Considering the prolonged recovery time, less cosmesis, chronic post-sternotomy pain, sternal instability, delayed wound and bone healing, wound infection associated with conventional coronary Artery Bypass Grafting (CABG), minimally invasive surgery has been being tried for decades. Endoscope assisted CABG (Endo-CAB) is a newer development. This reported case is the first one of our series of Endo-CABG, where two grafts were done successfully. Cardiovasc j 2024; 17(1): 48-50
Background: Cardiorespiratory fitness (CRF) is a powerful predictor of outcome in health and diseases, including cardiovascular disease (CVD). CRF shows significant racial variation, and for this, region- and county-specific normative values are needed. The study was done to determine the CRF of healthy Bangladeshi adults. Methods: In this prospective observational study involving 240 men and 70 women, CRF was assessed by symptom-limited exercise tolerance testing (ETT), maximal exercise capacity was determined and expressed in metabolic equivalents (METs), maximal oxygen consumption (V̇O2 max) was calculated and compared with the previously published data. Apparently healthy men and women aged >18 years without significant disease and with negative ETT test results were included. Those with significant illness, including cardiac, respiratory or rheumatological, those on drugs having potential effect on chronotropic or haemodynamic response were excluded. Results: The mean exercise capacity of men and women was 11.56±6.21 and 9.01±1.61 METs, respectively. The METs and estimated V̇O2 max decreased with age in both sexes. Overall, the Bangladeshi men and women had lower maximal exercise capacity than the Western people, almost similar exercise capacity compared to the Koreans, and higher exercise capacity than the Indians. Conclusion: CRF of Bangladeshi healthy subjects should be validated by larger studies and national registry. Future assessment of CRF should be based on cardiopulmonary exercise testing. Cardiovasc j 2024; 17(1): 12-17
Background: Acute kidney injury (AKI) is a common serious complication of cardiac surgery. A low hematocrit during cardiopulmonary bypass is associated with an increased risk of acute kidney injury, mainly due to a low oxygen delivery. Hemodilution is required for effective function of cardiopulmonary bypass during cardiac operations and moderate hemodilution is found to be beneficial for renal protection. But extreme per-operative low hematocrit is linked to adverse renal outcome. The main objective of this study was to determine the utility of per-operative hematocrit level in predicting AKI following cardiopulmonary bypass. Methods: It was a cross sectional study involving fifty patients who underwent cardiac surgery supported by cardiopulmonary bypass. Group A (25 patients) had hematocrit level ≥ 24 % and group B (25 patients) had hematocrit level <24% during cardiopulmonary bypass. Each patient was categorized by Acute Kidney Injury Network (AKIN) criteria based on creatinine changes within the first 48 hours. The independent impact of lower hematocrit on post-operative acute kidney injury was assessed. Results: In this study of the 50 patients, 30% were diagnosed with AKI. Among those 15 patients, 4 were from group A and 11 were from group B (p= 0.031). Most of the patients developed stage 1 AKI according to AKIN criteria (80%). None developed stage 3. Post-operative creatinine was significantly higher in group B than group A. When considering baseline characteristics, we found no difference in age, gender, pre-operative LVEF, diabetes and hypertension. Regarding the intraoperative characteristics, we found no relation with CPB time and cross clamp time (p value 0.982 and 0.596 respectively) with CSA-AKI. Postoperative urine output was not also significantly involved with post-operative AKI. Conclusion: Patients with per-operative hematocrit level above 24% during cardiopulmonary bypass had good postoperative renal function than patients with per-operative hematocrit level below 24%. Cardiovasc j 2024; 17(1): 40-44
Background: Because of concern about the ability to tolerate beating heart grafting, patients with left main coronary artery stenosis (≥50%) have been excluded from off-pump bypass. The objective of the present study was to evaluate the safety and efficacy of off- pump coronary artery surgery in patients with left main coronary artery disease. Methods: From March 2020 to December 2021, a total of 437 patients, 159 of whom had significant LMCA disease, underwent isolated OPCAB surgery under a single Cardiac surgeon at Khulna City Medical College Hospital. We compared the clinical outcomes of 100 patients with LMCA stenosis (LMCA group) with those of 100 propensity score-matched patients without LMCA stenosis (non-LMCA group). We performed off-pump technique in all coronary artery bypass grafting cases. Patients were followed up for any major