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The prevalence of CAD in patients requiring valvular surgery is 20-40%. Clinically the patient is advised to receive surgery when the level of stenosis exceeds 50%. The aim of our study was to provide a complete picture of the prevalence and incidence of CAD in valvular surgery patients along with examining the mortality rates and causes of CAD within the same group of patients. A wide ranged literature search was conducted using PubMed, to find all the various published original articles comparing morbidity and mortality rates, along with the prevalence of CAD in valve surgery patients, as late as May 2015. Consequently, 3957 articles were found and then reviewed as part of the exclusion criteria, after which 10 studies were incorporated in our study. Out of which, 5 were based on incidence of CAD among AVR patients, 2 focused on CAD with MVR and remaining 3 indicated overall picture of CAD in DVR (dual valve replacement) patients. Our study suggests, an incident rate of CAD to be 30% in AVR patients, rates slightly higher in MVR patients but the least in DVR patients. However, the mortality rates for DVR patients were the greatest, the rates decreased among MVR patients and were the least among those receiving AVR. [ABSTRACT FROM AUTHOR]

Objective: To establish association of phosphorus levels with surgical outcome of patients in our setup. Methodology: This was an case control study conducted at Department of Cardiac Surgery, Civil Hospital Karachi from May 2015 to August 2015 . Phosphorus levels were measured at three points of hospital stay; a) preoperatively b) immediately post operatively and c) at first post operative day. Patients were divided in two groups according to immediate post operative phosphate levels; those with hypophosphatemia (<2.7 mg/dl) and a control group with normal phosphate levels (2.7-4.5 mg/dl). Pre and post operative management including duration of Heart Lung Machine, cross clamp, duration of ventilation, ICU Stay, cardio active support needed and amount of blood loss, use of IABP and mortality were recorded. Results: A total of 55 patients were included in the study .Hypophosphatemia was found in 27.3% patients immediately after surgery and 38.2% patients at first post operative day. No significant difference was found in intra operative management of patient. However, post operative course of both groups differed significantly in two groups in terms of duration of ventilation (11.9±11.6 versus 6.1±5.5 hours, p=0.002), duration of ICU stay (3.5±1.5 versus 2.4±0.7 days, p=0.01) and duration of inotropic support needed (45.5±31.2 versus 25.0 ±12.4 hours, p=0.001). Patients with hypophosphatemia had significantly more blood loss (998.7±1217.8 versus 526.8±322.0, p=0.001) and received more blood transfusions post operatively (1.80±2.09 versus 0.8±0.9, p=0.009). No significant difference of post operative mortality was found in both groups (15.3% versus 3.2%, p=0.07). Conclusion: Hypophosphatemia is documented in one third of postoperative cardiac surgery patients and is associated with prolonged ventilation, duration of ICU stay and inotropic support with more blood loss. [ABSTRACT FROM AUTHOR]

Objective: To determined the percentage of myocardial infarction (MI) patients in Karachi who mistook their MI pain with heartburn and to study which socioeconomic class had the highest misconception. Methodology: This cross sectional study was conducted from June 2014 to Feb 2016. Patients included in the study were divided in upper, middle and lower socioeconomic classes. Upper and middle class patients were taken from Liaquat National Hospital while lower class patients were chosen from Civil Hospital Karachi. There were no age or gender limitations. Informed consent was taken. Subjects diagnosed with MI were interviewed according to a pre-designed questionnaire. Result: Of total 375 patients , 71.5% were males. Hypertension, diabetes and smoking was present in 66.9%, 36.8% and 36% respectively. Misconception of MI pain with heartburn was reported in 59.5% cases in first attack and 3.3% in successive attacks. This misconception in lower, middle and upper class was 66.4%, 54.4% and 57.6% respectively. Gastric reflux disease was reported in 45.9% people. Gastric reflux diseases and epigastric pain showed association with this misconception (p<0.001). Among gastric diseases, indigestion was most commonly seen as a positive misconception (p<0.001). Conclusion: Misconception of MI pain with heartburn is very common, mostly prevalent in lower socio-economic class, followed by upper and middle classes. It was more common with gastric reflux diseases and epigastric pain. Among gastric diseases, indigestion and bloating showed significant association as a misconception. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of low flow IMA, the effect of topical vasodilators, its use on LAD and immediate post-operative outcome. Methodology: This cross-sectional study was conducted at Dow University Health Sciences, Karachi, from 1st January 2012 to 31st December 2014. Data was collected of patients who underwent CABG. Free flow of IMA was measured immediately after harvesting with a syringe. Data was analysed on SPSS 15 with sample t test used for comparison. P-value of less than 0.05 was considered statistically significant Results: Total of 158 consecutive patients were included. Males were 81.6%, with mean age of 52 years The mean flow was 11.6±9.6ml/30 seconds.About 40 patients had IMA flow less than 5ml/30seconds (25.3%). The low flow IMA did not showed a good response to topical vasodilators and its use on LAD showed significantly higher need of inotropic support(p=0.004), more LCOS(p=0.022), more use of IABP(p=0.028), and higher incidence of atrial fibrillation. The mortality and readmission were also high but not reached to significant levels. Conclusion: Low flow IMA should be used cautiously on LAD. If low flow IMA after harvesting does not give good response to topical vasodilators it may be better to use the vein graft on LAD. If use of low flow IMA necessary than mechanical and pharmacological support should be consider early. [ABSTRACT FROM AUTHOR]

