Mediastinal Bleeding Research Articles

Spontaneous Hemomediastinum due to thyroid artery aneurysm A rare case report

Spontaneous Hemomediastinum is a rare pathological disorder. Multiple underlying causes and contributory factors can be identified, such as trauma, malignancy, iatrogenic, bleeding disorder or mediastinal organ hemorrhage. Using contrast enhanced computed tomography (CT) of the chest, hemomediastinum can be adequately diagnosed. Spontaneous hemomediastinum may occur due to muliple and cotributory causes such as: secondary to haemorragic disorders, mediastinal tumors or after sudden increase in intrathoracic pressure, (e.g. during coughing, sneezing or vomiting, or sudden sustained hypertension) [1, 2]. In this case report, a 76-year-old male is presented with of thyroid artery aneurysm resulting in hemomediastinum causing thoracic pain.

The Use of Arterial Grafts of the Left Internal Mammary Artery is Not a Predictor for the Incidence of Pericardial Effusion

BACKGROUND: The left internal mammary artery (LIMA) is used very often for coronary artery bypass grafting (CABG). During the cardiac surgery, surgical preparation of LIMA graft could be the reason for mediastinal bleeding and pericardial effusion (PE).
 AIM: This current study was, therefore, undertaken to show the prediction of PE occurrence comparing the usage of LIMA and venous graft.
 METHODOLOGY: The study population comprised 1929 patients (1.562 men mean age 57.1 years) who underwent CABG due to coronary disease. Patients were separated into two groups: Patients with venous and patients with arterial grafts on left anterior descending (LAD) artery. The first group included 1468 patients with arterial graft (LIMA) who underwent surgery from October 2008 to January 2014 and the second group included 461 patients with venous graft on LAD that were treated before 2008. Both groups were compared with respect to occurrences, size, and location of PE, which was determined on the 5th day after surgery by echocardiography.
 RESULTS: PE was identified in 1219 (63.1%) patients. There was no difference between compared groups in the proportional occurrence or absence of effusion: In the first group 931 (63.4%) and in the second 288 (62.4%) patients had PE (p > 0.05). There were significant differences (p < 0.001) in localization of effusion; circular effusion was found in 797 (41.3%) patients while localized effusion in 422 (21.8%) patients.
 CONCLUSION: Surgical experience can lead to a reduced risk of occurrence of PE when using arterial graft with no differences compared to using a venous graft. The use of arterial LIMA graft is not a predictor for the incidence of PE.

Safety and Impact of Direct Left Atrial Pressure Monitoring in Patients Undergoing Continuous-Flow Left Ventricular Assist Device Implantation

Hemodynamic monitoring plays a critical role in the perioperative management of patients supported by continuous-flow left ventricular assist devices (CF-LVAD). Data published on left atrial pressure monitoring (LAPm) in patients with CF-LVAD support is limited. Our primary aim was to examine the safety and impact of direct LAPm in patients undergoing CF-LVAD implantation. Retrospective data on demographics, LAPm, hemodynamics, and endpoints were extracted on patients at our institution with CF-LVAD implants from January 2017-June 2019. The decision to use a LAPm is based on institutional standards related to right ventricular failure risk and/or presence of severe pulmonary hypertension. The primary safety endpoint of LAPm was a composite of mediastinal bleeding requiring transfusion, cardiac tamponade, and LA thrombus. Secondary endpoints were LAPm device malfunction leading to premature LAPm removal and lack of hemodynamic trends, air embolism, surrogates of left ventricular (LV) unloading, inhaled epoprostenol use, and post-implant ICU and hospital length of stay (LOS). Statistical analyses were by two-tailed Student's t-test or chi-square tests (SAS, version 9.4). Of the 242 patients (mean age 58.1 ± 11.0 years), 88.4% had durable centrifugal pumps for destination therapy (58.3%). Most had Intermacs status 2-4 (95.5%) at implant. One hundred fifty-three patients (63.2%) had LAPm for a median of 20h. Prior to LAPm explant, 90.2% had an LAP <15 mm Hg and 8.5% had LAPm device malfunction. The primary safety endpoint in patients with and without LAPm was 14.4% versus 19.1% (p=0.34), respectively. There were no cases of air embolism related to LAPm use. Inhaled epoprostenol use in patients with and without LAPm was 3.5 ± 7.3 days versus 2.0 ± 2.9 days (p=0.23), respectively. There was no difference in post-implant LOS in the ICU (5 (1, 117) versus 6 (2, 320) days, p=0.22) and hospital (18 (2, 171) versus 21 (1, 320) days, p=0.32)) in patients with and without LAPm. Use of LAPm to guide management is both safe and feasible in patients requiring CF-LVADs. In the vast majority of this cohort, we were able to achieve optimal LV unloading. Future analyses are warranted to better understand the clinical outcomes' associations of LAPm on CF-LVAD parameters.

