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Background Patients undergoing coronary artery bypass graft (CABG) sometimes have critical proximal lesion in left anterior descending (LAD) artery or chronic total occlusion followed by either skip lesions or diffuse disease of late mid-to-distal LAD artery. Such lesions require endarterectomy or atheroma bridging via long venous or arterial patch (patch-plasty), for which clinical outcomes are conflicting in studies due to a more thrombogenic milieu created by patch-plasty as well as incomplete endarterectomy. We present a hybrid approach with drug-coated balloon (DCB) angioplasty of mid-to-distal LAD through LAD arteriotomy followed by left internal mammary artery (LIMA) insertion to LAD. Case summary A 35-year-old man who was thrombolyzed for anterior wall myocardial infarction in another city, reported to our hospital four weeks later with persistent angina. Coronary angiography showed severe multivessel coronary artery disease. There was diffuse disease in LAD distal to potential site of LIMA insertion and needed patch-plasty. We carried out a hybrid procedure by performing DCB angioplasty of mid-to-distal LAD through the LAD arteriotomy site during CABG followed by LIMA insertion to the LAD. The patient remained asymptomatic post procedure with a 6-month follow-up computerized tomography scan showing patent LIMA and mid-to-distal LAD. Discussion This case shows a novel technique, first in the world, of performing angioplasty during CABG through arteriotomy followed by graft insertion.

Objective: To evaluate the outcome of thrombolysis in patients of prosthetic valve thrombosis. Methods: This retrospective analysis was conducted on data of 84 patients of prosthetic valve thrombosis who presented to emergency room of Faisalabad Institute of Cardiology between July 2017 to December 2019. The diagnosis of prosthetic valve thrombosis was based on clinical suspicion and bed side transthoracic echocardiography done by a consultant cardiologist. Fluoroscopy was done to confirm the diagnosis by observing immobile valve leaflet. The confirmed patients were then treated in emergency with streptokinase after taking an informed consent. Quantitative variables like age were summarized by mean and standard deviation. Qualitative variables like gender, successful thrombolysis, stroke, major bleeding, mortality or re-do surgery were summarized by frequency and percentage. Results: Mean age was 29 ± 6.36, years and there were more female patients (n=43, 51.25%) as compared to males (n=41, 48.8%). Among the 66 surviving patients thrombolysis was successful without any complications in 56 patients (66.7%). Thrombolysis was successful with minor complications in six patients (7.1%) and it failed to produce desired results in four patients (4.8%). In this study 18 (21.4%) patients died. The common complications included minor bleeding in four patients (4.8%) and major bleeding in 10 patients (12.0 %). Conclusion: Thrombolysis produces reasonable success rate in cases of prosthetic valve thrombosis who are in functional class I or II. However, it has very high mortality rate in patients presenting with functional class III and IV. doi: https://doi.org/10.12669/pjms.37.2.3226 How to cite this:Abbas S, Hameed N, Khilji SA, Jalal A. Outcome of thrombolysis with streptokinase in patients with prosthetic valve thrombosis. Pak J Med Sci. 2021;37(2):325-330. doi: https://doi.org/10.12669/pjms.37.2.3226 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Novel drug targets for sustained reduction in body mass index (BMI) are needed to curb the epidemic of obesity, which affects 650 million individuals worldwide and is a causal driver of cardiovascular and metabolic disease and mortality. Previous studies reported that the Arg95Ter nonsense variant of GPR151, an orphan G protein-coupled receptor, is associated with reduced BMI and reduced risk of Type 2 Diabetes (T2D). Here, we follow up on GPR151 with the Pakistan Genome Resource (PGR), which is one of the largest exome biobanks of human homozygous loss-of-function carriers (knockouts) in the world. Among PGR participants, we identify 3 GPR151 putative loss-of-function (plof) variants (Arg95Ter, Tyr99Ter, and Phe175LeufsTer7) with a cumulative allele frequency of 2.2% and present at homozygosity. We confirm these alleles in vitro as loss-of-function. We test if GPR151 plof is associated with BMI, T2D, or other metabolic traits. GPR151 deficiency in complete human knockouts is not associated with a clinically significant difference in BMI. Moreover, loss of GPR151 confers a nominally significant increase in risk of T2D (odds ratio = 1.2, p value = 0.03). Relative to wild-type mice, Gpr151-/- animals exhibit no difference in body weight on normal chow, and higher body weight on a high-fat diet, consistent with the findings in humans. Together, our findings indicate that GPR151 antagonism is not a compelling therapeutic approach for obesity.

