Cardiovascular Function during First 24 Hours after Off-Pump and On-Pump CABG—A Prospective Observational Comparative Study

Purpose: Myocardial revascularization by coronary artery bypass grafting (CABG) in ischemic heart disease patients has direct impact on hemodynamic parameters in the immediate post-operative period. The peri-operative cardiovascular functioning is an important determinant for outcome of surgery. In On-Pump CABG (ONCAB), the cardiopulmonary bypass has a negative effect on myocardium. Off-Pump CABG (OPCAB) avoids the effect of CPB but complete revascularization with difficult positioning of heart is technically demanding. This study is aimed to compare the cardiovascular functioning in the immediate post-operative period after OPCAB and ONCAB. Methods: Total 106 patients were operated for CABG from January 2015 to June 2016, of which 75 patients were operated for OPCAB and 31 patients were operated for ONCAB. For the comparison, hemodynamic parameters were measured during anesthesia before surgery, postoperatively after 1 and 4 hours (h) in the ICU, and in the morning after surgery, approximately after 20 h. Results: The time-dependent rise of hemodynamic parameters like Cardiac Output (CO), Cardiac Index (CI), Stroke volume (SV) and Left Ventricular Stroke Work Index (LVSWI) in the immediate post-operative hours (1 h and 4 h) are more predominant in OPCAB group than ONCAB group although the difference is eliminated mostly at 20 h. The better peripheral vasodilation after OPCAB causes immediate fall of Systemic Vascular Resistance Index (SVRI) after OPCAB. Conclusion: Better cardiovascular functioning immediately after OPCAB than ONCAB may be important for better hemodynamic stability. The difference is however eliminated after 24 hours indicating little significance in long term outcome.

Prevalence of Preoperative Anemia in Elective Rheumatic Valve Surgery at a Tertiary Care Center in Nepal

Background: Rheumatic Valvular Heart disease (RVHD) is common in developing countries often associated with anemia;however its burden is often overlooked. Anemic patients undergoing surgery are likely to receive blood transfusion, increasing morbidity and mortality. Prevalence of anemia in cardiac surgical patients are studied extensively, however its burden in RVHD is lacking. This study attempted to investigate the prevalence of preoperative anemia in RVHD and its effect on blood transfusion, morbidity and mortality in patients undergoing valve surgery. Methods: This is a retrospective observational study conducted at a tertiary care hospital in Nepal. We considered 340 patients who underwent Rheumatic valve replacement surgery from 2014 January to December 2016 and data on their socio-demographic and clinical characteristics were extracted from the patient’s records. The analyses meeting the study objectives were conducted using IBM SPSS v25 for Windows (IBM Statistical Package for Social Sciences, 2015IBM Corporation, New York, United States). Results: The prevalence of no anemia, mild, moderate, and severe anemia was 34.1%, 57.7%, 39.6%, 2.5%, respectively. The units of Red Blood Cell used for transfusion were 1.2 units, 2.0 units, 2.3 units, and 1.6 units in patients without anemia, and those with mild, moderate and severe anemia respectively. The incidence of reexploration was higher in patients with severe anemia as compared to the non anemic with an incidence of 66.6%. A proportion of the patients with no anemia, mild, moderate and severe anemia with less than 7 days stay in the intensive care unit were 89%, 82%, 84.7% and 100% respectively. The length of hospital stay more than 10 days was seen in 58.9%, 71.6%, 63% and 100% in patients with no anemia, mild, moderate and severe anemia. An overall incidence of mortality in anemic patients was 11% while in non anemic patients was 5.3%. Conclusions: The prevalence of anemia was high in the Nepalese patients with Rheumatic valvular heart disease planned for elective surgery. There was an increased incidence of blood transfusion, longer hospital stay, and increased mortality in anemic patients compared to their non anemic counterparts.

