. CHF associates with declining of circulating mononuclear progenitor cells (MPCs). The objective of this study was to evaluate the interrelationship between SUA concentrations and proangiogenic MPCs in ischemic CHF patients. The study population was structured retrospectively after determining the coronary artery disease (CAD) by contrast-enhanced spiral computed tomography angiography in 126 subjects with symptomatic ischemic mild-to-severe CHF and 128 CAD subjects without CHF. Baseline biomarkers were measured in all patients. Cox proportional multivariate hazard ratio was calculated for predictors of MPCs declining in both CHF and non-CHF patient population predictors of MPCs declining in CHF subjects were examined in stepwise logistic regression. C-statistics, integrated discrimination indices (IDI) and net-reclassification improvement were utilized for prediction performance analyses. Cox proportional adjusted hazard ratio analyses for CD14+CD309+ and CD14+CD309+Tie2+ MPCs by SUA has shown that the higher quartiles (Q3 and Q4) of SUA compared to the lower quartiles (Q1 and Q2) are associated with increased risks of depletion of both CD14+CD309+ and CD14+CD309+Tie2+ MPCs. The addition of Q4 SUA to the ABC model improved the relative IDI by 13.8% for depletion of CD14+CD309+ MPCs and by 14.5% for depletion of CD14+CD309+Tie2+ MPCs. Circulating levels of proangiogenic MPCs are declined progressively depending on the levels of SUA in the HF subjects with CHF. We suggest that even mild elevations of SUA might be used to predict of relative depletion of proangiogenic MPCs among chronic HF patients.

Pulmonary valve replacement (PVR) is being performed more commonly lateafter the correction of tetralogy of Fallot. Most valves are replaced with an allograft or xenograft,although reoperations are a common theme. Mechanical prostheses have a less favorable reputationdue to the necessity of lifelong anticoagulation therapy and higher risk of thrombosis, but they arealso less likely to require reoperation. There is a paucity of data on the use of prosthetic valves inthe pulmonary position. We report the midterm outcomes of 38 cases of PVR with mechanicalprostheses. 122 patients who underwent PVR were studied. Thirty-eight patients, mean age 25 ±8.4 years underwent PVR with mechanical prostheses based on the right ventricular functionand the preferences of the patients and physicians. Median age of prosthesis was 1 year (range 3months to 5 years). Seven (18%) patients had malfunctioning pulmonary prostheses and two patientsunderwent redo PVR. Mean International Normalized Ratio (INR) in these seven patientswas 2.1±0.8. Fibrinolytic therapy was tried and five of them responded to it well. There wasno significant association between the severity of right ventricular dysfunction, patient’s age,prostheses valve size and age of the prosthesis in the patients with prosthesis malfunction. PVR with mechanical prostheses can be performed with promising midtermoutcomes. Thrombosis on mechanical pulmonary valve prostheses remains a seriouscomplication, but most prosthesis malfunction respond to fibrinolytic therapy, underscoring theneed for adequate anticoagulation therapy.

Studies evaluating temporal trends of Coronary artery disease (CAD) in youngpatients, from the India, are still lacking. The aim of this study was to evaluate temporal differencesin risk factors of young patients of CAD over a decade. This is a single centre retrospective study performed in a tertiary care teaching institutionin North India. Case records of young patients (≤40 years) with acute coronary syndrome betweenJanuary 2000 to December 2001 and January 2009 to December 2010 were obtained. Recordswere sought for active smoking, family history, waist size, blood pressure, hypertension, fastingand postprandial blood sugar and lipid profile for both groups and analyzed using SPSS v.17. Forthe purpose of the study, p value <0.05 was considered statistically significant. Medical records of a total of 79 and 83 patients with young CAD (≤ 40 years) wereobtained for 2000-01 and 2009-10 period respectively. An increase in proportion of femalepatients, hypertension (p=0.004), dysglycemia (p<0.001), family history (p=0.01), metabolicsyndrome (p<0.001), low high density lipoprotein (HDL) (p=0.07) and mean waist size (0.03)was noted over the years. Among males, increase in number of dysglycemics (p=0.0002), positivefamily history (p<0.0001) and mean waist size (0.032) was statistically significant. Over a decade the patients with young CAD in our study, there was an increase inproportion of patients with metabolic syndrome, dysglycemia and low HDL.

Natriuretic peptides are secreted from the heart in response to increased wall stress. Their levels are expected to be increased in patients with mitral stenosis (MS) due tohigh left atrium (LA) pressure and pulmonary artery pressure (PAP). Percutaneous transvenousmitral commissurotomy (PTMC) if successful is pursued by a rapid decrease in LA pressure andsubsequent decrease in pulmonary artery pressure. The concurrent changes in natriuretic peptidelevels could be affected with heart rhythm. Forty five patients with severe rheumatic MS undergoing PTMC were enrolled. Weevaluated the serum NT-Pro BNP levels before and 24 hours after PTMC. BNP levels were alsomeasured from the blood samples obtained from LA before and 20 minutes after the procedure.Changes in biomarkers were assessed based on heart rhythm and success of the procedure. While serum NT-Pro BNP levels showed significant decrease 24 hours after theprocedure (P= 0.04), BNP levels taken 20 minutes after PTMC from LA were similar to theirbaseline concentrations (P= 0.26). NT-Pro BNP levels decreased 51.7±182.86 pg/ml for SR and123.4±520 pg/ml for AF (P= 0.68). Immediate changes in BNP levels did not predict the success of procedure probablydue to the additional balloon inflation attempts in LA in several patients and half-life of BNP. BNPlevels obtained later may be of more value considering the half-life of this marker. Heart rhythmwas not found to influence the changes in biomarker levels. BNP and NT-pro BNP changes werenot found to predict success of the procedure.

