Abstract Background Coronary artery bypass grafting (CABG) is a proven life-saving intervention for ischemic heart disease (IHD). However, literature on its post-surgical quality of life (QoL) and mental health is limited in resource-constrained settings, where IHD burden remains high. This study determined changes in depression, anxiety, and QoL pre-operatively to 1- and 6-month post-CABG in a South Asian low- and middle-income country (LMIC). Methods This prospective study was conducted at a large private hospital in Pakistan (February 2022-March 2023). Data were collected pre-operatively, 1-month, and 6-month post-CABG. Beck Depression Inventory II (BDI-II), Beck Anxiety Inventory (BAI), and 36-Item Short Form Health Survey (SF-36) were used to assess depression, anxiety, and QoL, respectively. Pre-operative scores were compared with 1-month and 6-month post-operative scores using paired t-tests, with p-value < 0.05 considered significant. Results The mean age of 82 patients with complete pre-operative data was 58.48 ± 10.07 years. 1- and 6-month follow-up rates were 63% and 53.7%, respectively. No significant differences were noted for depression, but mean anxiety scores reduced preoperatively to 6-month postoperatively (7.48 ± 8.44 to 4.39 ± 7.25, p-value:0.0216). 6-month postoperative results demonstrated significant improvements from preoperative scores in physical functioning (57.39 to 81.36), role limitations due to physical health (32.39 to 69.89), role limitations due to emotional problems (58.33 to 84.09), and general health perceptions (71.36 to 81.36). Conclusion This study showed improvement in anxiety and QoL 6 months after CABG. However, depression scores remained unchanged. Interventions like pre-operative counselling, post-operative cardiac rehabilitation, and long-term psychiatric evaluation are critical to support sustained recovery post-CABG.

Objective: Endoscopic vessel harvest (EVH) is evolving as the standard of care for coronary artery bypass grafting. However, the increase in upfront equipment-related costs has resulted in reluctance of uptake globally. We investigated the costs involving a non-sealed technique for EVH versus open vessel harvesting techniques (OVH) for both the greater saphenous vein and radial artery with a 6-month follow-up. Methods: From September 2016 to December 2018, 226 patients underwent OVH while 251 patients underwent EVH using a reusable non-sealed system and a single-use radiofrequency sealing system. Cumulative costs for OVH versus EVH were calculated as a summation of total operative and in-hospital stay costs. Costs related to harvest site complication management were also analyzed for up to 6 months. Results: Total operative costs were greater in the EVH group (Can$2,283.70 [Can$1,377.60 to $4,183.50] vs Can$1,742.40 [Can$998.50 to $3,628.10], P < 0.001). Total length of stay was significantly shorter for the EVH group (5.9 [4 to 43] days vs 6.8 [4 to 55] days, P = 0.018). Cumulative costs were comparable at the end of the hospitalization period (EVH, Can$6,534.70 [Can$2,076.50 to $33,087.70] vs OVH, Can$6,112.50 [Can$3,322.30 to $45,503.50], P = 0.06). After discharge, harvest site–related complications occurred more frequently in the OVH group (27% vs 4.4%, P < 0.001), resulting in increased use of antibiotics (2.2% vs 0.8%, P = 0.02) as well as more frequent requirement for home nursing assistance in the OVH group (5.7% vs 0.8%, P = 0.002) at 6 months of follow-up. Conclusions: Cumulative costs did not show a statistical difference between OVH and EVH, with higher intraoperative costs for EVH being offset by higher harvest site management costs in the OVH group.

A 38-year-old female with no known comorbidities or previous history of heart disease presented to the hospital with a three-day history of drowsiness and shortness of breath. Transthoracic echocardiography was performed, which showed large vegetations on aortic and tricuspid valves. In addition, there was severe aortic regurgitation with a possible abscess on the non-coronary cusp of the aortic valve. The patient was admitted, and a provisional diagnosis of disseminated tuberculosis, Infective endocarditis (IE), and sepsis was made. Surgical intervention was planned. Intraoperative findings revealed that a fistula had formed connecting the aorta and right atrium, which was closed with an autologous graft derived from the patient's pericardial tissue. Vegetations were removed, and the aortic valve was replaced with a metallic valve. This case report presents a patient with complicated IE with a ruptured aortic root abscess. Mechanical complications associated with IE, such as in our case, are rare among patients with IE. However, surgical intervention should be considered as an option in complicated cases of IE when standard therapy fails.