Central vs peripheral venoarterial ECMO in postcardiotomy cardiogenic shock.

Central or peripheral venoarterial extracorporeal membrane oxygenation (va ECMO) is widely used in postcardiotomy cardiogenic shock (PCS). Available data suggest controversial results for both types. Our aim was to investigate PCS patients treated with either peripheral (pECMO) or central ECMO (cECMO) concerning their outcome. Between April 2006 and October 2016, 156 consecutive patients with va ECMO therapy due to PCS were identified and included in this retrospective analysis. Patients were divided into cECMO and pECMO groups. Statistical analysis of risk factors concerning 30-day mortality of the mentioned patient cohort was performed using IBM SPSS Statistics. Fifty-six patients received cECMO and 100 patients were treated with pECMO due to PCS. In the group of cECMO peripheral vascular disease was significantly more present (cECMO 19 [34%] vs pECMO 14 [14%]; P < .01). On-site ECMO complications occurred significantly more frequent in patients treated with cECMO (cECMO 44 [79%] vs pECMO 54 [54%] g/dL; P < 0.01). More often cECMO patients required a second look operation due to mediastinal bleeding (cECMO 52 [93%] vs pECMO 61 [61%] g/dL; P < .01). Thirty-day mortality was comparable with nearly 70% in both cohorts (cECMO 39 [70%] vs pECMO 69 [69%]; P = .93). Patients supported by cECMO or pECMO due to refractory PCS did not show significant differences in 30-day mortality, despite a lower incidence of on-site ECMO complications and re-exploration in pECMO patients. PCS itself is associated with high mortality and peripheral cannulation might help to save resources compared with central cannulation.

Video-assisted thoracoscopic surgery for large anterior mediastinal hematoma.

Anterior mediastinal bleeding caused by blunt chest injury is dangerous. Patients with rupture of large cardiac vessels often die of massive blood loss before getting to a hospital. The internal thoracic artery and vein, intercostal vessels or fracture ends caused bleeding that resulted in a mediastinal hematoma (1,2). Due to the nature of blunt chest injuries, the variation of anterior mediastinal hematoma cases is wide, and the specific source of bleeding is not always clear. The most commonly utilized methods of treatment are thoracotomy and hemostasis, and vascular interventional embolism (3). Video-assisted thoracoscopic surgery (VATS) is rarely reported as being used in the treatment of acute traumatic anterior mediastinal hematoma. This paper reports a case of traumatic giant anterior mediastinal hematoma treated by thoracoscopy.

Safety and Efficacy of Carbon-ion Radiotherapy Alone for Stage III Non-small Cell Lung Cancer.

We evaluated the efficacy and safety of carbon-ion radiotherapy (CIRT) alone for Stage III non-small-cell lung cancer (NSCLC). Data of 65 patients (median age=73 years) with Stage III NSCLC who underwent CIRT alone in the QST Hospital, Chiba, Japan, between 1997 and 2015 were retrospectively analysed. The median dose was 72.0 Gy (relative biological effectiveness). The median follow-up was 27.6 months (range=1.6-207.7 months). Two-year local control, progression-free survival (PFS), and overall survival (OS) rates were 73.9%, 38.6%, and 54.9%, respectively. Overall, 1 (2%), 4 (6%), and 1 (2%) patient developed Grade 4 (mediastinal haemorrhage), Grade 3 (radiation pneumonitis), and Grade 3 (bronchial fistula) toxicities, respectively. On univariate analysis, clinical T and N stage and CIRT timing were significant predictors of PFS and OS; clinical target volume was a significant predictor of PFS. CIRT alone is effective with acceptable toxicity for Stage III NSCLC.

