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Background: Mitral valve replacement (MVR) plays a central role in the management of patients with mitral stenosis with moderate to severe pulmonary hypertension. Pulmonary hypertension has an impact on short term outcome of MVR. It can influence left ventricular function (low output syndrome), incidence of arrhythmia, ARDS leading to respiratory failure and right ventricular failure which may be irreversible. Methods: The immediate postoperative hemodynamics in 40 patients with moderate to severe pulmonary arterial hypertension who underwent mitral valve replacement (BLMV) between July 2010 and June 2012 were studied prospectively. Patients were divided into two groups: Group A (n=20): Patient having MS with moderate pulmonary hypertension (PASP: 40-59 mm-Hg) and Group B (n=20): Patient having MS with severe pulmonary hypertension (PASP e" 60mm-Hg). Total two follow up were done-1st follow up after 10 days and 2nd follow up after 1 month of MVR. Each patient was assessed by medical history, clinical examination & color doppler echocardiogram. Results: It was shown that surgery can be beneficial for the patients if MVR is done in the state of mild PAH irrespective of age but beyond this level of PAH, the patients may still remain with mild pulmonary hypertension which may trigger the cascade of pulmonary vascular Disease may be the cause of unsatisfactory outcome. So, early surgical outcome of mitral stenosis with moderate pulmonary hypertension is better than mitral stenosis with severe pulmonary hypertension. Conclusion: We conclude that MVR in patients having MS with moderate PAH is a safe and effective measures for preventing pulmonary hypertension related complications. [ABSTRACT FROM AUTHOR]

Background: Homocysteine is increasingly recognized as an independent risk factor for vascular disease specially peripheral arterial occlusive diseases. In the present study, an attempt was made to find out the association between the raised fasting plasma total homocysteine level and early onset atherosclerotic peripheral arterial occlusive diseases (PAOD). Methods: In this prospective observational study a total of 50 study subjects were included. All patients were clinically and angiographically documented for atherosclerotic PAOD. All patients underwent surgical intervention as well as estimation of serum total homocysteine level. Arterial segment was sent for histopathological examination to find out whether atherosclerosis was present or not. Patients were divided into two groups-Group-1 included patients of 20-40 years of age and group-II included those of 41-60 years of age. The groups were compared to see association between elevated level of plasma homocysteine and atherosclerotic peripheral arterial occlusive diseases in elderly as well as in early age. Results: 41 (82%) patients were male and 9 (18%) patients were female. Serum homocysteine level was higher in group I than group II (71.4% vs. 40.9%). Besides, the level of mean serum homocysteine level was significantly (p=0.02) higher in group I than group II (21.18±9.53 vs. 17.24±8.92 μmol/L). Conclusion: In conclusion, this study suggests that serum homocysteine has an association with early onset atherosclerotic PAOD. Therefore, a raised serum homocysteine level can be used as an independent biochemical predictor of early onset atherosclerotic PAOD. [ABSTRACT FROM AUTHOR]

Background: coronary artery bypass surgery (CABG) is expensive, uses disposable appliances and patients require more perioperative intensive care, long stay in hospital and often have a lengthy recovery time. These complications, together with the growing trend towards less invasive techniques in other areas of surgery, have encouraged cardiac surgeons to see if minimally invasive cardiac surgery can become a reality with improved outcomes and costs. Methods: This is a prospective nonrandomized comparative clinical study done at the Department of Cardiac Surgery in National Institute of Cardiovascular Diseases (NICVD) Sher-E-Bangla Nagar, Dhaka from July 2006 to June 2008 among routine CABG patients. Purposive sampling was done with 26 patients in group A selected for MIDCAB and 24 patients in Group B selected for conventional CABG surgery. Patients were followed up for three months. Postoperative outcomes were assessed to evaluate the safety and efficacy of MIDCAB in relation to conventional CABG. Results: Mean age were 54.19 vs 53.87 in group A and Group B. 92.3% vs 87.5% were male respectively. Mean duration of operation, per operative blood loss transfusion and arrythmia were lower in MIDCAB group (p<0.05) number of grafts were also statistically significant (p< 0.001). Regarding post-operative outcome ventilation time in hours ICU stay post-operative hospital stay in days, postoperative MI and stroke rate were lower in favor of group A MIDCAB patients (p<0.001). Three months postoperatively six-meter walking distance is also statistically significant in favor of Group A MIDCAB (p<0.01) patients. However, pain score in early post-operative period was higher in group A significantly but it decreased significantly in late post-operative period which is also highly statistically different (p<0.001). However, mortality and quality of life at three months were similar in both groups. Conclusion: No difference in mortality rates detected between MIDCAB and CCABG group. But there was evidence that MIDCAB is associated with less perioperative and early postoperative morbidity and improved quality of life. The MIDCAB surgery is an effective procedure of complete revascularization in ischemic heart diseases like CCABG. The procedure is associated with shorter operating time, shorter ICU stay time, shorter hospital stays and better quality of life than for CCABG. [ABSTRACT FROM AUTHOR]