Simulation is a commonly utilized technique in healthcare education as it provides trainees a realistic, but safe, environment to learn a variety of skills. Trainees belonging to fields known for high stakes with low margins for error, such as cardiac surgery, can greatly benefit from simulation-based education. We propose the establishment of the first multi-tier high fidelity cardiac surgery simulation lab with a structured curriculum that will eventually provide multidisciplinary training to promising cardiac surgeons across Pakistan. The simulation lab may also be used for research, grant acquisition and patent development. Our setup will include the following levels of simulation: a simple bench model, a virtual reality simulator and a unique human performance simulator. Our multitiered approach allows for appropriate sequential trainee skill progression. Finally, we hope that our model inspires the development of similar curricula and modules for trainees belonging to other surgical fields.

Basilic vein transposition (BVT) is the preferred permanent haemodialysis access due to better patency and lower infection rates compared to synthetic grafts. The outcomes of BVT cases, performed at Shifa International Hospital, Islamabad, from March 2006 to June 2018, were ambispectively investigated. The primary patency of the fistula was assessed immediately after surgery, at 24 hours, at 7-14 days, at 6-8 weeks and then at 3-6 months. A total of 160 patients were included in the study, out of which 83 (51.87%) were males while 77 (48.12%) were females. Of the total 160 patients, 119 (74.4%) underwent one stage BVT, while 41 (25.6%) underwent two stage BVT. One hundred and thirty-five (84.4%) procedures were successful and survived while in 25 (15.6%) cases it failed. Mean basilic vein diameter was 2.712 (±0.772) mm. Overall, 10(6.3%) patients had bleeding, 15(9.4%) fistulae thrombosed, 6(3.8%) had steal syndrome and only 1 (0.6%) patient developed pseudo aneurysm. We conclude that BVT is a feasible technique with very good patency rate especially for those patients who have multiple forearm AVF surgeries.Key words: Arteriovenous Fistula (AVF), Basilica Vein Transposition (BVT), Permanent Vascular Access, End Stage Renal Disease (ESRD).

A 34-year-old woman had a history of 3 miscarriages and presented with symptoms of an unproductive cough and rising serum beta-human chorionic gonadotropin (b-hCG) levels. There were no gynaecological symptoms. A diagnosis of Choriocarcinoma with pulmonary metastasis was made. In Pakistan, the incidence of Choriocarcinoma remains exceedingly rare, accounting for less than 0.3% of all gynaecologic tumours. Though rare, if managed appropriately, it has a reasonably good prognosis, as demonstrated by the outcome of the current case.

•The learning points of this manuscript are;•To recognize the anatomy of a mitral arcade anomaly on transthoracic and transesophageal echocardiography.•To understand the importance of collaborative discussion and planning among a heart team.

Fibrosing mediastinitis (FM) is a rare disorder which is characterized by dense proliferation of fibrous tissue within the mediastinum surrounding and causing obliteration of the vital mediastinal structures, most commonly the superior vena cava. To date, the primary pathophysiology is not known however it has been associated with a wide spectrum of diseases ranging from infections such as histoplasmosis and granulomatous diseases such as tuberculosis and sarcoidosis to autoimmune disorders and malignancies. Therefore, early histopathological diagnosis of this rare disorder is crucial and requires a computed tomography scan to determine the extent of the disease within the mediastinum. We report a case of a 14-year-old male, who presented to us with initial impression of an anterior mediastinal mass due to malignancy and a massive pericardial effusion. However, he was later diagnosed as a case of fibrosing mediastinitis from aspergillosis on histopathology and fungal culture.

Tracheal injuries, following blunt neck trauma, are life-threatening surgical emergencies with high risk of mortality. A high index of suspicion is necessary to avoid missing an occult injury because delays in diagnosis and definitive treatment are associated with poorer outcomes. We, herein, report a case of a 28-year man who presented in Emergency Department 15 days after blunt neck trauma from an accident involving electric cable. Anaesthetic challenges, airway management and importance of effective close loop communication, during repair of complex tracheal reconstruction, will be discussed in this case report.