The surgeons and their patients are now seeing the benefits and extendedpossibilities of minimally invasive cardiac surgery. Anterior mini-thoracotomy approach is agood alternative to median sternotomy since it reduces operative trauma, accelerates recoveryand yields a better cosmetic outcome. Our purpose is to explain the details of our technique andmanifest the experience results. Seventy five patients with secundum Atrial Septal Defect (ASD) (52 female and 23 male)were operated with anterior mini-thoracotomy approach in our tertiary research center betweenMarch 2012 and March 2014. The mean age was 14±10 ranged from 2 to 42 years. Outcomes weredefined according to cardiopulmonary and aortic cross-clump time, intensive care unit stay time,morbidity, mortality, the size of incision, the amount of post-operative bleeding, the amount ofblood transfusion, reoperation and the surgical details. Mean Cardiopulmonary bypass time (CPB time) was 49.62 minutes (from 26 to 105minutes) and mean aortic cross clamp time was 22.29±6.77 minutes (between 11 to 47 minutes).The mean amount of blood transfusion was 47.49± 62.22 mm (ranged 0 to 200 cc) and themean chest tube drainage after surgery was 80.17 ±121.06 mm (ranged 0 to 600 cc). One patientre-operated for dehiscence of ASD surgical sutures and there was no reoperation for surgicalbleeding or tamponade drainage in these patients. In 74 cases the defect was secundum type ASD,in 2 patients it was sinus venosus type and in one with associated partial Anomalous repair. Anterior thoracotomy approach is safe and may be the surgical technique ofchoice for secundum ASD repair in all age groups and we can utilize this technique also formore complicated kinds of surgery for instance, sinus venosus type ASD with or without PartialAnomalous Defect.

The present research investigated the effects of two different types of music on cardiovascular responses in essential hypertensive men in comparison with healthy men based on introversion and extraversion. One hundred and thirteen hypertensive men referred to Madani Heart Hospital in Tabriz completed the NEO-FFI Questionnaire and after obtaining acceptable scores were classified in four groups: introvert patients, extravert patients, introvert healthy subjects, and extravert healthy subjects (each group with 25 samples with age range 31-50). Baseline blood pressure and heart rate of each subject was recorded without any stimulus. Then subjects were exposed to slow-beat music and blood pressure and heart rate were recorded. After15 minute break, and a little cognitive task for distraction, subjects were exposed to fast-beat music and blood pressure and heart rate were recorded again. Multivariate analysis of covariance (MANCOVA) test showed that extravert patient subjects obtained greater reduction in systolic blood pressure and heart rate after presenting slow-beat music compared with introvert patients (P= 0.035, and P= 0.033 respectively). And extravert healthy subjects obtained greater reduction in heart rate after presenting slow-beat music compared with introvert healthy subjects (P= 0.036). However, there are no significant differences between introvert and extravert groups in systolic and diastolic blood pressure and heart rate after presenting fast-beat music. Based on our results, introvert subjects experience negative emotions more than extravert subjects and negative emotions cause less change in blood pressure in these subjects compared with extravert subjects.

High sensitive C-Reactive Protein (hs-CRP) is increased in acute and chronic rheumatic fever (RF), but is unknown whether serum levels of hs-CRP is correlated with late restenosis of mitral valve (MV) after Percutaneous transvenous mitral commissurotomy (PTMC). The aim of this study is to determine relationship between hs-CRP and MV restenosis 48-36 months after performing PTMC. A total of 50 patients who had undergone PTMC due to rheumatic etiology (41 female, 9 male; mean age 46 ± 11, range 27-71), all followed up on an out patients basis 36 months after PTMC, were included in the study. The hs-CRP was measured using an enzyme-linked immunosorbent assay (ELISA) kits. No association was found between hs-CRP level and mean transmitral valve gradient 36 months after PTMC, MV area by planimetry, pulmonary artery systolic pressure, mitral regurgitation grade, left atrial diameter, atrial fibrillation (AF) rhythm and Wilkins score. Our study have shown that there is no association between hs-CRP and MV restenosis in patients with rheumatic heart disease (RHD) who underwent PTMC. Therefore, it has been postulated that inflammation is not a cause of post PTMC restenosis.

Endocardial cushion defect (ECD) can be partial (with two distinct valves) or complete (only one atrioventricular valve), and surgical therapy is usually required. The optimal surgical technique is controversial but De Vega’s annuloplasty is widely performed. Tricuspid valve thrombosis are rarely seen after surgery. We present a 39-year-old male patient with tricuspid valve thrombosis after De Vega’s annuloplasty without the use of a ring.