Early Surgical Correction of Transplant Renal Artery Stenosis (Tras)—A Case Report

Saphenous vein graft (SVG) bypass of the renal artery from the aorta has been well documented, though bypass of the internal iliac artery to the individual renal arteries is not yet described. We herewith present a case of early TRAS detected 6 hours after a successful renal transplant. Renal angiography showed complete stenosis of the internal iliac to renal artery anastomosis. Percutaneous transplant artery angioplasty was attempted, but was not successful;hence the surgical correction of the same was done. This is to demonstrate the use of saphenous vein bypass of anastomotic obstruction of the previous anastomosis, in case of short renal artery.

Level of Cardiac Biomarkers in Immediate Post-Operative Period after Off-Pump CABG and Its Comparison with On-Pump CABG: A Prospective Analytical Study

Background: Coronary artery bypass grafting (CABG) is an important modality of treatment for ischemic heart disease. Both off-pump and on-pump CABG have direct effect on the level cardiac biomarkers in the perioperative period. The use of cardiopulmonary bypass (CPB) and aortic cross-clamping may cause additive myocardial damage leading to further elevation of blood markers. The present study is aimed at measuring and comparing the cardiac biomarker levels in immediate post-operative period after on-pump CABG (ONCAB) and off-pump CABG (OPCAB). Methods: All the patients who underwent CABG from January 2015 to June 2016 on elective or emergency basis at Nilratan Sircar Medical College & Hospital have been included in the study. Total 106 patients were operated for CABG of which 75 patients were operated for OPCAB and 31 patients were operated for ONCAB. For the comparison of data the blood markers Troponin-T (Trop-T) and Creatine Kinase-MB (CK-MB) are measured during anesthesia before surgery, post-operatively after 1 hour, post-operatively after 4 hours and post-operatively after 20 hours. All recorded data are analyzed using standard statistical methods. Results: We found the markers are elevated immediately after surgery and gradually come down within 24 hours after surgery in both OPCAB and ONCAB groups. The elevation is more after ONCAB than OPCAB group in immediate post-operative period but the difference is not significant after 20 hours of surgery. Conclusion: Elevated levels of cardiac biomarkers in the immediate post-operative period indicate myocardial damage during surgery, especially after ONCAB in comparison to OPCAB. This may attribute to the better hemodynamic stability in the immediate post-operative period after OPCAB than ONCAB assuming comparable and adequate revascularization in patients of both groups. The avoidance of CPB and cross-clamp may explain better myocardial functioning immediately after OPCAB. But after 20 hours, the level of cardiac markers is comparable in both groups indicating little difference in post-operative recovery and long-term prognosis.

A Case of Giant Mediastinal Liposarcoma of Thymic Origin: A Rare Clinical Entity

Thymoliposarcoma is an exceedingly rare tumor of thymus with a very few cases reported till date. This case study presents a 45-year male with rare type of thymoma. On the contrast-enhanced CT images, there was a large mass lesion of predominantly fat attenuation in the pre-vascular compartment of the mediastinum insinuating on both sides of the visceral compartment of the mediastinum, and extending upto the bilateral cardio phrenic and anterior costophrenic angles, anterior to the right ventricle with loss of fat plane with the pericardium, with few sub-centimetric lymph nodes in the right paratracheal and AP window and a calcified right hilar lymph node, suggestive of well-differentiated liposarcoma/thymoliposarcoma. Initial CT guided tru-cut tissue biopsy was inconclusive, and the repeat biopsy revealed as fibro-collagenous tissue with area of necrosis, focal myxoid changes in the background with presence of cells which are spindle to oval in shape with mild nuclear pleomorphism and negative for S100, Cytokeratin, CD34, desmin. The entire tumor was resected en masse after meticulous dissection without the support of cardiopulmonary bypass (CPB) with an intact pericardium. Final histopathology report of the surgical biopsy specimens is consistent with dedifferentiated thymoliposarcoma with focal ganglionic cell differentiation. Postoperative follow-up CECT of thorax revealed no evidence of residual mass in the pre-vascular compartment. The patient is disease-free and asymptomatic after 6-month and he is under routine follow-up under Radiotherapy department since he received 30 Gy of postoperative radiotherapy (PORT).