Objective: To identify the effect of duration of cardiopulmonary bypass as a risk factor in the incidence of stroke in elective conventional surgery for coronary artery bypass grafting (CABG). Methodology: It was a cross-sectional, descriptive, retrospective study conducted from 1st February 2014 to 31st January 2015 at Department of Cardiac Anaesthesia & Surgery, National Institute of Cardiovascular Diseases (NICVD), Karachi. All patients between 30-70 years of age undergoing elective isolated CABG surgery were included while emergency CABG, patients with history of TIA or stroke, patients with coronary stents, diagnosed case of atrial fibrillation, low ejection fraction, intraoperative hemodynamic instability and renal dysfunction were excluded. The effect of duration of cardiopulmonary bypass with emphasis on the occurrence of stroke was analyzed in consecutive patients who underwent conventional CABG. Variables included demographic data, clinical symptoms, risk factors for stroke and CABG, investigations and other surgical parameters. Chi square test was applied for comparison. Significant p value was set for <0.05. Results: The study included 80 (100%) patients who underwent conventional CABG. There were 30 (37.5%) female patients with mean age of 64.6±2.1 years. Postoperative stroke was found in 03 patients (3.75%). Out of these, stroke was found in patients in whom bypass time was more than 100 minutes. Conclusion: Prolonged cardiopulmonary bypass time is a common risk factor for post CABG stroke. [ABSTRACT FROM AUTHOR]

Objective: To determine the percentage prevalence of cardiovascular risk factors among males of Karachi aged above 40 years and to compare them between health and non-health professionals. Methodology: It was a descriptive cross-sectional study. The participants were males aged above 40 years and were divided in two equal groups, one comprising of health professionals and the other of non-health professionals. Data was collected by a questionnaire which contained variables including hypertension, diabetes, hypercholesterolemia, smoking, excessive alcohol consumption, type A personality, obesity, sedentary lifestyle, family history of CVD and past history of CVD. Frequencies were calculated for each variable and their association with the profession was determined by Chi-Sq test and p value. Results: Among male population of Karachi above 40 years of age, prevalence of hypertension, diabetes, hypercholesterolemia, smoking, alcoholism, Type A personality, obesity, physical inactivity, family history of CVD and past history of CVD were found to be 33.3%, 21%, 21.4%, 15.7%, 2.4%, 35.7% and 21.4%, 46.7%, 84.8% and 12.4% respectively. Except for physical inactivity, all the risk factors were found to be more common among non-health than health professionals. Conclusion: CVD risk factors are present but not very commonly among males of Karachi aged above 40 years. Non-health professionals have a higher prevalence of CVD risk factors. Physical inactivity was more common in health than nonhealth professionals. [ABSTRACT FROM AUTHOR]

Embolic occlusion of a coronary artery subsequent to mitral valve replacement is a rare condition with undocumented incidence. Here we present a case of 55- year-old female, ex-smoker, with complain of sudden onset of severe dyspnea, left sided chest pain and signs of decreased cardiac output within eighteen months after MVR. The patient discontinued her anti-coagulants, as a result she developed sub therapeutic International normalized ratio of 1.45. The angiogram revealed triple vessel disease with complete occlusion of Left Main Coronary Artery. Due to the deterioration of general condition, hemodynamic instability and extensive occlusion of multiple coronary arteries, plan was made to operate the patient for coronary artery bypass grafting surgery. This case report highlights the importance of continuation of anti-coagulant therapy and management of multi-vessel lesion by coronary artery bypass grafting surgery. [ABSTRACT FROM AUTHOR]