adverse cardiovascular events up to three years. Results: All CABG were performed by off-pump technique without conversion to on-pump. One patients in the LMCA group (1 of 100; 1%) and one in the non-LMCA group (1 of 100; 1%) died within 30 days after surgery. Follow-up was completed in 98% of the patients. The rates of three-year freedom from all cause death were 97.3% and 77.7% in the LMCA group and non- LMCA group, respectively (p = 0.17), and the corresponding rates for the combined endpoint of myocardial infarction, angina pectoris, repeat coronary intervention, and heart failure were 80.4% and 70.4% (p = 0.98).Conclusions: Off-pump coronary artery bypass grafting is feasible and safe in patients with critical LMCA stenosis and LMCA disease is not recognized as a risk factor after off-pump coronary artery bypass grafting in either the short or the Mid-term. Cardiovasc j 2024; 17(1): 24-30
Background: Great saphenous vein is a popular conduit for coronary artery bypass graft. But the harvest site wound infection increases morbidity and prolong hospital stay. Closing techniques of saphenectony wound may contribute to early post operative outcome of the patient. The purpose of this study was to compare outcomes of the different closing techniques of saphenectomy wound. Methods: This comparative cross-sectional study was carried out with 58 patients who underwent coronary artery bypass graft (CABG) and great saphenous vein was harvested as a conduit. Out of which 29 patients underwent single layer (Group-A) and rest 29 patients underwent double layer closure (Group-B) of saphenectony wound. Incidence of wound complications was compared between the two groups. Results: On analysis of age, sex, weight, comorbidities and per operative variables, no significant differences were observed between two groups. There was significant statistical difference of mean ASEPSIS score (p=0.011) between the group A (4.17±5.9) and group B (9.55±9.44). Serous discharge was noted in 4 (13.8%) patients in group A and 10 (34.5%) patients in group B. Four (13.8%) patients had erythema in group A and 11 (37.9%) in group B. Four (13.8%) patients had purulent exudates in group A and 1 (3.4%) in group B. Three (10.7%) patients had edema in group A and 10 (34.5%) in group B. The differences of erythema and edema were statistically significant (p<0.05) between two groups. Almost three fourth (72.4%) of patients had satisfactory healing in group A and 12 (41.4%) in group B. No patient had severe wound infection. Conclusion: Single layer interrupted closure had shown an overall improved wound outcome and less pain compared to double layer closing technique in terms of erythema, edema and satisfactory wound healing. Cardiovasc j 2024; 17(1): 5-11
A 2.6-year-old girl weighing 10kg was diagnosed as Severe Coarctation of Aorta in October 2008. Subsequently, she underwent Balloon angioplasty in April 2009 & later stenting of coarct area was performed with a covered stent in April 2014. In January 2024 she came for follow up after a long gap and re-coarctation was noticed in echocardiography. Balloon dilatation of the covered stent was performed with a 16 × 40 mm Z-med balloon successfully at 17 years of age. Successful journey of this patient since her first admission to pediatric ICU till today led us to write this report. Cardiovasc j 2024; 17(1): 45-47
Background: Papaverine has been the conventional vasodilator used to combat vasospasm at the time of left internal mammary artery (LIMA) preparation. Recent evidence associating Papaverine with vascular wall damage in bypass conduits has prompted the search for safe and effective alternative vasodilators. A buffered vasodilator solution containing glyceryl trinitrate and verapamil solution (GV solution) made a promising vasodilator for preparation of vascular conduits. Methods: The study compared the effects and safety of GV solution to Papaverine solution on 60 patients. Group A (30 patients) received GV solution, while Group B (30 patients) received conventional Papaverine solution. The study analyzed LIMA flow before (Flow 1) and after (Flow 2) the organ bath, ICU stay, ECG, Echocardiography, mortality, morbidity, and other important parameters. Results: The administration of a vasodilator agent using the organ bath technique resulted in a significant increase in free flow (Flow 2) in both group A and group B compared to Flow 1 (p <0.0001). However, Flow 2 was significantly higher in group A than in group B (p <0.0001). There were no deaths in group A, but two deaths occurred in group B, indicating that the GV solution was safe solution. While there were lower rates of morbidity and ICU stay in group A compared to group B, these differences were not statistically significant (p >0.05). Conclusion: The GV solution was found to be a safe and effective substitute for Papaverine, preventing or rapidly reversing LIMA spasms during preparation for OPCAB surgery. Cardiovasc j 2024; 17(1): 18-23
