included 50 patients underwent urgent coronary artery bypass graft, ..... conginetal deformity. The anterior leaflet was excised ,the posterior leaflet was preserved.
King Abdul-Aziz university hospital study on URGENT CORONARY ARTERY BYPASS SURGERY by Prof. khaled Al-Ibrahim Dr. Ragab Shehata 2012
CONTENTS Introduction Aim of the work Patient & methods Results Discussion Review of literatures Summary and conclusion
Anatomy Anatomy Left main coronary a Left ant. Descending a Left circumflex a. Right coronary a.
Pathophysiology The resting coronary blood flow about 225 ml/min. It is about 4 to 5 % of cardiac output. The work output of the heart under severe conditions may
increase six fold to nine fold. The coronary blood flow increases three fold to four fold . The "efficiency" of cardiac utilization of energy increases to make up for the relative deficiency of coronary blood supply Coronary Blood Flow show Phasic Changes During Systole and Diastole.
AIM OF THE WORK The purpose of this study is : To evaluate the predisposing risk factors prior to and after urgent CABG To analyze clinical outcome and prognosis To characterize risk factors associated with morbidity and mortality
PATIENT & METHODS This study was done in King Abdul-Aziz University
Hospital, Jeddah, Saudi Arabia, from July 2009 to July 2011. One hundred patients included in this study Underwent coronary artery bypass grafting for acute coronary syndrome. Patients were divided into two groups, (urgent group) included 50 patients underwent urgent coronary artery bypass graft, Elective group included 50 patient underwent elective coronary artery bypass graft.
inclusion &exclusion criteria Inclusion criteria: Patients underwent urgent CABG are included in group A Patients underwent elective CABG are included in group B Exclusion criteria: Emergency CABG Patients with previous CABG CABG patients with other cardiac operation including valve and aortic surgery Off pump CABG patients CABG patients with previous cardiac operation
Definition of elective cabg According to society of thoracic surgeon definitions, Elective CABG referred to: The patient's cardiac function that has been stable in the days or weeks prior to the operation. The procedure could be deferred without increased risk of compromised cardiac outcome.
Definition of urgent cabg Procedure required during same hospitalization in order to minimize chance of further clinical deterioration. Examples include (but are not limited) to: Worsening, sudden chest pain, CHF, acute myocardial infarction (AMI), anatomy, IABP, unstable angina (UA) with intravenous (IV) nitroglycerin (NTG) or rest angina
All patients will be subjected to and evaluated history & clinical examination.
Full (labs) investigations. CBC,
U&E, LFT, coagulation profile, cardiac enzymes and troponin ECG. Chest X-Ray ECHO Coronary angiography: Time from presentation to surgery (STS) score.
Type of surgery elective or
urgent The cause of urgency. Cardiopulmonary bypass time Myocardial ischemic time Operation time. No. of grafts, arterial and venues grafts Complications Usage of inotropic ,IABP, and VAD Operative mortality
Post operative:
Cardiac output and cardiac index , SVRI, CVP, PCWP Inotropes. Amount of blood loss in ml. Numbers of (PRBc) (FFP), plat, and and factor VII if given. Mechanical ventilation in hours Labs, Chest X-Ray & ECG. (ICU) stays Hospital stays Follow up at 30 days post opertive clinically & by echocardiographic
Patients and methods Mean age /years
56.72±12.44 for urgent 61.06±7.26 for elective Significant stat difference P value 0.036
Gender distribution No significant difference
Risk factors
Patients and methods Urgent
Elective
n= 50
n= 50
56.72±12.44
61.06±7.26
0.036
Male (%)
36 (72)
38 (76)
0.41
Female (%)
14 (28)
12 (24)
Diabetes mellitus (%)
32 (64)