The aim of this study was to determine the effect of major risk factors like age, gender, hypertension, diabetes, smoking, dyslipidemia on coronary artery disease in Karachiites and highlighted the angiographic data of local population like number of vessels involvement, site and severity of coronary lesions. This was a cross sectional analytical prospective study which was carried out at Abbasi Shaheed Hospital Karachi from August 2004 – July 2014. We included five hundred (500) consecutive patients (188 female & 312 male) between 26-80 years old, who came for coronary angiography with suspecting ischemic heart disease clinically or otherwise proven by relevant tests like ETT, ECHO, and Thallium stress test. Post PCI and CABG patients were excluded from study. During this study variables like age, gender, hypertension, diabetes, smoking and dyslipidemia were taken into account in relation to coronary artery disease in Karachiites. In addition we also assorted some important findings of coronary angiography like: number of vessels involved, site and severity lesions in our population and compared them with existing literature. Our study revealed that in our local population not only old age and male gender are potential threat for an early coronary artery disease but other variables like hypertension, diabetes, smoking, and dyslipidemia are also playing important role in coronary artery disease. It is also concluded that our population is more prone to multiple vessels involvement with almost involvement of LAD in majority of population [ABSTRACT FROM AUTHOR]

Objective: To find out any differences in free flow of internal mammary artery among different ethnic groups., Methods: This observational, cross-sectional study was conducted at the Civil Hospital, Karachi, from January 2013 to December 2015, and comprised patients who underwent coronary artery bypass grafting. The participants were divided into 5 groups, i.e. Sindhi, Muslim migrants from India, Punjabi, Pathan and Balochi patients. Free flow of internal mammary artery was measured immediately after harvesting within a syringe, and its flow was measured in 30 seconds. SPSS 18 was used for data analysis., Results: Of the 158 patients, 44(27.8%) were Sindhi, 33(20.9%) Punjabi, 8(5%) Baloch, 21(13.3%) Pathan and 52(32.9%) were migrants. The overall mean age was 52±8 years and the mean flow was 11.6±9.6ml per 30 seconds. The flow was 9.3±6 ml, 10±8ml, 13±11ml, 17±14ml and 15±13 ml in 30 seconds among migrants, Sindhi, Punjabi, Pathan and Baloch patients, respectively, with significant higher flow in Pathan patients compared to Sindhi and migrant patients (p<0.05). A flow of less than 5ml/30 sec was mostly found in migrants or Sindhi subjects 30/40(75%), and flow more than 30ml/ 30 seconds was found mostly in Baloch or Pathan patients 4/8(50%). Low flow internal mammary artery, which was used on left anterior descending artery, showed significantly higher need of inotropic support as compared to high flow internal mammary artery (p=0.004), more low cardiac output syndrome (p=0.022) and more use of intra-aortic balloon pump (p=0.028)., Conclusions: Internal mammary artery flow was higher in Pathan and Baloch patients and low in migrants and Sindhis.

A 62 years old patient developed myasthenia gravis 2 years after his percutaneous coronary intervention. He was advised thymectomy for myasthenia gravis. During his cardiological evaluation, he was incidentally diagnosed to have 3 vessel disease. Hence, a simultaneous surgical intervention was performed consisting of thymectomy and CABG via standard cardiopulmonary bypass through median sternotomy. Previous medical history of diabetes and corticosteroid therapy made the patient immunocompromised. Therefore, a careful overall therapeutic strategy was devised to prevent mediastinitis. After his thymectomy and coronary artery bypass grafting, he was extubated within 6 hours. Plasmapheresis was done one day before the surgery and on first postoperative day. His medications for myasthenia gravis (pyridostigmine and prednisolone) were not stopped before and after the surgery. Patient was discharged on 6th postoperative day without any complications. On his follow-up 6 weeks postoperatively, his condition was unremarkable.

Objective: To estimate the frequency of needle stick injuries (NSI) among health care workers (nurses, student nurses and paramedical staff) in public hospitals of Karachi., Study Design: Cross sectional, observational., Place and Duration of Study: This study was conducted in three public tertiary care hospitals of Karachi, from November 2007 to January 2008., Methodology: Data was collected by structured interview-based questionnaires in Urdu and English language. Questionnaire was designed to obtain information regarding demography, work experience, hepatitis vaccination status, and occurrence of needle stick injuries with associated factors. Needle stick injury that occurred in the previous month was the defined outcome. Data was entered in Epi Data and analyzed in SPSS version 15., Results: A total of 417 health care workers participated in the study. Mean age of the participants was 24+/-11 years. Estimated proportion of participants with history of at least one time NSI was found in 66%. Around 13% (n=54) had one or more NSI in the previous one month at work and half of them were affected by non-sterile needle. None of them sought medical care. Almost 90% of them were not wearing gloves or taking any other protective measures at the time of injury., Conclusion: There can be serious consequences of needle stick injuries in public hospitals as large proportion of injuries involve non-sterile used needles and health care workers do not take appropriate measures of protection.