TYPE: Case Report Publication TOPIC: Lung Cancer INTRODUCTION: Adenoid Cystic Carcinoma (ACC), a subtype of adenocarcinoma of the lung, is scarcely understood due to a global dearth of literature and number of cases. This salivary gland type malignant neoplasm accounts for 0.04-0.20% of all primary lung tumors, with airways being the most common site of occurrence. Moreover, this specific report also highlights its extension to the left atrium, a phenomenon that has hardly ever been documented in literature. CASE PRESENTATION: A 33-year-old male with no underlying comorbidities presented with hemoptysis since the past few days and chest pain for four years preceding that. He also had a history of successfully treated TB seven years ago. Based on the triad of clinical presentation, CT scan and transbronchial biopsy, a working diagnosis of ACC was made. Soon after, right posterolateral thoracotomy and right pneumonectomy with partial resection of the left atrium was performed. Histopathology analysis of the excised tissue revealed the tumor to be 4.5x3.5x3 cm in size but non-invasive (T2b), with no nodal involvement or metastasis. DISCUSSION: More commonly found elsewhere in the body (for example breast, skin and uterine cervix), ACC in the lung is commonly misdiagnosed as asthma or bronchitis. Literature suggests that surgical resection is the mainstay of treatment due to limitations with both radiotherapy and chemotherapy. Furthermore, one- and three-year survival rates have been documented at 71.8% and 37.8% respectively. CONCLUSIONS: This report aims to shed light on the unusual clinical pathophysiology, to register its atypical extensions and to navigate surgeons who may encounter this manifestation in the future. DISCLOSURE: No significant relationships. KEYWORDS: Neoplasm, Atypical, Cardiothoracic

Aneurysms are characterized by focal dilation of the blood vessel wall due to weakening. The involvement of two layers of the vessel wall is classified as a pseudoaneurysm while the involvement of all three layers is called a true aneurysm. Involvement of neoplastic lesions is rare, but the few reported cases have been associated with pulmonary artery pseudoaneurysms as opposed to true pulmonary artery aneurysms (PAAs). Our case of a true left PAA of a patient with metastatic sarcoma of the lung shows an association that has previously not been reported to the best of our knowledge.

TYPE: Case Report Publication TOPIC: Pediatrics INTRODUCTION: Pluripotent cells can give differentiate into teratomas, which are benign tumors (having cells from different germ layers) usually found in young and middle-aged adults. This report presents the case of a 10-year-old boy who presented with a mature mediastinal teratoma with significant vascular growth. CASE PRESENTATION: The patient presented with chest pain and cough for approximately one year. On examination, he had dullness on percussion and decreased breath sounds at the left side of the chest. CXR demonstrated a giant opacity in the left hemithorax with signs of calcifications and CT scan showed that the mass, measuring 115x92mm, had displaced structures to the right side of the chest. A median sternotomy with complete resection of the tumor was performed, along with repair of diaphragm and recreation of the pericardial wall. Histopathological analysis showed an encapsulated nodular mass having a multi-loculated cyst along with bony, cartilaginous and hemorrhagic areas derived from all three germ cell layers. DISCUSSION: Although uncommon, extragonadal teratomas may occur in the mediastinum and cause compressive symptoms such as dyspnea due to mass effect. Fortunately, these tumors are usually benign and can be surgically resected successfully, with the preferred imaging modality being CT with IV contrast. Post-operative care for three months is similar to that for any non-cardiac surgery; however, atelectasis is a common post-operative complication and can develop into pneumonia if not treated aggressively. CONCLUSIONS: Mediastinal teratomas are clinically relevant and should be included in the differentials upon encountering a mass in the thoracic region, even though their occurrence is rare. DISCLOSURE: No significant relationships. KEYWORDS: teratoma, mediastinum, paediatrics

TYPE: Case Report Publication TOPIC: Pulmonary Vascular Disease INTRODUCTION: Chronic thromboembolic pulmonary hypertension (CTEPH) is a frequent complication of pulmonary embolism (PE). Risk factors for PE include deep vein thrombosis (DVT), surgery, myocardial infarction, malignancy, thrombophilia and a BMI >30kg/mˆ2. It is unusual to see PE arise in patients without any underlying risk factors (de novo pulmonary embolism (DNPE)). CASE PRESENTATION: A 42 year old gentleman known case of hypertension, dyslipidemia and smoking presented with shortness of breath, productive cough and fever since 20 days. Past surgical history was unremarkable and there was no history of DVT, trauma or malignancy. His chest CT revealed large filling defects from the pulmonary bifurcation that extended to the left and right pulmonary arteries. Workup for hypercoagulability turned up negative. An elective pulmonary thromboendarterectomy was carried out without any complications DISCUSSION: Little is known about the pathophysiology of DNPE. Some studies report an increased prevalence of malignancy or a history of trauma in such patients, neither of which were present in our case. There is also a lack of literature linking PE to the presence of comorbid conditions like hypertension and dyslipidemia, or behavioral factors like smoking. CONCLUSIONS: Our case of PE leading to CTEPH without any risk factors is unique, as close to 50 % of patients who present with PE have an underlying DVT, while the others have at least one of the other risk factors mentioned previously. This highlights the need to investigate and correlate other conditions, such as hypertension, dyslipidemia and smoking, to developing PE. DISCLOSURE: No significant relationships. KEYWORD: Chronic Thromboembolic Pulmonary Hypertension, De Novo Pulmonary Embolism, Deep Vein Thrombosis