Background Genetic, lifestyle, and environmental factors can lead to perturbations in circulating lipid levels and increase the risk of cardiovascular and metabolic diseases. However, how changes in individual lipid species contribute to disease risk is often unclear. Moreover, little is known about the role of lipids on cardiovascular disease in Pakistan, a population historically underrepresented in cardiovascular studies. Methods We characterised the genetic architecture of the human blood lipidome in 5662 hospital controls from the Pakistan Risk of Myocardial Infarction Study (PROMIS) and 13,814 healthy British blood donors from the INTERVAL study. We applied a candidate causal gene prioritisation tool to link the genetic variants associated with each lipid to the most likely causal genes, and Gaussian Graphical Modelling network analysis to identify and illustrate relationships between lipids and genetic loci. Results We identified 253 genetic associations with 181 lipids measured using direct infusion high-resolution mass spectrometry in PROMIS, and 502 genetic associations with 244 lipids in INTERVAL. Our analyses revealed new biological insights at genetic loci associated with cardiometabolic diseases, including novel lipid associations at the LPL, MBOAT7, LIPC, APOE-C1-C2-C4, SGPP1, and SPTLC3 loci. Conclusions Our findings, generated using a distinctive lipidomics platform in an understudied South Asian population, strengthen and expand the knowledge base of the genetic determinants of lipids and their association with cardiometabolic disease-related loci.

Patient: Male, 62-year-old Final Diagnosis: Coronary artery disease • entrapped coronary guidewire • stent deformation Symptoms: Angina pectoris Medication: — Clinical Procedure: Angioplasty • coronary artery bypass grafting (CABG) Specialty: Cardiac Surgery • Cardiology Objective: Management of emergency care Background: Strangulation of the coronary guidewire is an infrequent complication of percutaneous coronary intervention (PCI), and it can lead to disastrous outcomes of stent thrombosis, vessel occlusion, and vessel damage. Case Report: Early-generation stents were made from stainless steel and had a bulky design as compared to cobalt-chromium or platinum chromium alloys, which have superior trackability at the cost of a thin core and low-strength struts, resulting in increased incidence of longitudinal stent deformation. We present a case of a 62-year-old active smoker with effort angina of Canadian Cardiovascular Society (CCS) class III. His coronary angiogram revealed a totally occluded right coronary artery (RCA). After placing 2 coronary guidewires (Run-through and Balanced middle-weight), Xience Xpedition (3.25×48 mm) and Promus Element (2.75×32 mm) were deployed through the whole length of the RCA. While placing the distal stent, the guidewire securing the posterior left ventricular (PLV) was trapped between 2 stents and all attempted maneuvers were unsuccessful in retrieving the wire. The stents sustained longitudinal deformation by the guide catheter, and subsequent arteriotomy for stent and wire retrieval and coronary artery bypass graft surgery were (CABG) performed. Conclusions: Despite the remarkable safety profiles of the percutaneous equipment, complications still occur even with experienced operators. Calcified and tortuous vessels are primarily at risk for wire strangulation between stents or side-branches, and better deliverability of newer drug-eluting stents (DES) comes at the cost of reduced longitudinal strength.

BackgroundGenetic, lifestyle, and environmental factors can lead to perturbations in circulating lipid levels and increase risk of cardiovascular and metabolic diseases. However, how changes in individual lipid species contribute to disease risk is often unclear. Moreover, little is known about the role of lipids on cardiovascular disease in Pakistan, a population historically underrepresented in cardiovascular studies.MethodsWe characterised the genetic architecture of the human blood lipidome in 5,662 hospital controls from the Pakistan Risk of Myocardial Infarction Study (PROMIS) and 13,814 healthy British blood donors from the INTERVAL study. We applied a candidate causal gene prioritisation tool to link the genetic variants associated with each lipid to the most likely causal genes, and Gaussian Graphical Modelling network analysis to identify and illustrate relationships between lipids and genetic loci.ResultsWe identified 359 genetic associations with 255 lipids measured using direct infusion high-resolution mass spectrometry in PROMIS, and 616 genetic associations with 326 lipids in INTERVAL. Our analyses revealed new biological insights at genetic loci associated with cardiometabolic diseases, including novel lipid associations at the LPL, MBOAT7, LIPC, APOE-C1-C2-C4, SGPP1, and SPTLC3 loci.ConclusionsOur findings, generated using a distinctive lipidomics platform in an understudied South Asian population, strengthen and expand the knowledge base of the genetic determinants of lipids and their association with cardiometabolic disease-related loci.