Objective: To analyse the data retrospectively and identify risk factors that may adversely affect mortality in patients aged seventy years and older with coronary artery bypass graft (CABG)., Methods: From Jan 2003 to Oct 2007, 63 consecutive patients of 70 years or older underwent primary isolated CABG on cardiopulmonary bypass (CPB) in Department of Surgery, Liaquat National Hospital. Forty one (65%) were male. The mean age was 72.7 +/- 3 years (range 70 to 81 years). Preoperatively 83% were in New York Heart Association (NYHA) class III or IV. Left main stem (LMS) lesion (> 70%) was present in 20 (32%). Renal impairment (RI) with creatinine more then 2 mg/dl was present in 9 (14%) patients. History of prior stroke was present in 7 (11%). Emergency surgery (within 48 hours after Myocardial Infarct (MI)) was performed in 33 (52%) patients., Results: The overall hospital mortality (30 days) was 9.5%. The mean Parsonet score was 23 +/- 3, and 10 +/- 3 in those who died or survived respectively. Mean intensive care unit stay was 2.3 +/- 0.7 days, mean ward stay was 6 +/- 3 days. Preoperative LMS lesion or MI less then 48 hours, poor left ventriculal function, prolonged CPB time and post operative stroke were the significant independent predictors of operative morality., Conclusion: CABG can be performed in a selected elderly population. Careful attention to risk factors associated with high mortality can be helpful in improving post-operative morality. Age in itself may not be responsible for high morality.

Objectives: This study considered the factors associated with prolonged ventilation and the effects of reduced extubation times on patient recovery, intensive care unit stay, and overall hospital stay., Materials and Methods: A retrospective study was performed, including 86 consecutive patients who underwent cardiac surgery from August 2006 to January 2007. The patients were divided into two groups following intensive care unit admission: Group A, duration of intubation <4 h (n=34); Group B, duration of intubation >4 h (n=52)., Results: Two deaths occurred in 86 patients, and overall hospital mortality was 2.32%. Patients in Group A were younger (33.2+/-12 versus 45.8+/-13 years; p=0.001) and had better preoperative left ventricular ejection fraction (LVEF) (62.4+/-9.8 versus 44.6+/-9.4; p=0.003) than those in Group B. Moreover, Group A patients had a shorter intensive care unit length of stay (1.7+/-0.5 versus 2.2+/-0.8 days; p=0.006) and were discharged earlier than Group B patients (2.7+/-2.4 versus 4.01+/-3.96; p=0.014)., Conclusions: Early extubation offers a substantial advantage in terms of accelerated recovery, shorter intensive care unit, and hospital stay, suggesting that efforts to reduce extubation times are cost-effective.

Purpose: It is not uncommon for aspirin therapy to be withheld before coronary artery bypass grafting (CABG) because it is thought to increase the risk of postoperative bleeding. Many studies have shown that continued aspirin therapy reduces postoperative myocardial infarction and increases survival. The purpose of this study is to analyze the effect of preoperative aspirin on postoperative bleeding in patients undergoing CABG., Material and Methods: Patients (n=30) undergoing CABG were divided into two groups, group 1 (n=15) who received aspirin till the day of surgery, and group 2 in whom aspirin was stopped 5 days before surgery. Postoperative bleeding up to 76 h (approximately 3 days) was noted in both groups., Results: Preoperative, intraoperative, and postoperative variables were equal in both groups. Postoperative bleeding in the 2nd hour was significantly lower in group 1 compared to group 2 (p=0.004). Bleeding 28-76 h postoperatively was also significantly lower in the first group (p=0.043)., Conclusion: Our study suggests that contrary to the commonly held beliefs in our setup, the use of aspirin till the date of surgery does not increase the risk of postoperative bleeding after CABG. In contrast, our data show reductions in the bleeding incidence of those in whom aspirin was not withheld prior to surgery. Therefore we strongly recommend its continued use of aspirin until the date of surgery.