Caproamin Fides® Versus Transamin® in High Risk Patients Undergoing CABG

Background: This randomized clinical trial was carried out so as to discover the efficacy of both ɛ-aminocaproic acid (Caproamin Fides®) and tranexamic acid (Transamin®) among high risk patients in primary coronary artery bypass grafting surgery. Methods: From December 2010 to January 2013, 100 consecutive high-risk adult patients undergoing CABG at Rajaie Cardiovascular Medical & Research Center, Tehran, Iran were included in this randomized double-blinded study. Patients who had a past history of, coagulation disorders and allergy reactions to both Caproamin Fides® and Transamin® were excluded. One group of patients received 150 mg/kg Caproamin Fides at the beginning of surgical incision and an additional 1 gr/h during operation (group 1). The second group were administered transamin with a primary dose of 10 mg/kg infusion being coincident with surgical incision (group 2). Then, patients were followed by their blood transfusion volumes, mediastinal bleeding and postoperative complications. Results: One hundred patients as 79 males and 21 females with ages at the mean of 66.4 ± 7 years were enrolled in the study. The mean volumes of chest drainage in group one (416 ± 322 in 24 hours and 681 ± 374 in 48 hours) and group 2 (420 ± 303 in 24 hours and 532 ± 399 in 48 hours). The 56% of patients in Caproamin Fides group and 58% of patients in transamin group received a mean of 1.46 ± 1.06 and 1.65 ± 1.04 units of packed cell respectively. During ICU stay 66% of patients in Caproamin Fides group and 25% of patients in transamin group required additional red blood cell transfusion at the rate of 2.4 ± 1.8 and 1.5 ± 0.6 units. Only 1 patient in transamin group received a pack cell transfusion. There were no significant differences in postoperative major adverse cardiovascular and cerebrovascular events (MACCE) between two groups. Conclusions: Caproamin Fides and transamin are both safe and effective in postoperative bleeding reduction. They also reduce the need for blood transfusion in high risk patients undergoing CABGs and could be used as an acceptable alternative for aprotinin. Tranexamic acid seems to be more effective regarding the need for blood product transfusion in these patients.

Chronic Kidney Disease and Left Ventricular Assist Device Patients: A Retrospective Review

Introduction Left ventricular assist device (LVAD) implantation remains a valuable long-term option for patients with end-stage heart failure. Often these patients present with multiple comorbidities, including concomitant renal dysfunction. Patients with renal dysfunction prior to LVAD implantation are considered to be at increased risk for bleeding, right ventricular dysfunction, and mortality. Due to this increased risk, it is suggested that patients with end-stage renal disease (ESRD) should be excluded from LVAD implantation, unless they are being considered for heart and kidney transplantation. No current guidelines are provided for chronic kidney disease (CKD) stage 3-5 patients who are implanted with an LVAD. We intend to examine outcomes in these patients. Methods We retrospectively investigated all patients with CKD stage 3-5 who received a durable LVAD at our institution from January 2015 until December 2017. Those patients who underwent a second LVAD implantation or were lost to follow up were excluded from the analysis. CKD stage 3-5 was defined by eGFR Results Of the 293 patients who underwent LVAD implantation between January 2015 until December 2017, 135 were identified to have CKD stage 3-5. 82.2% of patients had CKD stage 3, 9.6% had CKD stage 4, and 8.2% had CKD stage 5. The median eGFR was 44 mL/min/1.73m3 prior to LVAD implantation and 51 mL/min/1.73m3 after implantation. 62.2% had diabetes and 76.3% had hypertension. The adverse event rates were as follows: 62.2% bleeding (including gastrointestinal bleeding, epistaxis, and mediastinal hemorrhage), 29.9% bacteremia, 22.2% hemolysis, 20% stroke, and 11.9% had home inotropes for right ventricular dysfunction. After implantation, 28.2% required renal replacement therapy (RRT). 7% of patients requiring RRT had persistent renal failure, and required hemodialysis at the time of discharge. 74% of patients were implanted as DT, and 11.9% underwent heart transplantation. The 1- year survival rate was 80.7%, with 63.7% of the cohort alive presently. Conclusions Our findings suggest that those patients with eGFR