28(56)
0.27
Hypertension (%)
37 (74)
27 (54)
0.03
Dyslipidemia (%)
26(52)
12 (24)
0.004
Obesity (%)
6(12)
7(14)
0.48
Smoking (%)
22 (44)
13 (26)
0.046
Family history (%)
16 (32)
11 (22)
0.184
Renal impairment (%)
4 (8)
6 (12)
0.37
Chronic lung disease (%)
7 (14)
4(8)
0.262
PVD (%)
10 (20)
7 (14)
0.298
CVA (%)
4(8)
3 (6)
0.5
P value Age mean ± SD
Sex
Clinical presentation ST myocardial infarction Non ST myocardial infarction Unstable angina
Coronary angiography
Operative data
RESULTS (mortality) Urgent mortality 6(12%) Elective 1(2%)
Results (post op complications) Urgent
Elective
15 (30%)
8(16%)
P value Myocardial infarction
7(14)
1(2)
0.025
Atrial Fibrillation
6(12)
5(10)
0.5
Prolonged ventilation
8(16)
2(4)
0.011
Pneumonia
2(4)
1(2)
0.5
ARDS
1(2)
0(0)
0.5
5(10)
2(4)
0.218
Exploration for bleeding
4(8)
1(2)
0.181
Rewiring
4(8)
2(4)
0.5
7(14)
3(6)
0.159
SWI
13(26)
7(14)
0.105
CVA
3(6)
1(2)
0.308
7(14)
7(14)
1
Dialysis
4(8)
1(2)
0.181
GIT bleed
1(2)
0(0)
0.5
5(10)
2(4)
0.218
Pleural effusion
DSWI
Renal impairment
Readmission
Clinical outcome for urgent group
Clinical outcome for elective group
Results & discussion In our study we found that: Urgent CABG group were younger age More hypertensive, dyslipidemic, and smokers. Presented mainly by ST elevated MI Higher heart failure and angina class. Mostly required inotropic support, vasodilators, and IABP
Results & discussion Left main CAD found in significant large numbers of urgent groups Significant lower ejection fraction Lower WMSI Higher STS risk stratification
Results & discussion In our study, the most common cause of urgency was the presence of chest pain and left main CAD. All urgent cases were operated on within one week of presentation, With significant longer CPB time and AXC time. Post operative use of inotropic support, vasodilators, and IABP , ventilation time, ICU stays, and hospital stay were significantly higher in the urgent group.
Results & discussion Early significant postoperative improvement in functional status and angina incidence in urgent group, With mild improvement in ejection fraction and WMSI. In elective groups mild early improvement
Results & discussion 1- The in hospital mortality of urgent cases was 6 times higher. Causes of mortality include: low cardiac output state was the most common cause of deaths, 2- Morbidity is also higher including: Periopertaive myocardial infarction, Increased amount of bleeding and re-exploration rate, Prolonged ventilation, Atrial fibrillation, and Wound infections
Summary & conclusion Urgent coronary artery bypass graft is associated with
significantly higher mortality and morbidity than elective CABG. This was because of the higher proportion of patients in
left main coronary artery disease and critical preoperative clinical status. Female gender, long CPB time, and low ejection fraction
Added further to mortality.
Summary & conclusion Despite the higher surgical mortality rate (12%) after the
urgent CABG, a favorable early clinical outcome observed, acceptable mid and long term outcome can be expected if the patients survive. High-quality clinical evidence is still needed to define the
optimal time for urgent surgery after acute coronary syndrome, and to define the optimal periopertaive and operative management of these patients, also we need risk profile stratification, and clear
indicationa for urgent surgery.
THREE EXAMPLES OF VERY HIGH RISK OPEN HEART SURGERIES DONE LAST MONTH
Case #1 Cardiogenic shock , poor LV function ,and moderate mitral regurgitation 60 years male post persistant chest pain >4 days , ECG showed nonST elevation MI, Troponin and ckmb were continuously rising Echo showed 30% ejection fraction, hypokinetic multiple
wall motion abnormalities, moderate to severe mitral regurgitation Coronary angio showed occluded LAD and RCA.