An adult male had a penetrating injury of the chest resulting in cardiac tamponade. The injury resulted as a consequence of a detached iron piece from an iron bar in a steel mill. Emergency sternotomy and percardiotomy revealed blood in the pericardial cavity and full thickness penetration of the right ventricle. The defect was repaired following the removal of the iron fragment. Postoperative recovery was uneventful.

Purpose: Coronary artery bypass graft (CABG) surgery in patients with cardiogenic shock (CS) is a rare and very high-risk procedure carrying high mortality. In this study we reviewed hospital outcomes and 1-year survivals in these high-risk patients., Materials and Methods: During a 4-year period (May 2001 to April 2005), 412 patients were operated on for CABG by a single surgeon, and 13 (3.1%) of them were in CS at the time of procedure., Results: The 30-day mortality of patients who underwent CABG during CS was 16%, and mean age was 57+/-10 years. A total of 77% were male, 77% were hypertensive, 38% were diabetic, and 31% had renal impairment. Myocardial infarction (MI) affected 62% within 48 h of surgery. Moderate to poor left ventricular function was found in 92%. Twenty-three percent had a preoperative intra-aortic balloon pump. Postinfract ventricular septal defect was present in 16%, and catheter-related problems were present in 23% of patients. After 1 year, all patients (11) were alive, and 85% of them were in New York Heart Association (NYHA) classes I to II., Conclusion: CABG in CS produces significant 1-year survival benefits and improvements in functional class. Therefore, early surgical intervention is suggested where percutaneous coronary intervention is not possible or contraindicated for anatomical reasons.

Objective: To compare the effect of long-term (7 days) versus short-term (2 days) postoperative antibiotics in preventing postoperative infective complications in patients who have undergone open-heart surgeries., Design: Interventional, randomized controlled trial (RCT)., Place and Duration of Study: Department of Cardiac Surgery, Dow University of Health Sciences, from February 2006 to July 2006., Patients and Methods: Cardiac patients (n=42), operated for valvular disease (36%), coronary artery bypass grafting (50%), or septal repair (14%), were included in our study. Patients were prospectively randomized into two groups. Group A (n=21) patients received oral antibiotics for 7 days, whereas group B (n=21) patients were given the same for 2 days postoperative. Pre-operative and intra-operative variables were equal in both groups. Total leukocyte count and temperature were monitored daily until the patients were discharged. The chest and leg wounds were inspected daily for any signs of infection. Sputum and urine cultures were sent for selected patients in case of respiratory tract infection or urinary tract infection, respectively. Each patient was followed until the next routine visit in outpatient department., Results: In group A, 3 patients (14%), developed infection postoperatively, whereas in group B, 13 patients (62%) (p =0.001) had to be started on oral or intravenous antibiotics as a result of developing either wound infection, a positive sputum culture, a positive urine culture or a localized infection elsewhere. Mean ward stay in group A was 4.8 +/- 4.5 days and in group B 6.5 +/- 4.1 days (p =0.011)., Conclusion: In this series, there was a significantly higher frequency of infection and longer hospital stay in patients who received antibiotics for 2 days postoperatively as compared to those who received antibiotics for 7 days.

Purpose: Intermittent cold crystalloid cardioplegia by antegrade route to arrest the heart for coronary artery bypass grafting (CABG) is a commonly used technique. The aim of this study is to compare the intermittent antegrade warm blood cardioplegia with cold crystalloid cardioplegia by means of measuring myocardial injury markers CKMB and troponin T. We also compared the results with antegrade and retrograde warm blood cardioplegia., Materials and Methods: Patients (n=30) undergoing CABG were prospectively randomized into group 1 (n=10) which received cold crystalloid cardioplegia by antegrade route, group 2 (n=10) which received warm blood cardioplegia by antegrade route and group 3 (n=10) which received antegrade/retrograde warm blood cardioplegia., Results: Preoperative and intraoperative variables were equal in all three groups. Control levels of troponin T and CKMB were in a normal range. Postoperative troponin T was significantly lower in group 3 compared to group 2 (p"=0.008") and to group 1 (p"=0.005"). CKMB is significantly higher in group 1 compared to group 2 (p"=0.013") and higher in group 2 than that in group 3 (p"=0.043")., Conclusion: Antegrade with retrograde warm blood cardioplegia is a simple delivery method. Troponin T and CKMB levels were significantly lower, suggesting that this offered better myocardial protection than antegrade cold crystalloid and warm blood cardioplegia. We recommend its wider use.