Pill-Induced Esophagitis From Intake of Dietary Supplements

ABSTRACTCases of pill-induced esophagitis can be associated with significant acute symptoms leading to hospitalization and have resulted in mediastinal penetration and hemorrhage. Clinicians often consider the diagnosis in patients taking classically associated medications. However, because many patients take dietary supplements, it is important to consider these as a potential etiology in a patient presenting with esophageal symptoms. We present a case of pill-induced esophagitis in a 40-year-old woman after the ingestion of l-arginine, selenium, and vitamin E supplements. Literature review revealed 6 cases of l-arginine–induced esophagitis reported, and no previous cases associated with vitamin E or selenium.

Early Experience of Cardiac Surgery in the Maldives

Introduction:From stitching a heart wound to the current level of sophistication, cardiac surgery has come a long way as a discipline. Heart surgery in South Asia has advanced tremendously; both, quantitatively and qualitatively. This is a report of the first fifteen surgeries done in the Maldives where cardiac surgery has started as an organized program.&#x0D; Methods: Data on the first fifteen consecutive cardiac surgeries done in our hospital, over a period of 7 months, was analyzed. We briefly describe our usual perioperative management, and the pretext of the beginning of the cardiac surgery program.&#x0D; Results: Fifteen patients, 13 males, aged 59.9±13.8 years, with a EuroScore of 0.9±0.4%, were operated. Eleven underwent CABG; and four had a valve replacement. Nine out of 11 had TVD, including 6 who had an LMCA disease. The first surgery was an off-pump CABG. The CABG group had a total of 2-5 grafts. Pump and cross-clamp times were 239.6 (± 56.1) min and 154.2 (± 45) min respectively. Five (33.3%) had at least one non-fatal complication. Two (13.2%) required re-exploration for mediastinal bleeding. The length of hospital stay was 16.5 days (±6.9 days). The chest tubes stayed for an average of 4.8 (±0.7) days. There was no in-hospital, 30-day and 90-day mortality recorded.&#x0D; Conclusion: Cardiac surgery has begun in the Maldives. It is safe and feasible to sustain cardiac surgery program in the country, provided continued national support and international collaboration is ensured.

Early Experience of Cardiac Surgery in the Maldives

Introduction: From stitching a heart wound to the current level of sophistication, cardiac surgery has come a long way as a discipline. Heart surgery in South Asia has advanced tremendously; both, quantitatively and qualitatively. This is a report of the first fifteen surgeries done in the Maldives where cardiac surgery has started as an organized program. Methods: Data on the first fifteen consecutive cardiac surgeries done in our hospital, over a period of 7 months, was analyzed. We briefly describe our usual perioperative management, and the pretext of the beginning of the cardiac surgery program. Results: Fifteen patients, 13 males, aged 59.9±13.8 years, with a EuroScore of 0.9±0.4%, were operated. Eleven underwent CABG; and four had a valve replacement. Nine out of 11 had TVD, including 6 who had an LMCA disease. The first surgery was an off-pump CABG. The CABG group had a total of 2-5 grafts. Pump and cross-clamp times were 239.6 (± 56.1) min and 154.2 (± 45) min respectively. Five (33.3%) had at least one non-fatal complication. Two (13.2%) required re-exploration for mediastinal bleeding. The length of hospital stay was 16.5 days (±6.9 days). The chest tubes stayed for an average of 4.8 (±0.7) days. There was no in-hospital, 30-day and 90-day mortality recorded. Conclusion: Cardiac surgery has begun in the Maldives. It is safe and feasible to sustain cardiac surgery program in the country, provided continued national support and international collaboration is ensured.