Background: Myocardial protection is a critical component of surgery in congenital heart disease (CHD). Since the commencement, several cardioplegia solutions have been developed to accomplish the goal. This study was aimed to compare the myocardial protection provided by Del Nido cardioplegia and St. Thomas cardioplegia solution in paediatric patients undergoing surgical repair for CHD. Methods: This comparative cross-sectional study was carried out with a total of 30 paediatric patients who underwent elective cardiopulmonary bypass surgery for repair of congenital heart disease were included. They were divided into two groups: group-A (15 patients, who received Del Nido cardioplegia solution) and group-B (15 patients, who received St. Thomas cardioplegia solution). After surgery of all patients, biochemical markers (Troponin-I and Creatine Kinase MB) was done at 6th hour and 24th hour postoperatively and Vasoactive Inotropic Score (VIS) was taken immediately and at 24th hour postoperatively. pre and post operative left Ventricular Ejection Fraction (LVEF) was evaluated. Post operative events (Mechanical ventilation time, postoperative CICU stay period, postoperative hospital stay and complications) were recorded. Results: The mean age, height, weight and body surface area were not statistically significant in both groups (p>0.05). Group-B patients had significantly higher cardiopulmonary bypass time (83.8±20.39 vs 106.87±31.33, p=0.022) and aortic cross clamp time (40.66±10.68 vs 50.73±12.10, p=0.020) than that of group A patients. Group-A patients had significantly lower value of Troponin-I (33.68±20.80 vs 268.15±297.48, p=0.005) and CK-MB (17.98±7.57 vs 49.66±52.32, p=0.035) after 24 hours of surgery. There was significantly higher number of patients in Group B, who had their Troponin-I (20% vs 73.33%, p = 0.003) and CK- MB (13.33% vs 60%, p = 0.008) at 24th postoperative hour in comparison to Group A. Besides, value of postoperative vasoactive inotropic score was significantly lower in group-A than group-B during immediately postoperative (11.81±3.03 vs 15.01±3.40, p=0.011) and at the 24th postoperative hour (9.1±2.73 vs 12.82±2.26, p<0.001). Conclusion: Better myocardial protection is provided by Del Nido cardioplegia in comparison to St. Thomas cardioplegia in paediatric patients who underwent surgical repair for congenital heart disease. So, the application of Del Nido cardioplegia can minimize the morbidity and mortality with early postoperative recovery of the paediatric patients. Cardiovasc j 2024; 17(1): 31-39
Background: Cardiac Surgery is one of the most sophisticated branches of medical science, which is continually being updated. With very little inclusion in medical course curriculum, medical graduates have limited orientation of this pristine subject. Capacity building is lengthy and cardiac surgery units often contain unrelated junior doctors due to scarcity of cardiac surgeons. New residents may also face similar difficulties. The objectives of this article are to describe the difficulties faces by newly posted doctors and offer some solutions. Methods: This study was conducted in the Department of Cardiac Surgery, Chittagong Medical College & Hospital (CMCH) between January 2020 and December 2022. A confidential self-report system questionnaire was used to interview 30 newcomers in CMCH and other cardiac surgery set ups and their findings are compiled in the article. Results: The interviewed doctors and residents have described individualities of cardiac surgery department and the difficulties they faced while working here. They also offered some solutions of the problems faced by them. Conclusion: Cardiac surgery is a stressful job. The new residents and unrelated doctors face various problems while beginning here. This is more troublesome for the female doctors, but doctors trained in cardiology or other surgical disciplines suffered least. Orientation initiatives by the cardiac surgery department and publishing a complete manual handbook to provide guidelines will be helpful in this regard. Cardiovasc j 2024; 16(2): 81-85
During the realm of cardiovascular health, where disease remains strong, cardiopulmonary bypass (CPB) is a crucial tool in surgical interventions. Navigating through CPB and the turbulent waters of shock can unveil a difficult opponent called vasoplegia. Despite the heart's efforts to maintain its rhythm, the body may experience a state of low systemic vascular resistance, a key feature of vasoplegia. Physicians commonly resort to vasopressor medications to fight this condition, however, vasoplegia's subtle nature can resist these efforts, leading to catecholamines resistance and increased risks of mortality. To tackle this issue, the medical field has introduced new treatment options such as angiotensin II, a non-catecholamine vasopressor, and nitric oxide scavengers, providing