Objective: To evaluate the Effectiveness of Pre-operative Respiratory Muscle Training versus Conventional Treatment for Improving post-operative pulmonary health after Coronary Artery Bypass Graft Surgery (CABG). Methods: A Prospective Randomized clinical trial was performed on sixty patients who underwent elective CABG at Faisalabad Institute of Cardiology. At the time of admission all patients were subjected to 6-minutes’ walk test (6MWT) as baseline. The subjects were then divided into two groups. The Group-I was subjected to respiratory muscle training whereas the Group-2 received the routine preoperative care. The 6-minute walk test (6MWT) was then repeated a day before surgery (pre-operative) and before discharge (post-operatively). Duration of post-operative mechanical ventilation, oxygen therapy and hospital stay were also noted as outcome measures of this study. Results: The pre-operative and post-operative readings showed that the patients in the interventional group performed better than the control group in their 6MWT with P-value of less than 0.05. Similarly the interventional group had shorter duration of mechanical ventilation, dependence on oxygen therapy and postoperative hospital stay as compared with the control group showing P-values below 0.05. Conclusion: The results showed that respiratory muscle training results in improved postoperative functional capacity and reduces of hospital stay. doi: https://doi.org/10.12669/pjms.36.6.2899 How to cite this:Sahar W, Ajaz N, Haider Z, Jalal A. Effectiveness of Pre-operative Respiratory Muscle Training versus Conventional Treatment for Improving Post operative Pulmonary Health after Coronary Artery Bypass Grafting. Pak J Med Sci. 2020;36(6):1216-1219. doi: https://doi.org/10.12669/pjms.36.6.2899 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

We investigated type 2 diabetes (T2D) genetic susceptibility in a multi-ethnic meta-analysis of 228,499 cases and 1,178,783 controls in the Million Veteran Program (MVP) and other biobanks. We identified 558 autosomal and 10 X-chromosome T2D-associated variants, of which 286 autosomal and 7 X-chromosome variants were previously unreported. Ancestry-specific analyses identified 25 additional novel T2D-susceptibility variants. Transcriptome-wide association analysis detected 3,568 T2D-associations with T2D-colocalized genetically predicted gene expression of 804 genes in 52 tissues, of which 687 are novel. Fifty-four of these genes are known to interact with FDA-approved drugs and chemical compounds. T2D polygenic risk score was strongly associated with increased the risk of T2D-related retinopathy, and additionally showed evidence for association with chronic kidney disease (CKD), neuropathy, and peripheral artery disease (PAD). We investigated the genetic etiology of T2D-related vascular outcomes in the MVP and observed statistical SNP-T2D interactions at 13 variants, including 3 for coronary heart disease, 1 for PAD, 2 for stroke, 4 for retinopathy, 2 for CKD, and 1 for neuropathy. Our findings may identify potential novel therapeutic targets for T2D and genomic pathways that link T2D and its vascular outcomes.

We investigated type 2 diabetes (T2D) genetic susceptibility via multi-ancestry meta-analysis of 228,499 cases and 1,178,783 controls in the Million Veteran Program (MVP), DIAMANTE, Biobank Japan and other studies. We report 568 associations, including 286 autosomal, 7 X-chromosomal and 25 identified in ancestry-specific analyses that were previously unreported. Transcriptome-wide association analysis detected 3,568 T2D associations with genetically predicted gene expression in 687 novel genes; of these, 54 are known to interact with FDA-approved drugs. A polygenic risk score (PRS) was strongly associated with increased risk of T2D-related retinopathy and modestly associated with chronic kidney disease (CKD), peripheral artery disease (PAD) and neuropathy. We investigated the genetic etiology of T2D-related vascular outcomes in the MVP and observed statistical SNP-T2D interactions at 13 variants, including coronary heart disease (CHD), CKD, PAD and neuropathy. These findings may help to identify potential therapeutic targets for T2D and genomic pathways that link T2D to vascular outcomes.

