Post CABG Research Articles

Role of ascorbic acid in reduction of the incidence of the atrial fibrillation in patients under B-blocker and undergoing coronary artery bypass graft operation in early post-operative period

BackgroundThe study was done to project the important role of the anti-inflammatory and anti –oxidant properties of Ascorbic acid (vitamin C) in reducing the incidence of atrial fibrillation (AF) in the early post-operative period after coronary artery bypass graft operation (CABG). MethodsThis prospective randomized study included 100 patients admitted to cardio-thoracic surgery department, Benha University Hospital, Benha, Egypt between 2011 and 2016. Those patients scheduled for CABG, were randomized into two groups of patients: the first; group 1: A fifty CABG patients were given β -blocker (bisoprolol 5 mg o.d.) & ascorbic acid (2 g daily in divided doses qds) for at least three days pre-operatively. The second; group 2: A fifty CABG patients were given β -blocker (bisoprolol 5 mg o.d.) for at least three days pre-operatively. Patients were followed up for AF after (CABG) for the short term of 3 weeks. ResultsThe incidence of AF after CABG in1st 48 h and after 1 month was statistically significantly lower in Group 1 than Group 2 with p value 0.022 and 0.025 respectively. Intensive care unit stay, need for inotropic support and ventilator stay were also significantly decreased in Group1 than Group 2 with p value 0.035, 0.045 and 0.048 respectively. ConclusionsThe incidence of post CABG AF, intensive care unit stay, need for inotropic support and ventilator stay were decreased by patients intake of vitamin C in combination with β -blockers pre-operatively.

Failure of Stent Delivery in Lima PCI

AbstractBack Ground: The internal mammary artery was the most effective conduit for coronary artery bypass surgery and it was associated with significantly better long term patency, survival, and reintervention rates compared to other bypass conduits. The internal mammary artery (IMA) is not immune to atherosclerosis. IMA interventions constitute low percentage out of all coronary interventions. In addition to the tortuous course, the long length of IMA than native coronaries adds procedural difficulties to IMA PCI.Aim: To analyze the acute outcomes of Percutaneous intervention procedures to the internal mammary artery and to found any association with clinical and demographic parameters to the procedural success at a single tertiary care hospital from IndiaMaterials And Methods: This study was a retrospective analysis of post CABG patient who required and undergone the IMA intervention. We collected the clinical, demographic and procedural details of the IMA intervention. We defined as failure of the procedure when the stent could not be delivered to the lesion site through IMA.Results: Total 21 patients were included in this retrospective analysis. Mean age of the study population was 56.1± 9.98 years and 18 patients were male. Twelve (57.1%) patients presented with chronic stable angina and six (28.6%) had Left ventricular dysfunction (LVD) (mild LVD in 5 and one patient had severe LVD). Mean stent diameter was 2.75±0.442 mm and the mean stent length was 17.71 ±5.63 mm. Transient slow flow occurred in 5 patients, but the end result of PCI procedure was good in them. In 4 (19.1%) patients stent could not be delivered. No LIMA dissections were observed. On binary logistic regression, there was no significant difference between successful PCI to the failed PCI with respect to age (p=0.9, z=0.16, OR=0.99, 95%CI=0.83to1.17), male sex (p=0.7, Z=0.34, OR=1.68), type of presentation (p=0.7, Z=0.38, OR=1.60, 95%CI= 0.14 to 17.7), presence of Left ventricular dysfunction (p=0.7, z=0.38, OR=1.60, 95%CI= 0.14 to 16.97) and with pre-dilatation during PCI (p=0.9, z=-0.16, OR=0.99).Conclusion: PCI to the internal mammary artery was associated with 80.95% of success. Not able to deliver the stent to the target lesion was the major problem with LIMA PCI, in addition, to slow or no flow. The success or failure of PCI were not dependent on the age, sex, type of presentation or LV dysfunction.