TYPE: Abstract Publication TOPIC: Cardiothoracic Surgery PURPOSE: INTRODUCTION: Hydatid cyst is a common infestation caused by Echinococcus granulosus, a parasitic flatworm. The ability of the cyst to manifest in almost any part of the human body can lead to very challenging therapeutic dilemmas. Cardiac Hydatid Cysts comprise 0.2-2% of all patients presenting with hydatid cyst, mostly affecting left ventricle (60%) and rarely involving the interventricular septum (4%). [1-3] We share the successful management of cysts developed in the chest including involvement of the interventricular septum. METHODS: CASE PRESENTATION: A 47-year old male patient with a history of chest heaviness and dyspnea in the last one month. Imaging revealed multi-loculated intramyocardial hydatid cysts presenting with heart failure. Over the course of 6 years he underwent multiple surgeries including open heart procedures and pulmonary surgeries for removal of left pericardial and bilobed pulmonary hydatid cyst. These surgeries included a right lobectomy with final successful resolution of the disease. The greatest challenge was safe removal of drains and chest tubes placed in the cardiac territory given that they were abutting pressurized myocardium. In this case report, we share the approach taken and lessons learnt. RESULTS: Our approach involved prolonged retention of chest tubes to allow adequate fibrosis of myocardium for safe removal. CONCLUSIONS: CONCLUSION: Hydatid Cyst with cardiac involvement can be fatal. Surgical excision is the gold standard treatment; however, persistent creative approaches can be adopted to attain successful outcomes in challenging cases like the above. [4,5] CLINICAL IMPLICATIONS: Not Applicable DISCLOSURE: No significant relationships. KEYWORDS: Hydatid Cyst, Intramyocardial, Pakistan

Abstract Background The dangers of water-pipe smoking have been documented, but data from water-pipe (WP) cafés is lacking. Assessing carbon monoxide (CO) levels in the air inside WP cafés may aid the understanding of the toxins and exposure of the employees. The results can provide novel information regarding WP's effect on air quality which may help generate regulatory efforts to protect the café employees against WP smoke. We wanted determine the air quality through measurement of CO levels in closed room cafés and restaurants of Karachi, Pakistan. Methods It was a cross sectional study design. 3 WP cafes in the city of Karachi, Pakistan were surveyed during June 2015. All cafés were indoors and air-conditioned. Carbon Monoxide (CO) air samples were collected from the included cafés using CO USB Data logger. The Sampling device was left with café admin managers and was left for 30 hours at venue #1, for almost 7 hours at venue #2, and for 70 hours at venue #3 to measure the CO levels in cafés. The average sampling duration was around 36 hours. The graphs were automatically generated by the device. Results Overall, readings of the CO monitoring samples from all included venues were within / lower than threshold limit value (TLV) of 25 ppm, and MAK maximum workplace value of 30 ppm. Conclusions The findings of this study provide evidence that the air quality in water-pipe cafes is potentially hazardous to the health of its employees, which is critical to inform tobacco control policies and regulations for such venues. The study findings indicate a clear need to extend research to not only focus on the indoor air quality of water-pipe cafes, but also the biological monitoring of employees in water-pipe cafes. Key messages Employees working in waterpipe cafes are exposed to toxic substances that can potentially manifest adverse health effects. Air quality of indoor waterpipe cafes should be assessed to protect employees.