Background: Postoperative cardiac dysfunction is a common cause of mortality and morbidity associated with CABG Surgery. Adenosine enhances tolerance of the myocardium to ischemic arrest. Therefore, the study on adenosine pre-treatment as an adjunct to cardioplegia in patients undergoing CABG will definitely help to provide better myocardial protection for better postoperative outcome. Methods: Quasi experimental study was done in the Department of Cardiac Surgery, NICVD during July 2012 to June 2014 with patients who underwent conventional CABG surgery. Patients were divided in two groups. Group A: Patients received at regular institutional high-potassium ([K+] = 20 mol/l) cold (12 °C) blood cardioplegia. and Group B: Patients received 250 μg/kg bolus dose of adenosine pre-treatment, which was immediately followed by high-potassium cold (12 °C) blood cardioplegia after clamp-on. Patients were followed up to evaluate the degree of myocardial damage by measuring perioperative Troponin I, amount of inotropic support, time of assisted ventilation, arrhythmia and mortality. Results: Most of the patients in each group belongs to 51-60 years of age range. There was no difference regarding operative parameters in two groups. Time to arrest was significantly shorter in group B compared to group A, indicating that adenosine has the potential to enhance the efficacy of cardioplegic arrest. Plasma level markers of myocardial damage: cardiac Troponin I (cTnI) obtained from serial venous blood samples post-operatively were significantly lower in group B than group A (p<0.05). There was significantly decreased requirement of inotrope in group B during first 24 hrs (p <0.05). Conclusion: Decreased level of cardiac enzymes and lower inotropic requirement suggests that an optimal myocardial protection with less cellular damage is obtained with adenosine pre-treatment as adjunct to cold blood cardioplegia. [ABSTRACT FROM AUTHOR]

Background: Identification of predictors of morbidity and mortality is an important issue for the management of cardiac surgical patients. Elevated lactate concentrations in the immediate postoperative period reflect unmet metabolic demand and may be associated with outcome. Methods: A prospective observational study was carried out in the department of cardiac surgery, at National Heart Foundation Hospital& Research Institute(NHFH&RI), Dhaka. commencing from July 2016 to March 2018. In all Adult patients irrespective of sex undergoing elective off-pump coronary artery bypass grafting (OPCABG). Purposive sampling was applied with patient with blood lactate level < 3 mmol/L 6hours after shifting from OT to ICU in Group-A and blood lactate level ≥3mmol/l, 6hours after shifting to the ICU in Group-B.Postoperative early adverse outcomes were analyzed in both the patient groups. Results: Blood lactate level 6 hours after ICU transfer is an independent predictor for prolonged mechanical ventilation time, (OR 2.540, 95% CI 1.781-3.621, p= <0.001).prolonged ICU stay, .(OR 1.767, 95% CI 1.348-2.315, p=< 0.001) pulmonary complication (OR 1.503, 95% CI 1.104-2.046, p= 0.010).and renal dysfunction(OR 1.460, 95% CI 1.156-1.843, p= 0.001). following off-pump coronary artery bypass grafting. Other risk factors for adverse outcome including, low LVEF, diabetes mellitus, blood transfusion and inotropic support were also found to be predictors of major complications in our study. Conclusion: The findings of this study permits to conclude that blood lactate level 6hours after ICU transfer is associated with an increased risk of postoperative early adverse outcome after off-pump coronary artery bypass grafting. It is found that lactate is an independent predictor of major postoperative complications. So, achieving normal blood lactate level following OPCABG is essential for minimizing postoperative adverse outcome. [ABSTRACT FROM AUTHOR]