hope for vasoplegia management. Our investigation explores the characteristics, risk factors, and pathophysiology of vasoplegia. Vasoplegic syndrome typically occurs after cardiothoracic surgery, causing high-output shock with compromised systemic vascular resistance. The syndrome's core lies in the dysregulation of vasoconstriction and vasodilation in smooth muscle cells, influenced by various mechanical and patient-specific factors. A promising advancement is the emergence of catecholamine-sparing agents, showing potential in managing vasoplegia. Recent accounts suggest new treatment strategies, highlighting the need for large-scale clinical trials to validate findings and establish optimal management approaches. The ongoing fight against vasoplegia provides hope for improved outcomes in cardiovascular care as discoveries shape the field. Cardiovasc j 2024; 16(2): 92-97
Eosinophilic myocarditis is a rare form of myocardial inflammation characterized by eosinophilic infiltration and often accompanied by eosinophilia. It can be fatal in in its initial presentation. Although the condition is rare, it’s quite variable in terms of clinical presentation and prognosis ranging from fulminant myocarditis to uneventful recovery. We present a case of a young female patient with eosinophilic myocarditis who had favorable outcome after treatment with steroid and immunosuppressive agents. Cardiovasc j 2024; 16(2): 102-104
Quadricuspid aortic valve (QAV) is a rare congenital heart disease. The functional status of QAV is predominantly a pure aortic regurgitation. Clinical manifestations of patients with a QAV depend on the functional status of the QAV and the associated disorders. Significant valvular regurgitation and (or) stenosis is often present with subsequent operation performed at the fifth to sixth decade of life. The functional status of QAV is predominantly regurgitant; whereas pure stenotic QAV can be as few as in only 0.7% of the patients. QAV is usually an isolated anomaly, but other congenital heart defects can be present in 18- 32% of the patients. About one-fifth of them require a surgical operation. Tricuspidalization is a preferred technique for QAV repair. As not all the patients with a QAV necessarily warrant a surgical operation, decision-making in patient selection and surgical procedure of choice are crucial. Antibiotic prophylaxis against infective endocarditis is necessary in the QAV patients with unequal-sized cusps. Cardiovasc j 2024; 16(2): 114-121
Aortic valve replacement is the commonest valvular surgery done around the world. In Asian population the aortic valve annulus size is smaller. So there is always a chance of patient prosthesis mismatch. There a number of techniques of aortic root enlargement during aortic valve replacement. We have used ‘Y incision technique’ in six of our patients in this case series. This technique is feasible and perioperative outcomes are promising. But it needs more mid and long - term results. Cardiovasc j 2024; 16(2): 98-101
Background: The effects of glucose abnormalities on in-hospital outcome after Primary Percutaneous Coronary Intervention (PCI) in acute STEMI remain unclear. The study assessed the relationship of admission blood glucose level to in-hospital outcome in patients presenting with a STEMI and treated with Primary PCI. Methods: This prospective study was conducted in the department of cardiology, NICVD, Dhaka Bangladesh from May 2018 to April 2019.Total 80 patients with admission normal blood glucose and hyperglycemia with acute STEMI underwent Primary PCI were considered for the study. Results: Mean age of the studied patient was 44.0±9.1 years ranging from 30 to 61 years and the mean age of the group II patients was 48.0±7.8 years ranging from 37 to 61 years. Itwas found that acute heart failure occurred 10% in group II and 2.5% in group I patients with statistically significant (p=0.04) difference. Cardiogenic shock observed 2.5% patients in group II and 2.5% patients in group I with statistically no significant (p=0.56) difference. Significant arrhythmias were found 5% patients in group II and 2.5% in group I patients with statistically no significant (p=0.40) difference. No MI and CVA were occurred in both group of patients. In group II, 2.5% patients died and no patients died in group I with statistically no significant (p=0.31) difference. Conclusion: Admission hyperglycemia is a predictor of poor prognosis in STEMI patients undergoing primary PCI. Cardiovasc j 2024; 16(2): 70-77