Objectives: To identify the pattern of un-operated grown up congenital heart defects at our tertiary care cardiac institute. Methods: This is a prospective observational study. All un-operated GUCH patients who presented to Faisalabad Institute of Cardiology (FIC) from May 2017 to 30th July 2017 were enrolled. Diagnosis was established on Transthoracic Echocardiography done by dedicated pediatric cardiologist at FIC. The mode of presentation, presenting complaints, type, severity, complications and co-morbid conditions of CHD were recorded. Results: A total of 200 consecutive patients were enrolled. Mean age was 29.92 ± 11.21 years. There were 104 females (52%) and 96 males (48%). Majority of patients presented in Out-Patient Department (84%) while 16% presented in emergency (n=32). The most common cardiac anomalies were: Atrial Septal Defect (ASD) 41.5% (83), Tetralogy of Fallots (TOF) 42 (21%), Ventricular Septal Defect (VSD) 28 (14%) and Patent ductus arteriosus (PDA) 8 % (16). Cyanotic CHD was present in 43% (86) while TOF was the most common of it. The disease was of moderate complexity in 77.5% patients. Certain complications like Pulmonary hypertension 69(34.5%), Eisenmenger 33(16.5%), Rhythm disturbances 15 (7.5%), Infective endocarditis 5(2.5%) were also present along with co-morbid conditions like coronary artery disease (1.5% and systemic hypertension (2.5%). Dyspnea on exertion (59.5%) followed by cyanosis (41%) were the most common presenting complaints. The most common reason for hospital admission was cardiac signs and symptoms (19.5%) followed by cardiac catheterization (10.5%). Conclusion: The ASD, TOF, VSD and PDA remain the most common CHD in descending order while pulmonary hypertension, Eisenmenger, heart failure, arrhythmias, infective endocarditis and stroke were the common complications of CHD at this particular age.

Objectives: To evaluate the effect of oral progesterone for the treatment of abnormal uterine bleeding in patients taking warfarin after prosthetic valve replacement. Methods: A total of 85 women of reproductive age, who were on warfarin due to prosthetic valve replacement were enrolled in the study. After detailed evaluation, their menstrual bleeding was quantified using Pictorial Bleeding Evaluation Chart. The patients were then prescribed an oral progesterone (Norethisterone) 5mg three times daily. The first follow up was done after one-month then at 3-months and at six months. The improvement in PBAC score was recorded at each visit. Data was entered and analyzed using SPSS (version 23.0). The mean ± Standard Deviation were calculated for quantitative variables while qualitative variables were presented in frequency table. The normality of data was checked using Kolmogorov-Smirnov test. Due lack of normal distribution of data in various groups, the Wilcoxon Sign Rank test was used to test the significance before and after treatment. The p-value of

Objectives: To identify the pattern of un-operated grown up congenital heart defects at our tertiary care cardiac institute. Methods: This is a prospective observational study. All un-operated GUCH patients who presented to Faisalabad Institute of Cardiology (FIC) from May 2017 to 30th July 2017 were enrolled. Diagnosis was established on Transthoracic Echocardiography done by dedicated pediatric cardiologist at FIC. The mode of presentation, presenting complaints, type, severity, complications and co-morbid conditions of CHD were recorded. Results: A total of 200 consecutive patients were enrolled. Mean age was 29.92 ± 11.21 years. There were 104 females (52%) and 96 males (48%). Majority of patients presented in Out-Patient Department (84%) while 16% presented in emergency (n=32). The most common cardiac anomalies were: Atrial Septal Defect (ASD) 41.5% (83), Tetralogy of Fallots (TOF) 42 (21%), Ventricular Septal Defect (VSD) 28 (14%) and Patent ductus arteriosus (PDA) 8 % (16). Cyanotic CHD was present in 43% (86) while TOF was the most common of it. The disease was of moderate complexity in 77.5% patients. Certain complications like Pulmonary hypertension 69(34.5%), Eisenmenger 33(16.5%), Rhythm disturbances 15 (7.5%), Infective endocarditis 5(2.5%) were also present along with co-morbid conditions like coronary artery disease (1.5% and systemic hypertension (2.5%). Dyspnea on exertion (59.5%) followed by cyanosis (41%) were the most common presenting complaints. The most common reason for hospital admission was cardiac signs and symptoms (19.5%) followed by cardiac catheterization (10.5%). Conclusion: The ASD, TOF, VSD and PDA remain the most common CHD in descending order while pulmonary hypertension, Eisenmenger, heart failure, arrhythmias, infective endocarditis and stroke were the common complications of CHD at this particular age. doi: https://doi.org/10.12669/pjms.35.4.878 How to cite this:Mughal AR, Tousif R, Alamgir AR, Jalal A. Pattern of un-operated Grown Up Congenital Heart (GUCH) patients presenting to a Tertiary Care Cardiac Institute of Punjab. Pak J Med Sci. 2019;35(4):1066-1071. doi: https://doi.org/10.12669/pjms.35.4.878 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective To review the incidence of stroke in patients undergoing CABG and the impact of a preventive strategy adopted at tertiary care unit of cardiac surgery. Methods The data of all patients who underwent isolated CABG (N= 722) from July 2016 to August 2017 at Faisalabad Institute of Cardiology was retrieved for this retrospective study. All operations were done on cardiopulmonary bypass and cold blood cardioplegia. Numeric data was summarized as Mean ± Standard Deviation while categoric variables were summarized into frequency and percentage. Results Mean age of patients was 53.83±8.8 years. Mean Parsonnet and Logistic EuroScore were 4.3±3.2 and 3.3±0.9 respectively. Forty nine patients (6.78%) had significant carotid artery disease. Mean number of grafts was 2.8±0.82. Diabetes was present in 27.8% patients. Neurological complications were noticed in 14 patients (1.94%) who included 12 permanent paralyses. Further subgroup analysis revealed that 67 patients who were operated by single clamp technique remained free of neurological complications. This is clinically remarkable finding but due to small population size it is statistically non- significant. Conclusion The incidence of neurological complications can be reduced significantly by adopting the appropriate preventing measures. Use of Single Clamp technique may be the reasons of such a low incidence of stroke in this study.