Background: Atrial Fibrillation (AF) is the most common arrhythmia occurring after cardiac surgery and its peak incidence is between second or third postoperative day. It occurs in 40% to 50% of patients after valve surgery alone or combined valve and CABG surgery respectively. Among all the anti-arrhythmic drugs evaluated for AF, amiodarone has shown the most promising results with successful conversion and maintenance of normal sinus rhythm achieved in 50%–70% of patients. Methods: Sixty diabetic patients purposively selected who underwent isolated off pump coronary artery bypass procedure in NICVD. Group A – 30 patients receiving loading dose of amiodarone intra-operatively before establishment of CPB during valve replacement surgery and Group B- 30 patients without receiving loading dose of amiodarone intra-operatively during valve replacement surgery. Incidence of atrial fibrillation in postoperative period was evaluated. Results: Atrial fibrillation was observed in 8 (26.7%) patients in group A and 18 (60%) patients in group B (p=0.009). Ventricular tachycardia developed in 6.7% patients in group B and none in group A (p=0.47). Mean duration of ICU stay was 2.04±0.30 days in Group A and Group B was 2.98±0.77 days (p=0.03). Mean duration of post-operative stay was 7.20±0.66 days in Group A and Group B was 7.85±0.60 days (p=0.10). Conclusion: A single intra operative dose of intravenous amiodarone increases the incidence of conversion of AF to normal sinus rhythm. When AF persisted, use of amiodarone reduces the frequency of need for cardioversion and the energy required for it. [ABSTRACT FROM AUTHOR]

Background: Diabetes mellitus is an independent risk factor for coronary artery disease and it adversely affects the postoperative outcome after CABG surgery. Adequate control of diabetes for a longer period, which can be assessed by HbA1c, before OPCAB may reduce development of postoperative atrial fibrillation and thus improve outcome. Methods: This was an observational study included sixty diabetic patients purposively who underwent isolated off pump coronary artery bypass procedure in NICVD. Total sample contained 60 diabetic patients, which were divided in two equal groups. Grouping was Group I – 30 Diabetic patients with preoperative HbA1c <7% and Group II – 30 Diabetic patients with preoperative HbA1c ≥7% and all of whom underwent isolated OPCAB. Postoperative atrial fibrillation and other complications were recorded and compared in two groups of patients. Results: Most postoperative atrial fibrillation (AF) developed in higher age group 61-70 years (61.5%). Postoperative complications were higher in group II. Postoperative AF was significantly higher in diabetic patients having preoperative HbA1c ≥7% compare to diabetic patients with HbA1c <7% in early postoperative period after OPCAB. Age (61-70 years) (OR=1.872, p=0.018), preoperative HbA1c ≥7% (OR=19.029, p=0.002) and hypertension (OR=1.091, p=0.019) was found significantly associated with increased development of postoperative atrial fibrillation. Conclusion: Our study revealed that higher preoperative HbA1c level was associated with increased incidence of new onset atrial fibrillation after OPCAB. So, it can be used as a reliable indicator for adequate control of diabetes preoperatively among patients selected for isolated elective OPCAB in future. [ABSTRACT FROM AUTHOR]