Mid-term Results of First Experience in Sutureless Aortic Valve Replacement in Iran

Background: Although the TAVI technique has been widespread in Europe and America, concerns have emerged regarding the associated complications, mainly paravalvular leakage, vascular complications, stroke, post-operative pacemaker implantation due to complete AV block, optimal access sites, long-term valve durability, and economic sustainability, therefore controversy remains about the ideal treatment of high-risk operable patients. Sutureless tissue valves like Perceval S may be a good option for these high risk operable patients. We will present the clinical outcomes of first cases of Perceval S in Iranian patients. Methods: From July 2015 to August 2016, 11 patients (8 male, 3 female) with severe aortic stenosis who were candidates for aortic valve replacement were included in this study. The mean age of patients was 73 ± 8 ranged from 65 to 86 years. The most common presenting symptom was dyspnea and three of the patients had coronary artery disease in need for concomitant revascularization. Preoperative peak gradient across the aortic valve ranged from 72 to 135 mmHg (mean = 97 ± 25). All patients were followed up from 3 to 20 months with a median of 13 months. Results: Dramatic reduction of trans-aortic peak gradients was seen in all patient (mean postoperative gradient = 29 ± 8 mmHg). Small degrees of transvalvular and paravalvular leakage were seen in intraoperative echocardiographies but only one patient had small asymptomatic paravalvular leakage during midterm follow up. Two patients need for transient pace maker; however we had no case of complete heart block. Mean post-operative mediastinal bleeding was 480 ± 150 mL and no patient needed re-exploration for bleeding or tamponade management. ICU stay time was 3 ± 1.54 days, and there was no in-hospital mortality. All patients were discharged in good status and there was no mortality during follow-up period. Conclusions: Preliminary clinical results of the first experience was encouraging; however we need to continue the study with more study volume, more follow up period and more high risk or complicated patients.

Twenty-year results of surgical pulmonary thromboembolectomy in acute pulmonary embolism

Background. Acute massive pulmonary embolism is often a life-threatening condition and should be treated immediately. The aim of this study was to investigate risk factors and clinical outcomes of patients undergoing emergency pulmonary embolectomy for acute massive pulmonary embolism. Methods. We evaluated 49 patients undergoing emergency pulmonary embolectomy in our institution between 1995 and 2015, retrospectively. We reviewed preoperative conditions and risk factors, surgical complications, postoperative courses, predictors of mortality and long-term survival. Results. At the time of presentation, the median patients’ age was 58 years. Preoperatively, seven (14%) individuals had cardiac arrest and required cardiopulmonary resuscitation. At the time of surgery, other 23 (47%) patients presented with cardiogenic shock. The most common risk factor for development of pulmonary embolism was major surgery in the last 30 days (29%, n = 14). Five (10%) patients received systemic thrombolysis preoperatively. The median cardiopulmonary bypass (CPB) time was 82 minutes. The median length of stay in the intensive care unit and in hospital were 1 and 14 days, respectively. Postoperative complications included revision as a consequence of mediastinal bleeding (6%, n = 3), stroke (2%, n = 1), and acute renal failure requiring temporary dialysis (4%, n = 2). The 30-day mortality was 29% (n = 14) with four (8%) cases of death during the surgery. The one-, five- and 15-year survival rates were 65%, 63%, and 57%, respectively. Conclusion. Pulmonary embolectomy can be performed in high-risk patients with massive pulmonary embolism with acceptable clinical outcome and good long-term survival.