Background and Objective: Ventricular septal rupture (VSR) is one of the fatal complications of myocardial infarction (MI). Surgery provides the maximum survival benefit. Our objective was to investigate the risk factors of surgical mortality and to do the survival analysis in the past six years at our hospital. Methods: All the patients operated at CPE Institute of Cardiology Multan Pakistan, between 2009 and 2015 for repair of post MI VSR were analysed retrospectively for demographics, comorbidities, operative and post operative outcomes. The primary outcome was 30 days mortality. The follow up was done till April 2017 and the follow up data was obtained from hospital records and by telephoning the patients. SPSS was used for statistical analysis. P value < 0.05 was considered significant. Results: A total of 31 patients were operated for VSR repair with a mean age of 57.19±7.73 years. Eighteen patients also had a concomitant coronary artery bypass grafting (CABG). The operative mortality in this series was 25.8% Univariate analysis showed that pre-operative ejection fraction (E.F) (p value 0.010) and cardiogenic shock (p value 0.031) were a significant risk factors for operative mortality while on logistic regression analysis only the cardiogenic shock was found to be an independent risk factor for operative mortality with the odds ratio of 2.17. Low ejection fraction only acted as a confounding variable. The mean survival at six years was 34 months with a survival rate of 28.6%. The additional CABG did not confer any survival benefit. Conclusion: The patients in cardiogenic shock pre-operatively have a high operative mortality. Low ejection fraction (E.F) acts as a confounding factor. Concomitant CABG does not confer any survival benefit.

Background & Objective: Antiplatelet drugs are frequently used after coronary artery bypass graft (CABG) surgery to prevent venous graft occlusion. The fear of bleeding complications prevents them to be given early post operatively, which is the time when antiplatelets use confers maximum benefit. Our objective was to determine the effect and influence of early aspirin therapy on fatal and nonfatal bleeding complications and blood requirements after coronary bypass surgery (CABG). Methods: The patients who only underwent coronary artery bypass surgery for the first time in the past three years and did not have any bleeding diathesis were retrospectively analyzed from the cardiac surgery database of CPEIC Multan. The patients either received aspirin within six hours of CABG or had it given after 12 hours. The patients were analyzed for mean blood loss and number of blood units transfused. SPSS was used for statistical analysis. P value < 0.05 was considered significant. Results: Total 281 patients received aspirin within six hours while 326 patients did not. Mean blood loss in early aspirin group was 727ml as compared to 767ml in the other group (p value 0.74). The median number of blood units transfused was 2 (p value 0.98). Our results did not show any statistical difference in both the groups. Conclusion: Aspirin can safely be given early after CABG without the fear of bleeding complications thus conferring the advantage of increased graft patency.

The use of inferior vena caval (IVC) filters has been an accepted method for preventing pulmonary embolism, especially in cases where there are contraindications to anticoagulation. However, these filters have numerous potential complications some of which could be life threatening like, thrombosis and migration of the filter. The "Antheor" filter was designed to prevent this complication. Unfortunately, we encountered one patient where it has been unsuccessful in this regard. We therefore, believe that there is no ideal filter and the selection of a filter requires thorough knowledge of the limitations of individual brand.