Mortality and Thromboembolic Events in Hypercoagulable States From ROTEM-Thromboelastometry in Patients Who Undergo Coronary Bypass Surgery

Objective: To test the hypothesis that post CABG thromboembolic events and MACCE at 1, 3, 6,and 12 months after surgery are related to the pre-surgical TEG status and investigate the prevalence of preoperative hypercoagulability in the high risk population in Thailand assessed by Rotational Thromboelastography (ROTEM). Method: This is a prospective cohort study consecutively assessing pump CABG surgery patients. Hypercoagulability was defined as any clotting time (CT) clot formation time (CFT), amplitude 10 min after CT (A10), or maximum clot firmness (MCF) in ROTEM measurement above the upper normal limit of EXTEM, INTEM and FIBTEM in the worldwide population. Results: Forty per cent of patients show a state of hypercoagulability in terms of ROTEM. The majority of hypercoagulable patients were female. ROTEM data illustrate the significant upward trends of A10, A20 and MCF above the upper limit in hypercoagulable patients with levels of 90%, 68% and 95% in EXTEM, INTEM AND FIBTEM, respectively. The mortality and MACCE event rates were slightly increased in hypercoagulable patients both at 30 days and at 1 year with statistical significance in all event rates at the 1-year follow-up. In univariate terms, ROTEM hypercoagulability is also associated with uneventful combinations in the follow-up at 1 year. Conclusion: Hypercoagulability was found in 43% of on pump CABG patients and is associated with high risk for mortality and morbidity in the 1-year follow-up.

MEAN ARTERIAL PRESSURE AND PULSE PRESSURE, INFLUENCE ON POSTOPERATIVE RENAL AND NEUROLOGICAL OUTCOMES IN ELDERLY PATIENTS UNDERGOING CORONARY REVASCULARIZATION

Objectives: To observe the impact of bothMAPand PP for the postoperative renaland neurological outcomes in patients undergoing CABG. Methodology: This prospective double blinded observational study of patientsundergoing CABG, at Cardiac Surgery department, Punjab Institute of Cardiology,Lahore Pakistan, was conducted from January 2011 to November 2011.Preoperatively urea, creatinine, ultrasound kidney, X-Ray abdomen and CarotidDoppler study was performed. Postoperatively RIFLE criteria was used for AcuteRenal Injury. Patients with neurological deficit and seizures underwent CT andEEG. Data was analyzed by using SPSS 20. P 0.05 was considered assignificant. Results: Total number of patients included were 115. Co morbid conditions foundin patients with high MAP and PP were hypertension (34.8%; p=0.612),diabetes mellitus (39.1%; p=0.305), obesity (65.2%; p= 0.001) and COPD(21.7%; p=0.001). Acute Kidney injury was in patients with pulse pressurebetween 31-40 mmHg & mean arterial pressure between 71-90 mmHg. The onlyassociation of ARI was found with hypertension (p=0.050). Stroke, RIND, TIA,coma and seizures had no association with pulse pressure <30mmHg and Meanarterial pressure of <70mmHg. Conclusion: For post CABG patients MAP and PP are good markers for theneurological deficit but not for renal disease. Key Words: Mean Arterial Pressure, Pulse Pressure, Neurological Deficit, RenalDisease, CABG

TCTAP C-144 Successful Delivery a Covered Stent Across Saphenous Vein Graft Pseudo-aneurysm with Tortuous Anatomy Using Child Support Catheter (The GuideLiner)

### Patient initials or identifier number H.H. ### Relevant clinical history and physical exam A 70-year-old man presented on August 17, 2015 with chest discomfort. He had a history of hypertension, hypercholesterolemia and status post CABG in 2005. He had a LIMA (left internal mammary artery) to

Italian survey on CArdiac RehabilitatiOn and Secondary prevention after cardiac revascularization: ICAROS study. A survey from the italian cardiac rehabilitation network: rationale and design

In this paper, the Italian Association for Cardiac Prevention and Rehabilitation (GICR) presents the rationale and design of the "Italian survey on CArdiac RehabilitatiOn and Secondary prevention after cardiac revascularization (ICAROS)". The survey is a prospective, longitudinal, multicentric survey, with a on-line web-based data collection. Its design corresponds to the survey's goal, i.e. to describe accurately in the Italian cardiological setting, through a representative number of cardiac rehabilitation centers belonging to the GICR national network, the characteristics, content and effects in the medium term of cardiac rehabilitation (CRP) inpatient or outpatient programs offered to patients after coronary artery bypass (CABG) or percutaneous revascularization (PTCA). The primary aims of the study are: a) to define the principal clinical characteristics of patients who have undergone PTCA or CABG and have been admitted to a CRP program; b) to identify the components of the CRP programs in terms of diagnostic procedures and assessment tests performed, treatments administered, educational programs and physical exercise interventions employed; c) to identify and analyze drug treatments prescribed at discharge from the acute facility and those prescribed at the end of the CRP program; d) to verify the clinical outcome during the course of the CRP program and at 6 months and 1 year after the end of the post-acute CRP program, as well as patients' adherence to the prescribed pharmacological therapy and to the recommended life styles, and the achievement and maintenance of the targets in relation to the modifiable risk factors; e) to define the consumption of major healthcare resources (major cardiac events, hospital re-admission, emergency care access, specialist visits) during the first year following a CRP program. The survey population will consist of all patients consecutively discharged in the period November 3-30, 2008 at the end of an inpatient, day-hospital or outpatient CRP programme after CABG (isolated or associated to valve or ascending aorta surgery) or PTCA (rescue, primary or elective). There are no age, sex or other patient selection criteria. Based on ISYDE 2008 data analysis, we plan to recruit approximately 1300-1400 patients, 75% of whom with post CABG diagnosis and 25% with post PTCA diagnosis. Preliminary results of the survey are expected in the late winter 2009.