Clinical outcomes of carbon‐ion radiotherapy for locally advanced non‐small‐cell lung cancer

The efficacy and safety of carbon‐ion radiotherapy (CIRT) for locally advanced non‐small‐cell lung cancer (LA‐NSCLC) remain unclear. We reported the clinical outcomes of CIRT for LA‐NSCLC. Data for 141 eligible patients who received CIRT between 1995 and 2015 were retrospectively analyzed. Local control (LC), locoregional control (LRC), progression‐free survival (PFS) and overall survival (OS) were calculated using the Kaplan‐Meier method. The median age was 75.0 years. Overall, 21 (14.9%), 57 (40.4%), 43 (30.5%) and 20 (14.2%) patients had T1, T2, T3 and T4 disease, respectively. Moreover, 51 (36.2%), 45 (31.9%), 40 (28.4%) and 5 (3.5%) patients had N0, N1, N2 and N3 disease, respectively. Furthermore, 34 (24.1%), 42 (29.8%), 45 (31.9%) and 20 (14.2%) patients had stages IIA, IIB, IIIA and ΙΙΙB disease, respectively. Overall, 62 (44.0%), 60 (42.6%), 8 (5.7%) and 11 (7.8%) patients had adenocarcinoma, squamous cell carcinoma, large cell carcinoma, and others, respectively. The median dose was 72.0 Gy (relative biological effectiveness). No patient received concurrent chemotherapy. Median follow‐up periods were 29.3 (1.6‐207.7) and 40.0 (10.7‐207.7) months for all patients and survivors, respectively. Two‐year LC, PFS and OS rates were 80.3%, 40.2% and 58.7%, respectively. Overall, 1 (0.7%), 5 (3.5%) and 1 (0.7%) patient developed Grades 4 (mediastinal hemorrhage), 3 (radiation pneumonitis) and 3 (bronchial fistula) toxicities, respectively. Multivariate analysis showed adenocarcinoma and N2/3 classification as significant poor prognosticators of PFS. CIRT is an effective treatment with acceptable toxicity for LA‐NSCLC, especially for elderly patients or patients with severe comorbidities who cannot be treated with surgery or chemoradiotherapy.

Establishing Cardiac Surgery in Eastern Nepal: Early Results

Only few dedicated cardiac centres provide cardiac surgery service in Nepal. We are the only government affiliated centre outside the capital providing this service. In this study, we aim to present our early results of cardiac surgery. This retrospective study was conducted at B P Koirala Institute of Health Sciences with objective of analysing the early results of cardiac surgery in the patients operated from July 2016 to March 2017.The data were analysed for patient demographics, type of surgery and cardiac disease, mortality, hospital and intensive care unit stay, valve related complications. Total 51 major cardiac surgeries (42 on pump and nine off pump) were performed. There were 27 (53%) males and 24 (47%) females with median age of 36 years (range: 1 to 70 years).The cardiac diseases consisted of 28 rheumatic heart disease, 12 congenital heart diseases, five coronary artery disease, five chronic constrictive pericarditis and one left atrial myxoma. The mean cardiopulmonary bypass and cross clamp times were 106 ±35 and 80±26 minutes respectively. The mean intensive care unit and hospital stay was 4±2 and 8±3 days respectively. Two (4%) patients required re-exploration for mediastinal bleeding. There was no prosthetic valve thrombosis or infection.Two patients (4%) had superficial wound infections.There were four (7.8%) in hospital mortalities. Remaining 47 patients (91.8%) are in NYHA class I aftermean follow up duration of five months. Our early result of cardiac surgery is encouraging and has established the safety and feasibility of starting open heart surgery in other parts of Nepal.

Bleeding Complication Rates Are Higher in Females after Continuous-Flow Left Ventricular Assist Device Implantation

The aims of this analysis were to characterize the burden and timing of bleeding events in females versus males on left ventricular assist device (LVAD) support. A single-center retrospective review of 375 patients receiving continuous-flow LVADs was performed. Bleeding events included gastrointestinal, naso-oropharyngeal, gynecologic (GYN), intracranial hemorrhage (ICH), and mediastinal bleeding. Cox hazard ratios (HRs) [95% CI] and incident event rates for females versus males were calculated. Eighty-four females (22%) and 291 males (78%) received an LVAD. There were 189 patients with 406 bleeding events over a median 399 days of support. Two-year freedom from bleeding was 33 ± 6.2% in females and 46 ± 3.7% in males (p = 0.027). Correlates of bleeding included female sex (adjusted HR = 1.6 [1.1-2.2]) and older age (adjusted HR = 1.2 [1.1-1.3] per 10 years). There was no sex-associated difference in 30 day mediastinal bleeding (males 12%; females 16% at 30 days; overall p = 0.35), but incident event rates for overall bleeding and naso-oropharyngeal bleeding were higher in females (p < 0.05) and trends were noted in ICH (eppy: 0.06 male vs. 0.10 female, p = 0.14). Eight females (10%) experienced 12 GYN bleeding events; five required surgical intervention. In summary, females had a 60% higher hazard of bleeding than males with significant morbidity encountered from mucosa (including vaginal) bleeding. Future large device studies should be inclusive of sex-specific outcomes.