Objective: To study the different operative techniques employed, the problems encountered and the outcome in bronchoplastic procedures both during and after surgery. Patients and methods: Forty-four patients with a mean age of 51.6 years (range 15‐80 years) underwent bronchoplastic procedures in the period from 1976 to 1998. There were 27 males and 17 females. Forty-two of these had planned surgery. Two trauma patients had emergency surgery. Out of 42 planned operations, 27 suffered from cancer and 15 had benign lesions. Amongst the non-small cell lung cancer (NSCLC) group, the nodal status was N0 in nine patients, N1 in 12 and N2 in six. Bronchial sleeve resection with lobectomy was performed in 24 patients. Six patients had sleeve pneumonectomies. Fourteen others had bronchial sleeve resections without lobectomies, and bronchoplasties for trauma and stricture. Reconstruction was performed in the earlier years with stainless steel wire of 38/40 SS gauge (na 22), vicryl (na 4) and prolene (na 1). More recently, ethibond (na 18) was routinely used for this purpose. Anaesthesia was maintained via oro-tracheal intubation, interrupted when necessary with a short period of intubation of one or the other bronchus through the thoracotomy incision. Results: The mean operating theatre time, including the anaesthesia, was 207 min (range 120‐375 min). The duration of stay in the high dependency unit (HDU) was no longer than 3 days. Post-operative problems included excessive bronchial secretions and partial atelectasis (one patient requiring therapeutic bronchoscopy), prolonged mechanical ventilation (na 1) and prolonged air leak (na 1). There was no per-operative, hospital, or 30 day mortality. Four out of 27 cancer patients lived more than 5 years, 12 died between 2 and 5 years, and 11 lived less than 2 years. Conclusions: Whilst bronchoplasties require special anaesthetic techniques and stringent high dependency post-operative care, there is minimal operative morbidity and mortality. Acceptable duration of survival can be expected even in the cancer patients. q 2000 Elsevier Science B.V. All rights reserved.

To evaluate the impact of preoperative oral trimetazidine on myocardial protection in coronary bypass surgery.We conducted a prospective double blind randomized study in the Department of Cardiac Surgery, Chaudhry Pervaiz Elahi (CPE) Institute of Cardiology, Multan, Pakistan. One hundred and seventy (170) patients of isolated CABG were included in the study. All operations were done by conventional technique of CABG using cardiopulmonary bypass, moderate systemic hypothermia and cold antegrade blood cardioplegia. The patients were randomized into 2 groups i.e. Group 1 (n = 85), who received and Group 2 (n = 85), who did not receive Trimetazidine. Trimetazidine (20 mg) was given orally, at 10:00 pm the night before operation and also at 7.00 am on the day of surgery. The CPK and CK-MB levels were determined before operation, immediately after shifting to the ICU, 12 hours and 36 hours after the operation. The comparison of CPK and CK-MB levels was carried out using analysis of variance with repeated measures. The peri-operative clinical and laboratory data were compared using Student's t-test for numeric variables and Chi-square test for categoric varaibles. The difference was considered statistically significant if the p-value was0.05.The pre-operative variables i.e. age, gender, Canadian Cardiovascular Society (CCS) class, ejection fraction, diabetes, history of smoking, haemoglobin level, serum creatinine etc had no differences in both group. Both groups showed no significant difference in Cardiopulmonary Bypass time (BPT), Aortic cross Clamp Time (CxT), prevalence of intra-operative arrhythmia and need for inotropic support. The analysis did not show any within group or between groups differences in the CPK and CKMB levels.This study showed that oral Trimetazidine given before coronary bypass grafting did not provide any benefit in myocardial protection.

To identify the risk factors for prolonged invasive mechanical ventilation after open heart surgery in Pakistan.This study is based on retrospective analysis of database.We conducted study of all patients who underwent open heart surgery at CPE Institute of Cardiology, Multan from March 2009 to May 2011.The data was retrieved from the database in the form of electronic spreadsheet which was then analyzed using SPSS software. The patients with incomplete data entries were removed from the analysis resulting in a set of 1,617 patients. The data of each patient consisted of 65 preoperative, operative and postoperative variables. The data was summarized as means, medians and standard deviations for numeric variables and frequencies and percentages or categoric variables. These risk factors were compared using Chi-sqaure test. Their ODDs ratios and 95% confidence intervals of ODD's Ratios and P values were calculated.Out of a total of 1,617 patients, 77 patients (4.76%) had prolonged ventilation for a cumulated duration of more than over 24 hours. Preoperative renal failure, emphysema, low EF (30%), urgent operation, preoperative critical state, prolonged bypass time, prolonged cross clamp time, complex surgical procedures and peri-operative myocardial infarction were found to be risk factors for PIMV. Old age, female gender, advanced ASA class, advanced NYHA class, diabetes mellitus, smoking, history of COPD, redo surgery, left main stenosis, obesity and use of intra-aortic balloon pump were not found to have significant ODDs ratios for PIMV. The patients with prolonged ventilation had significantly high mortality i.e. 32.47% while the normal ventilation group had 0.32% overall mortality.Many of the previously considered risk factors for prolonged ventilation after open heart study are no more significant risk factors. However, prolonged ventilation continues to be associated with very high mortality.