Background: Current cardioplegic technique during conventional coronary artery bypass grafting (CABG) does not consistently avoid myocardial ischemic damage in high risk patients. Alternatively revascularization without CPB is not always technically feasible. The on-pump beating technique eliminates global myocardial ischemia and thus reduce the mortality and morbidity in high risk patients. This study evaluates the early surgical outcomes of on-pump beating-heart CABG in comparison to conventional CABG. Methods: In this prospective study 60 high risk patients with EURO-SCORE of 6 and above were prospectively allocated into two groups in non-randomized way. Among them 30 patients underwent on-pump beating-heart CABG and 30 patients underwent conventional CABG. The early surgical clinical outcomes were compared between the groups. Results: On-pump beating heart CABG significantly reduced the duration of operation time, cardiopulmonary bypass time, postoperative ventilation time and intensive care unit (ICU) stay. Total blood loss and transfusion requirement were less with reduced Peak Creatine-Kinase level in On-pump beating heart CABG. 30 day mortality was less in On-pump beating heart CABG group (6.7% versus 13.3%). No significant differences between the groups were found in morbidity regarding stroke, renal failure, mediastinitis and atrial arrhythmia. Conclusion: On-pump beating heart CABG can be performed safely in high risk patients. It is still associated with the detrimental effect of CPB but eliminates intra-operative global myocardial ischemia. [ABSTRACT FROM AUTHOR]

Background: One of the main causes of post-operative morbidity in cardiac surgical patient is excessive bleeding requiring transfusion of blood component after CPB. Re-exploration due to bleeding occurs in 2% to 7% of post bypass patient and 50% to 80% of these patients not having any identifiable surgical bleeding source. Tranexamic acid is competitive inhibitor of plasminogen activator and at higher concentration a non-competitive inhibitor of plasmin. It is 10 times more potent than Epsilone Aminocaproic Acid in preventing post-operative haemorrhage following CPB. Methods: This study was conducted in the Department of Cardiac Surgery, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh between January 2009 and December 2010. The Study population was divided into two groups. Group A comprised of 35 patients, who had received Tranexamic Acid 10 mg/kg after induction and then 1 mg/kg/hour till time of protamin infusion and Group B comprised of 35 patients who had received same amount of normal saline 0.9% NaCl as placebo. Results: The postoperative bleeding during both 1 to 4 hours and 4 to 24 hours was significantly lower in the Tranexamic Acid group as compared to the placebo group (p value <0.001). There was no significant difference between groups in terms of platelet count and prothrombin time. Conclusion: From the study, we conclude that "Perioperative Administration of Tranexamic acid reduces post operative bleeding and also reduces the need for postoperative blood transfusion in CABG patents using Cardiopulmonary bypass". Therefore it is recommended that routine prophylactic use of Tranexamic Acid should be carried out to decrease the postoperative hemorrhage and requirement blood transfusion. [ABSTRACT FROM AUTHOR]

Background: In coronary artery bypass surgery (CABG) left internal mammary artery (LIMA) is considered gold standard conduit of choice for myocardial revascularization. Graft failure following CABG reduces cardiac mortality and morbidity both in short and long term. Although conventional angiography is gold standard for assessing graft patency but rarely available in same operating room. So intraoperative florescence imaging could be an efficient and reliable method of assessing the patency of graft. Methods: This study was conducted between July 2013 to June 2014 in the Department of Cardiac Surgery of National Institute of Cardiovascular Diseases (NICVD). Thirty six LIMA grafts were assessed by using IFI system .ICG administered through CVP line and imaging acquired during pass of the ICG through field of view graft flow. Quality of anastomosis was intra operatively to validate graft. Results: Mean age of study population was 54±8.38 years. Per operative assessment of LIMA to left anterior descending artery revealed 32 (88.8%) patent anastomosis, narrowing of anastomosis was found in 2 (5.55%) patients. Conclusion: Intraoperative fluorescence imaging is an effective and inexpensive way to validate patency of LIMA graft. [ABSTRACT FROM AUTHOR]