Establishing Cardiac Surgery in Eastern Nepal: Early Results

Background: Only few dedicated cardiac centres provide cardiac surgery service in Nepal. We are the only government affiliated centre outside the capital providing this service. In this study, we aim to present our early results of cardiac surgery.Methods: This retrospective study was conducted at B P Koirala Institute of Health Sciences with objective of analysing the early results of cardiac surgery in the patients operated from July 2016 to March 2017.The data were analysed for patient demographics, type of surgery and cardiac disease, mortality, hospital and intensive care unit stay, valve related complications.Results: Total 51 major cardiac surgeries (42 on pump and nine off pump) were performed. There were 27 (53%) males and 24 (47%) females with median age of 36 years (range: 1 to 70 years).The cardiac diseases consisted of 28 rheumatic heart disease, 12 congenital heart diseases, five coronary artery disease, five chronic constrictive pericarditis and one left atrial myxoma. The mean cardiopulmonary bypass and cross clamp times were 106 ±35 and 80±26 minutes respectively. The mean intensive care unit and hospital stay was 4±2 and 8±3 days respectively. Two (4%) patients required re-exploration for mediastinal bleeding. There was no prosthetic valve thrombosis or infection.Two patients (4%) had superficial wound infections.There were four (7.8%) in hospital mortalities. Remaining 47 patients (91.8%) are in NYHA class I aftermean follow up duration of five months.Conclusions: Our early result of cardiac surgery is encouraging and has established the safety and feasibility of starting open heart surgery in other parts of Nepal.Keywords: CABG; cardiac surgery; congenital heart disease; early results; RHD.

Reduced re-exploration and blood product transfusion after the introduction of the Papworth haemostasis checklist†.

Between 2% and 8% of patients return to the theatre for mediastinal bleeding following cardiac surgery. In the majority of patients, a surgical source of bleeding is identified. Both mediastinal bleeding and re-exploration are associated with increased morbidity and mortality and the use of blood products. The aim of this study was to develop a 'haemostasis checklist' with the intention of reducing mediastinal bleeding and re-exploration following cardiac surgery. The Papworth haemostasis checklist was developed with a multidisciplinary collaboration. It consists of 2 components: surgical sites and coagulation status. The checklist is completed at a 'time-out' prior to sternal wire insertion. The analysis compared the outcomes of patients undergoing cardiac surgery in the 1 year before and after implementation. A propensity analysis assessed the impact of re-exploration on outcomes. Three thousand eight hundred and eleven patients underwent cardiac surgery during the study period. Re-exploration for bleeding was associated with inferior outcomes. Following checklist implementation, there was a significant reduction in the re-exploration rate (3.47% vs 2.08%, P = 0.01) and proportion of patients bleeding >1 l in 12 h (6.1% vs 3.49%, P < 0.001). There was a significant reduction in consumption of blood products saving £102165 ($134198). The checklist implementation was associated with reduced intensive care unit length of stay and hospital length of stay, adding to the financial benefit. The haemostasis checklist represents a simple intervention which is quick and easy to use but has had a substantial impact on clinical outcomes. We have observed a significant reduction in the mediastinal blood loss, return-to-theatre rate and consumption of blood products, which is associated with a significant clinical and financial benefit.