TYPE: Case Report Publication TOPIC: Cardiothoracic Surgery INTRODUCTION: Autosomal Dominant hyper-IgE syndrome (AD-HIES) is a rare primary immunodeficiency condition that is characterized by abnormally high levels of serum IgE, with characteristic formation of pneumatoceles following a lung infection. To the best of our knowledge, this is the first reported case of a pulmonary pneumatocele secondary to an aspergilloma due to Aspergillus nidulans in an AD-HIES patient from the pediatric population. CASE PRESENTATION: A ten year old boy with AD-HIES was admitted with complaints of high grade fever, shortness of breath, and cough with bilateral wheeze for one month. CT scan revealed a large unruptured pneumatocele in the left lung and culture revealed Aspergillus nidulans. A diagnosis of left sided pneumatocele secondary to a fungal lung abscess was made. A left sided thoracotomy with decortication of the lung under general anesthesia was performed. The patient was discharged on voriconazole on the fifth postoperative day. DISCUSSION: Only two primary immunodeficiencies display susceptibility to aspergillus species: AD-HIES and chronic granulomatous disease (CGD). Aspergillus fumigatus is a common cause of pulmonary infection and aspergilloma in both CGD and AD-HIES, with A. nidulans being a rarity. Aspergillus nidulans has previously exclusively been seen in patients diagnosed with CGD, due to the microorganism’s unique interaction with its host’s defective NADPH-oxidase. CONCLUSIONS: A. nidulans is usually seen to be more virulent and has a higher chance of resistance against Amphotericin B when compared the commonly A. fumigatus., increasing the chance of mortality against this organism —emphasizing the importance of pathogen identification, early surgery, and the use of Voriconazole. DISCLOSURE: No significant relationships. KEYWORDS: Autosomal Dominant hyper-IgE syndrome, Aspergillus nidulans, Pulmonary aspergilloma

TYPE: Case Report Publication TOPIC: Cardiothoracic Surgery INTRODUCTION: Follicular Variant of Papillary Thyroid Carcinoma (FV-PTC) is a type of differentiated thyroid carcinoma. Bony metastasis is extremely rare, with greatly increased morbidity and mortality, and debulking/resection is often the best treatment. CASE PRESENTATION: We report a case of a 55 y/o female presenting with a bony mass in her anterior chest since 1.5 years, associated with 1 month history of dysphagia and 4 months of left arm stiffness. History revealed she had a thyroid lobectomy 20 years prior due to goiter (reason unknown). She was clinically euthyroid. Bone-scan showed osteolytic lesions in the sternum, manubrium and left proximal humerus. Thyroid-scan showed remnants of thyroid glandular tissue with ectopic growth at the sites mentioned above. CT scan revealed a large heterogeneous soft tissue mass with a central necrotic focus involving the entire sternum. TSH and T4 were normal but thyroglobulin was >6000ng/ml. A complete thyroidectomy and concomitant complete sternectomy with reconstruction using polypropylene mesh was performed under general-anesthesia. Histopathology revealed FV-PTC. Further treatment with Radio-Active Iodine therapy and EBRT for palliation. Patient is alive and well on 1 year follow-up. Bone-scan showed no recurrence of sternal lesion, however lesion at humerus was persisting. DISCUSSION: Review of Literature identified 16 cases of Thyroid CA metastasis to sternum, of which only 1 (ours) was identified as FV-PTC. We discuss an updated table on the reconstruction methods used for sternectomies due to Thyroid CA – Modified from Yanagawa et al. Journal of Thoracic Oncology. 2009;4:1022-5 CONCLUSIONS: Sternal resection is a useful therapy for FV-PTC sternal metastasis. DISCLOSURE: No significant relationships. KEYWORDS: Thyroid Carcinoma, Sternum, Bone metastasis

Approximately 40 cases of Hughes-Stovin syndrome have been recorded in the literature. The disease process exhibits an indefinite nature. It shares histopathologic and clinical features with Behcet disease, although there is no established association. The natural course of the disease is fatal in most cases. We report a case of a 31-year-old man with Hughes-Stovin syndrome who initially presented with occasional hemoptysis and a history of deep vein thrombosis. There was evidence of right-sided lower lobe pulmonary artery aneurysm that was managed with a lobectomy, after which he developed aneurysmal recurrence in the contralateral lung. Histopathologic analysis identified myxoid degeneration in the hilar region. (C) 2020 by The Society of Thoracic Surgeons

Tracheal stenosis is rare but a recognized complication after traumatic injury or prolonged intubation. We assessed the time lag between onset of indication for tracheal reconstruction surgery following trauma and actual surgical intervention. We reviewed our operative records for all patients undergoing tracheal reconstruction over the past 10 years. Files were reviewed retrospectively to collect all the relevant data. Surgically all patients were operated via cervical approach. Series 12 cases were identified with an equal split between external trauma and iatrogenic tracheal trauma from prolonged intubation. On, an average patients presented 185 days after initial indication of surgery however there was a wide range of time lag which leads to the importance of early diagnosis of such injuries to reduce delay of definitive management.

To analyze predictors that influence the learning curve of minimally invasive mitral valve surgery (MIMVS).