To study the differences in the prevalence of neurological complications following coronary artery bypass (CAB) carried out by conventional, on-pump beating and off-pump techniques.A retrospective analysis of all isolated coronary bypass operations (n=127) performed in King Fahad Cardiac Center, Riyadh over a period of one year starting from January 2005. Out of 127 patients, 73 underwent conventional CAB graft (CABG), 33 patents on-pump beating heart coronary bypass, and 21 had off pump coronary bypass grafting (OPCAB). All patients had preoperative carotid scans and those who developed neurological complications underwent CT-brain and expert neuro-psychiatric assessment.Preoperative characteristics of patients in all 3 groups were similar. The bypass times in the conventional CABG group were significantly longer than the on-pump beating group. The maximum number of grafts was in the on-pump beating group, followed by the conventional CABG, and the least in the OPCAB group. Seven out of 73 cases in the conventional bypass group developed neurological events of various severities. Only one out of 33 patients developed acute confusional state in the on-pump beating group and no neurological events were noticed in 21 patients operated by the OPCAB technique. Low ejection fraction, preoperative congestive cardiac failure, non-elective surgery and preoperative catastrophic state were found to be significant risk factors independent of the bypass technique.This study shows no significant difference in the prevalence of neurological complications among different types of bypass surgery in our institution. There was a trend towards less neurological outcomes in the OPCAB and on-pump beating groups.

An 18-year-old female suffering from severe mixed rheumatic mitral valve disease was operated on for mitral valve replacement. During the operation, an unusual swelling was noticed near the non-coronary sinus of the aorta, which turned out to be the left circumflex coronary artery. From its origin the artery curved around the right side of the aorta and then traversed in the transverse sinus to follow its normal course. The left anterior descending artery was arising from the left coronary sinus and the right coronary artery was arising from the right coronary sinus. This rare congenital anomaly was not suspected preoperatively as the patient did not have any relevant symptoms. Preoperative transthoracic echocardiography also failed to pick up this anomaly. However, postoperative detailed transthoracic echocardiography provided evidence of an abnormal vessel arising from the non-coronary sinus.

The impact of diffuseness of coronary artery disease on the outcome of coronary bypass grafting remains unclear due to the absence of an objective grading system for diffuseness. This study proposes a system and validates it by transit time flow measurements. All patients operated upon by the author from July 2004 to August 2006 were enrolled in the study. The patients who had procedures other than isolated coronary bypass grafting were excluded. This resulted in a set of 186 (151 male and 35 female) patients with a mean age of 59.55 years. Those vessels which had endarterectomies, on-lay patches, multiple/sequential grafts to a single artery were removed from analysis. The diffuseness of distal disease was graded from 0 to 3 on the basis of (i) the size of vessel and (ii) the number as well as significance of atheromatous lesions distal to the graft. The correlation analysis showed a moderate positive correlation between pulsitility index and grade of diffuseness and a moderate negative correlation between graft flow and grade of diffuseness (P

To compare myocardial injury caused by 3 commonly used methods for coronary artery bypass grafting (CABG).A prospective randomized study conducted at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. The study started in February 2003 and concluded in April 2004 after including 45 patients (15 patients in each of 3 sub-groups) who fulfilled the inclusion and exclusion criteria. The subgroups included coronary artery bypass surgery performed by: a) conventional technique, b) off-pump technique, and c) on-pump beating-heart techniques. All patients had similar operative risk profiles. Their ages were 70 years or less with an ejection fraction of 30-50%. The creatine kinase, myocardial band (CKMB) levels were determined 2 hours after arrival from the operating room then, at 4 hours, 6 hours, and 12 hours. The comparison of creatine phosphokinase and CKMB levels was carried out using analysis of variance with repeated measures. The p-values were used to evaluate the significance of differences.The pre-operative characteristics including age, gender, ethnic origin, diabetes mellitus, hypertension, and left ventricular function, were similar in the 3 groups. All groups had a median number of 3 bypass grafts. The stay in the intensive care unit and the duration of inotropes were shortest in the off-pump group, but the difference was not significant. There was a peak of CKMB levels at 6 hours in all groups. The trend of CKMB level showed significantly higher values in the conventional CABG group as compared with the other 2 groups.This study indicates that the off-pump technique provides better myocardial preservation than other methods.