CORONARY ANGIO
The patient was haemodynamically unstabe With frequent atrial fibrillations, cardioverted
twice On Nor epinephrine 120 ng/kg/min , Ventillated on the intra aortic balloon pump
mechanical support
IABP
EMERGENCY SURGERY Coronary bypass 1- Using saphenous vein to the posterior descending of the RCA and the diagonal
2- Internal mammary artery to the LAD
POSTOP. COURSE Smooth post op recovery Inotropes weaned off the first post op day
IABP removed the second post op day Extubated the third post op day Post op echo showed improvement of the LV function
and the mitral regurgitation Discharged 10 days posp op
Case#2,cardiogenic shock , failed coronary intervention 80 years admitted with cardiogenic shock , ventillated, on The intra aortic balloon pump support device , suffered at least
2 episodes of V.F., cardioverted On large doses of inotropes(200ng levophed, 200ng epinephrine
Received large amount of dye in the cath lab during Coronary intervention. Pushed to OR 6pm for emergency CABG
ECG
The worst surgical scenario 80 years Previous cardiac arrest , multiple defibrillation Several preop episodes of hypotension Unsuccessful, complicated coronary intervention Large doses of inotropes, esp. levophed Global ischaemia ECG Diffuse coronary dis . Small saphenous veins Father of a colleague
Surgery Harvesting both lower limbs ,only 10 cm of saphenous vein was suitable for grafting SO the internal mammary artery(IMA) was harvested
Sphenous vein to the obtuse marginal branch and the IMA anastomosed the LAD. Off pump at 11 pm on IABP, half the preop doses of inotropes(100 ng epinephrine, 100 ng norepinephrine)
Postop ECG
ECG
Postop Weaned off inotropes , IABP removed the second day
Bluish discoloration of toe tips Renal failiure requiring haemodialysis Tracheostomy for weaning
Case#3 The most giant left atrium in history 32 years male presented with severe mitral valve
disease , massive left atrial dilatation , atrial
fibrillation The patient had an old echo report since age of two
years with almost similar findings
Cardiac surgery steps The left atrium was massively dilated of about 21 cm in horizontal diameter The left atrial wall was extremely thin The mitral valve was heavily diseased rheumatic on top of conginetal deformity The anterior leaflet was excised ,the posterior leaflet was preserved Mitral valve replacement was done using the biggest mechanical valve available(33mm) using multiple pledgeted suture The left atrial appendage was ligated
Left Atrial Wall Plication The left atrial wall was closed following trimming and plication of the
anterior wall reducing its size to 10cm As the wall was sxtremely thin, there was multiple bleeding sites from
needle holes along the suture line Multiple suturing worsened the situation ,and the holes became bigger Multiple pledgeted sutures +the use of topical haemostatic agents
( Tachocel + surgiflo) controlled the bleeding
Surgical steps A small dysplastic part of the anterior anterior segment of the upper lobe was excised
Histopathology Histopathology of the mitral valve showed myxoid degeneration Histopathology of the left atrial wall showed fibrous layer composed of loose connective tissue and few strips of smooth muscles Histopathology of the lung segment showed paraseptal emphysema
Post op Postop the patient was initially in heart block paced
with epicardial leads which improved few days later The patient was discharged well on warfarin to be
followed in the clinic
Review of the literature Tex Heart Inst J. 2006; 33(3): 389–391. © 2006 by the Texas Heart® Institute, Houston Giant Left Atrium with Rheumatic Mitral Stenosisleft atrial diameter of 18.7 cm Mehmet Ates, MD, Yavuz Sensoz, MD, Gunseli Abay, MD, and Murat Akcar, MD Departments of Cardiovascular Surgery Istanbul, Turkey
Review of the literature Surgical treatment of giant left atrium combined with
mitral valvular disease. Plication procedure for reduction of compression to the left ventricle, 1983 bronchus, and pulmonary parenchyma K Kawazoe, S Beppu, Y Takahara, N Nakajima, K Tanaka, K Ichihashi, T Fujita and H Manabe Journal of thoracic and cardiovascular surgery A total of 40 patients with giant left atrium underwent
operation
1983 Jun;85(6):885-92
Left Atrial Reduction Plasty: A Novel Technique The Annals of Thoracic Surgery Volume 93, Issue 3, March 2012, Pages e77–e79 Corey Adams, Gian-Marco Busato, Michael W.A. Chu
Busato, Michael W.A. Chu