Acute Thrombosis of Bioprosthetic Mitral Valve Secondary to Peri-Operative VA-ECMO; The Dangers of Flow Stasis in the Left Atrium

Case report Veno-Arterial (VA) ECMO has been used to help patients recover from cardiogenic shock. VA-ECMO can complicate recovery due to the increase in afterload and decreased flow through the left sided chambers. We present a case of acute bioprosthetic mitral valve (MV) thrombosis in a patient who developed peri-operative cardiogenic shock. A 63 year-old male admitted for acute systolic heart failure found to have coronary artery disease and valvular heart disease underwent MV replacement, tricuspid valve repair and three vessel coronary artery bypass grafting. He developed intraoperative mediastinal bleeding requiring fresh frozen plasma, cryoprecipitate, and factor VII. The patient was unable to be weaned off cardiopulmonary bypass secondary to right ventricular failure. The patient remained centrally cannulated for VA-ECMO and had placement of a femoral intra-aortic balloon pump. The patient was transferred to the ICU in shock and on multiple vasopressors. Due to ongoing mediastinal bleeding, initiation of systemic anticoagulation was delayed by 48 hours. The intraoperative transesophageal echocardiogram (TEE) initially demonstrated a normally functioning bioprosthetic MV. The final intraoperative TEE images following conversion to VA-ECMO showed a poorly opening bioprosthetic MV, Image 1 . A TEE on postoperative day (POD) 2 demonstrated abnormal mobility of the bioprosthetic MV leaflets, left appendage thrombus and smoke-like echogenicity in the left atrium, Image 2 . On POD 5, a TEE demonstrated mean MV gradient of 22 mmHg and worsening of MV mobility secondary to thrombus, Image 3 . Because of concern for MV thrombosis, the patient was taken to the catheterization lab for placement of LV catheter to confirm MV stenosis. A thrombolytic agent was infused via a pulmonary artery (PA) catheter in order to attempt lysis of the MV thrombus. On POD 9, the PA systolic pressures reduced from 50 mmHg to 30 mmHg and the VA-ECMO flow requirements were reduced from 5 to 3.5 Liters per minute. Despite this small improvement in hemodynamics his overall clinical status did not improve. Ultimately the family decided to withdraw care. A post-mortem examination confirmed MV stenosis secondary to thrombosis of the valve extending into the left atrial appendage. Patients in cardiogenic shock who are placed on VA-ECMO are extremely sensitive to the high afterload created by retrograde arterial flow. Our patient developed severe thrombotic MV stenosis secondary to left atrial circulatory stasis when VA-ECMO was initiated. Maintaining adequate left sided flow is crucial to reduce the risk of thrombosis.

Vacuum assisted closure therapy for poststernotomy mediastinitis: Definitive or bridge to reconstruction

BackgroundVacuum assisted closure (VAC) system is used to promote granulation tissue formation and hence, wound healing in chronic difficult wounds when all traditional treatment strategies fail. The idea behind the device was introduced in 1997 which is simply putting the wound under continuous and controlled negative suction pressure inducing arteriolar vasodilation and wound stability. Methods17 patients (with a mean age of 65.8 ± 5.3 years (range 58–79 years) who were diagnosed with poststernotomy mediastinitis after cardiac surgery received VAC system during the course of their treatment. 11patients [64.7%] underwent coronary artery bypass grafting [CABG], 3 [17.6%] mitral valve replacement [MVR], 2 [11.7%], aortic valve replacement and 1 [5.8%]) Bental operation. Total operative time ranged between 145 and 300 min with a mean of 216.7 ± 45.5 min. 7 [41.1%] patients required exploration for mediastinal bleeding. ResultsHealing by secondary intention was achieved in 7 [41.2%] patients without the need of any further surgery. In 6 [35.3%] patients, primary closure of the wound in layers could be achieved after discontinuation of the VAC therapy. In the remaining 4 [23.5%] patients, the VAC therapy was considered as a bridge to further reconstruction with pectoral muscle flap. Of the group who received pectoral muscle flap, one [5.88%] patient died. ConclusionsVAC therapy can be considered as good alternative to more aggressive surgery that might not be suitable for some patients during certain times of their treatment course.