The right atrial trans-septal approach is one approach to the mitral valve. We used this approach in 25 patients from October 1990 to May 1993. Fourteen patients were in NYHA class II, 10 in class III and 1 in class IV. All had gross cardiomegaly with a left atrial dimension of 58±14 mm. The majority had advanced rheumatic heart disease involving more than 1 valve and therefore needed double or triple valve repair or replacement. A total of 49 operative procedures were performed, that is, about 2 per patient. The procedures for the mitral valve included open mitral valvotomy in 3 patients, valve repair in 12 patients and valve replacement in 10 patients. The average cross-clamp time was 84±14 min. No patient died while in hospital. Each heart maintained its preoperative rhythm (sinus in 13 cases and atrial fibrillation in 12 cases). None developed iatrogenic arrhythmia or conduction defect. There was no residual atrial septal defect. This approach is useful, safe and convenient.

We report a case of young male patient who developed left internal mammary artery to pulmonary artery fistula 9 years following the coronary artery bypass grafting operation. The clinical signs and symptoms were very subtle including recurrence of angina and heart murmur. Surgical division of the fistula and re-grafting of blocked coronary arteries resulted in satisfactory long term outcome.

We report a case of anomalous course of the right coronary artery in the wall of right atrium which was encountered during coronary artery bypass surgery. As the stenotic lesion in the vessel was proximal, the large posterior descending branch of the right coronary was grafted. Such an anomalous course of the right coronary artery has not been previously described in the literature and lack of knowledge of such an abnormal course may result in inadvertant damage during cannulation of the inferior vena cava or coronary sinus.

Objective: The statistical evaluation of the influence of age on the pattern of gastro-oesophageal reflux (GOR) identified by prolonged pH monitoring in asymptomatic subjects. Re-appraisal of the DeMeester scoring system for GOR. Method: Prolonged pH monitoring was performed on 45 asymptomatic elderly adults with normal contrast oesophagogram, manometry and endoscopy. They included 36 males and nine females. The mean age was 66.6 years. The monitoring time ranged between 20 and 24 h, including one complete daily feeding cycle. GOR was defined as a reflux event with a pH of ,4. The mean, standard deviation, kurtosis and skew were calculated for six parameters listed in the results. The mean values were compared with those of normal values determined by DeMeester et al. (in: Read NW, editor. Gastrointestinal motility: which test? 1989, pp. 43‐52) from their study of 50 young healthy adults, and the t-test was applied to determine the statistical significance of differences. The ‘null hypothesis’ for each parameter was defined as ‘the mean values of the elderly population are not statistically different from DeMeester’s normal values’. Results: The means (^SD) of six parameters studied in pH monitoring were as follows: supine reflux time as a percentage of total study time, 2.94 ^ 5.18%; upright reflux time as a percentage of total study time, 4.14 ^ 5.71%; total reflux time as a percentage of total study time, 3.5 ^ 4.38%; duration of longest reflux episode, 14.98 ^ 24.92 min; number of reflux episodes lasting .5 min, 1.76 ^ 2.75; total number of reflux episodes during study, 13.49 ^ 11.31. These results were significantly different from the normal values reported by DeMeester. In addition, the data for each individual parameter was grossly skewed, as well as kurtotic, which implied that the data did not represent a normally distributed population. Moreover, we believe that the equation used for calculation of the DeMeester score, is inappropriate. Conclusions: The null hypothesis is rejected as the mean values of these parameters in our group are significantly higher than those used as normal. This implies that the normal values defined by DeMeester would over-diagnose gastro-oesophageal reflux disease (GORD). Moreover, we have found that the formula used to calculate the DeMeester’s score is not according to the principle it is based on. DeMeester’s system scoring is therefore inappropriate. q 2000 Elsevier Science B.V. All rights reserved.

Haemangiopericytoma is a rare, highly vascular, slow-growing tumour which has both malignant and benign varieties. We report a case of a 63-year-old man in whom it was treated by initial radiotherapy followed by complete surgical excision. The preoperative radiotherapy markedly reduced the vascularity of the tumour. A brief review of the pathology and nature of tumour is provided.

Objective: To evaluate the impact of coronary bypass surgery on the function of the right ventricle (RV) in patients with a pre-operative ejection fraction ? 35% who did not have any perioperative myocardial infarction.Method: We performed a prospective study of 30 patients who underwent uneventful isolated coronary artery bypass grafting (CABG). All patients had echocardiography prior to surgery and 3 months postoperatively. Myocardial tissue Doppler velocities were used to measure left and right ventricular function. The right ventricular myocardial performance index (Tei) and the ratio between the velocities of the RV and left ventricle (LV) were also calculated.Results: There was a significant improvement in left ventricular ejection fraction before and after CABG (P = .046). The tissue Doppler imaging (TDI) velocities from the LV remained unchanged, but highly significant reductions in right ventricular TDI velocities were observed (P Conclusion: There is a marked impairment of RV function after CABG.