This case report details the successful surgical repair of an atrial septal defect (ASD) in a 28-year-old female with severe pulmonary arterial hypertension (PAH), who presented with dyspnea, fatigue, and palpitations. The patient had a large secundum ASD (26 mm size) with bi-directional shunt and severe PAH, with a Pulmonary Arterial Systolic Pressure (PASP) of 107 mmHg and Mean Pulmonary Arterial Pressure (mPAP) of 57 mmHg, as revealed by echocardiography. The patient was optimized medically with diuretics, oxygen, and pulmonary vasodilators (Sildenafil & Ambrisentan), and was deemed eligible for surgical closure of the ASD. A pericardial patch was used to close the defect, and the patient's postoperative recovery was uneventful. Follow-up echocardiography showed a significant reduction in mPAP and right ventricular size. Although surgical closure of an ASD with severe PAH is a high-risk procedure, it can be safely performed in carefully selected patients with appropriate preoperative evaluation, medical optimization, and careful surgical technique. Timely closure of the defect can result in a considerable improvement in the patient's hemodynamic status and quality of life. Cardiovasc j 2024; 16(2): 110-113
Background: Non-ST Segment Elevated Myocardial infarction (NSTEMI) is a potentially life-threatening condition. Dyslipidaemia is a major contributor of coronary artery disease (CAD) and TG/HDL-C ratio can be an important marker for the prediction of the extent of CAD. This study was aimed to find out the relation between TG/HDL-C ratio with severity of coronary artery lesion in NSTEMI patients. Methods: A total of 200 NSTEMI patients were included and classified into two groups on the basis of TG/HDL-C ratio: Group-A (TG/HDL-C ratio ≤4, n=100) and Group-B (TG/HDL-C ratio >4, n=100). Angiographic severity was measured by Gensini score in all the patients during the same hospital stay period. Relation between TG/HDL-C ratio and angiographic severity was evaluated. Results: Mean age of the study populations was 55.13±8.49 (years) with male predominance (75%). Hypertension, diabetes mellitus, dyslipidaemia and obesity were significantly higher in Group-B (p<0.05). Gensini score in Group-B were significantly higher than Group-A (71±23 vs 30±12, p<0.001). A strong positive linear relationship was found between TG/HDL-C ratio and Gensini score (r=+0.803). Multivariate logistic regression found TG/HDL-C ratio >4 as the powerful independent predictor of Gensini score >36 (AOR=7.98, 95% CI=4.0-15.91, p<0.001). Conclusion: There is a significant positive correlation between TG/HDL-C ratio with Gensini score indicating increased severity of coronary disease in patients with NSTEMI. So early risk stratification and intensive management of NSTEMI can be done by using this cheap and easily available marker on admission. Cardiovasc j 2024; 16(2): 63-69
Background: Innovation is an integral part of cardiac surgery. A number of natural barriers had to be overcome by the cardiac surgery pioneers to establish open heart surgeries in the 1950s. Since then, surgeons are continuously developing and adopting various innovative techniques to ensure safety and efficacy of cardiac surgery. The Department of Cardiac Surgery of Chittagong Medical College Hospital (CMCH) has some unique characteristics as it was developed isolated from the centers of Dhaka. A few interesting methods are in practice here, which worth mentioning for the outside readers. Some of these procedures have been colloquially named in our department often after the visiting surgeon or the team who introduced those here. Methods: The unique and unusual techniques applied in CMCH were sought and discussed. The hospital records, OT operation notes and ICU log books were thoroughly searched for any clue. The local and visiting team members were interviewed for any information. All available data were compiled and analyzed. Results: Six interesting and useful named surgical techniques adopted in CMCH Cardiac Surgery Department were identified. These are: 1. Marine city ASD Closure Technique, 2. Tendolkar’s Maneuver during CPB, 3. Turkish Sling in CABG, 4. Petlar Stitch in VSD closure, 5. Pyongyang Method of LA Closure and 6. NAK-NAKA De-calcification Procedure for valve surgery. The first two were introduced with the help of visiting Indian Professor Anil Tendolkar, whereas the 3rd was introduced by a visiting Turkish team. The 4th technique was adopted from a pediatric cardiac surgeon from Dhaka. The 5th and 6th techniques have long been in practice at NICVD, which were adopted with some modification in our department. Conclusion: The above mentioned six reproducible techniques are unique and useful. Sharing and discussion of these techniques will enable other Bangladeshi surgeons to adopt these useful tips. Cardiovasc j 2024; 16(2): 86-91
Internal mammary artery is considered as the priceless conduit in all forms of surgical coronary artery revascularization. Harvesting technique of this artery, as a result, was widely debated. Harmonic scalpel is showing excellent result and some of the pioneers are using it for decades together around the globe disregarding our population. We are routinely using harmonic scalpel from the year 2022 and arranged this study to observe the outcomes in our population. Cardiovasc j 2024; 16(2): 78-80