Background: Cardiopulmonary bypass (CPB) is an unphysiological state and widely regarded as an important contributor to renal failure. Despite improvement in cardiopulmonary bypass technique, anesthesia and intensive care, perioperative renal dysfunction still represents a significant and potentially lethal complication after coronary artery bypass graft surgery (CABG). Renal dysfunction is a serious complication of coronary revascularization with CPB and results in increased morbidity, mortality and prolonged hospital stay. We compared the incidence of perioperative renal dysfunction in patients who underwent CABG, on-pump and off-pump (OPCAB). Methods: A total of 60 high-risk patients with ischaemic heart diseases were included in the study who underwent CABG. Out of the total 60 patients, 30 were in the Off-pump group (Group A) and the rest 30 were in the On-pump group (Group B). They were diagnosed as high-risk patients considering serum creatinine level>1.7mg/dl with age >60 years, ejection fraction 30-40%. Renal function was evaluated in both groups preoperatively and postoperatively (on 1st, 2nd and 7th postoperative day) and compared between two groups. Results: One patient in the On-pump group died on 6th postoperative day. Preoperative renal parameters were also similar and showed no statistically significant difference. So both groups were comparable. Comparison of renal parameter in OPCAB and on-pump CABG between preoperative and 7th day postoperatively found in this study were blood urea 50.33±6.29, 39.87±4.8 vs 52.67±9.05, 66.21±6.91; S. Creatinine (mg/dl) 1.94±0.19, 1.28±0.19 vs 2.07±0.31, 2.82±0.47; Creatinine Clearance Rate(ml/min) 46.61±4.1, 71.51±12.3 vs 46.53±4.6, 34.02±4.49; Urine output (ml/24 hrs)1692.7±71.53, 1755.7±82.91 vs 1591.2±78.76, 1492.1±196.29 all are statistically significant(p<0.05). Mean period of mechanical ventilation, ICU stay and total postoperative hospital stay were significantly greater in On-pump group. One patient of Group-B died due to multi organ failure including acute renal failure on 6th postoperative day (3.3%) (p>0.05). Statistically significant difference of renal parameters in different postoperative days showed evidence of well preservation of renal function in OPCAB. Conclusion: Adaptation of OPCAB offers better preservation of renal function as well as better early postoperative outcome specially in high-risk CABG patients. [ABSTRACT FROM AUTHOR]

The Fontan procedure is a palliative surgical procedure used in children with complex congenital heart defects. It involves diverting the venous blood from the right atrium to the pulmonary arteries without passing through the morphologic right ventricle. A 23 years old adult male from Noakhali admitted with the diagnosis of transposition of great arteries (D-TGA) with large perimembranous ventricular septal defect (PM VSD) with severe pulmonary stenosis (PS) and single ventricle morphology in National Institute of Cardiovascular Disease (NICVD), Dhaka. He underwent Intracardiac lateral tunnel Fontan by using right atrial wall. Patient recovered uneventfully in his early postoperative period. The lateral tunnel Fontan procedure results in excellent long-term outcome even when used in patients with diverse anatomic diagnoses. The incidence of atrial tachyarrhythmia is low and mainly depends on the underlying cardiac morphology and preoperative arrhythmia. The good long-term outcome after an intracardiac lateral tunnel Fontan procedure should serve as a basis for comparison with other surgical alternatives. But using right atrial wall as a buffle is rare and done first time in Bangladesh. [ABSTRACT FROM AUTHOR]

Background: Atrial myxoma is the most common benign cardiac neoplasm. Most of the case series have focused on the variable clinical presentation of myxoma rather than its gross and microscopic features. The objective of our study was to evaluate prevalence of different morphologic types of myxoma and to correlate with their clinical presentations. Methods: 68 patients were included in the study. The study population was divided into two groups- Group-A (n-18) patients having soft (papillary) tumor in the left atrium, Group B (n=50) patients having solid tumor in the left atrium. Results: 88.3% patients suffered illness more than 12 months. 92% of the solid myxomas were located in the septal wall compared to 55.6% of the papillary myxomas (p = 0.031), while one-third (33.3%) the papillary tumors were found in the left atrial free wall compared to only 4% of the solid myxomas (p = 0.048). Fever, congestive heart failure and dyspnoea were significantly predominant in patients with solid myxomas (72% vs. 44.4%, p = 0.036; 92% vs. 22.2%, p < 0.001 and 88% vs. 55.6%, p = 0.010 respectively). Atrial fibrillation and neurologic manifestations were more frequently encountered in the papillary myxoma group. No statistically significant difference was found between the groups (p>0.05) by postoperative complication during in hospital follow up but one mortality in each group. Conclusion: Our findings lend support to the view that different gross left atrial Myxoma tumor types and tumor location predict presentation. [ABSTRACT FROM AUTHOR]

Background: Acute lower extremity ischemia is a common vascular disease and considered limb- and life- threatening. The present study evaluated and compared the outcome of early and late surgical intervention in acute lower limb ischemia due to thromboembolism. Methodology: This non randomized comparative parallel study was conducted at the Department of Cardiovascular Surgery, NICVD, Dhaka, Bangladesh from January 2007 to December 2008 for duration of two year. Total 80 patients were enrolled in this study. The patients were divided into equal two groups, Group A, for early surgical intervention (with in 24 hours) and Group B, late surgical intervention (more than 24 hours). Results: Mean (±SD) age of both Group A and Group B was 51.93 (±11.73) and 47.00 (± 11.01) years. Male and female ratio of the total study population was 1.76:1 Pain and absence of pulse distal to occlusion was common for all. Cold extremity, sensory deficit, motor deficit, diminish vascular flow was the commonest findings of both group. In Group A, 57.5% had superficial femoral artery occlusion, 22.5% had iliac artery and 20.0% popliteal artery occlusion. In Group B, 42.5% had superficial femoral artery occlusion, 32.5% had popliteal artery occlusion and 25.0% had iliac artery occlusion. Fasciotomy was performed in 15.0% patients of Group A and in 22.0% patients of Group B. After Fogarty embolectomy in group A and group B had warm extremity (80.0% vs. 65.0%), pulsation distal to occlusion (90.0% vs. 75.0%), intact sensory function (82.5% vs. 67.5%), intact motor function (80.0% vs. 65.0%), and normal vascular flow by Doppler US (80.0% vs. 65.0%). During postoperative period history of bleeding, infection, reperfusion injury, muscle necrosis and limb amputation were 12.5% vs. 10.0%, 5.0% and 7.5%, 17.5% vs. 35.0%, 15.0% vs. 12.5% and 37.5% vs. 32.5% respectively. Conclusion: Duration of embolism may be the significant factor determining the outcomes of the management of acute arterial embolism in the lower extremities. The 24-hour duration of arterial embolism is a crucial factor influencing the surgical the management and early diagnosis and shifting of patients to specified centre as early as possible to save limb as well as life. [ABSTRACT FROM AUTHOR]

Left atrial myxomas are benign, slow-growing primary cardiac tumors. They present with gradual onset of one or more of a triad of obstructive, embolic, or constitutional symptoms. Echocardiography aids in the detailed preoperative and intraoperative evaluation of the myxoma for surgical strategy planning. We describe a case of interstitial hemorrhage in a left atrial myxoma leading to rapid expansion of the tumor with features of acute, mitral valve obstruction. Echocardiography showed a cystic area in the left atrial tumor that corresponded to an area of recent hemorrhage confirmed on surgical removal. A 42 yrs old housewife presented with severe dyspnoea, cough and chest pain for 7 days, after detail evaluation she was diagnosed as a case of left atrial myxoma with heart failure. Subsequently she underwent emergency open heart surgery under cardiopulmonary bypass; removal of a huge LA myxoma was done, and recovered uneventfully. [ABSTRACT FROM AUTHOR]

Closure of patent ductus arteriosus (PDA) with device or coil is presently the first line of therapy, but it has got different acute and late complications. A 3 years old male child presented with history of percutaneous closure of the PDA Amplatzer device 18 months back. Now he presented with dislodgement of the device to descending thoracic aorta and reappearance of a large PDA. The child underwent surgical closure of PDA and removal of the device from descending thoracic aorta. We are presenting this case as one of the uncommon late complications of device closure of PDA. [ABSTRACT FROM AUTHOR]