Physical therapy program improves the physiological impact towards better quality of life and low cardiac risk factors in patients following coronary artery bypass grafting. Systematic review

Introduction: Studies suggest that exercise therapy may enhance heart rate variability in myocardial infarction, chronic heart failure and revascularization patients by increasing vagal tone and decreasing sympathetic activity. This review addressed the impact of cardiac rehabilitation programs (CRPs) in post CABG patients on the quality of life, in terms of physical function and cardiac risk factors. Methods: OVID, Science direct, Embase, AMED and Cochrane controlled Trial Register were searched for studies published from 2005 up to 2015. Two reviewers assessed the eligibility of each study based on predefined inclusion criteria. Results: Of 35 abstracts reviewed, 9 studies met the inclusion criteria. All studies compared CRPs of different interventions to a control (non-intervention) group. From the selected 9 studies, 6 studies included interventions compared with control groups (usual or standard care) while 3 studies compared two different intervention strategies with groups and included a no-intervention control group. Conclusion: This systematic review concludes that all types of CRPs lead to improvements in the quality of life and reduction of cardiac risk factors in post CABG patients. However, these improvements were quite varied between the 9 studies according to variations in the components of CRPs.

IN PATIENTS UNDERGOING ON-PUMP CORONARY ARTERY GRAFTING (CABG), INCREASED ATRIAL FARNESOID X RECEPTOR SIGNALING IS ASSOCIATED WITH ATRIAL MYOCARDIAL APOPTOSIS COMPARED TO OFF-PUMP CABG

The Farnesoid X receptor (FXR) a member of the nuclear receptor superfamily of ligand-activated transcription factors that functions as an endogenous sensor for bile acids, is expressed mainly in the liver, adipose tissue and intestine. Recent evidence suggests that FXR also acts as a novel functional receptor in murine myocardium, regulating apoptosis and contributing to ischaemia/reperfusion injury. The potential expression and possible function of FXR in the diseased human heart remains largely unknown. The present study aimed to examine the levels of FXR, its ligand proliferator-activated receptor gamma coactivator 1α (PGC1α), its target small heterodimer protein (SHP) at the mRNA and protein levels and parameters of apoptosis (pro-apoptotic BAX/anti-apoptotic BCL2 mRNA ratio) in 59 patients undergoing on- pump CABG and 31 patients off-pump CABG. The on-pump group consisted of 15 women and 44 men with a mean ± S.E. age of 66.57±1.78 and 64.02±1.25 years respectively, and the off- pump patients consisted of 3 women and 28 men with a mean + S.E. age of 69.00±2.08 and 63.46± 1.66 years respectively. We analyzed FXR, SHP, BAX and BCL2 mRNA expression by quantitative Real Time PCR using 18s as an internal control for standardization in right atrial biopsies taken before aortic occlusion and after reperfusion during CABG. FXR and SHP protein was determined by Western blot. FXR mRNA (fold change) post CABG was significantly (p<0.05) higher in on- pump (3.18±0.31) vs, off-pump (1.60±0.23) [mean ± s.e.]. SHP mRNA was also significantly (p<0.05) higher on-pump (4.58±0.60) vs, off-pump (2.06±0.31) post CABG. FXR and SHP protein paralleled mRNA levels. Post CABG, PGC1α mRNA/protein was not significantly different between on vs. off pump patients. The BAX/BCL2 ratio a measure of apoptosis, was significantly (p<0.05) increased in on-pump (3.50±0.44) vs, off-pump patients (1.44±0.24) post CABG. Of all the possible correlations tested, there was a positive correlation between FXR and BAX/BCL2 ratio (p=0.015, r=0.685) in on-pump patients post CABG. These results suggest that FXR and its target protein SHP are expressed in atrial tissue and are differentially regulated depending on on-pump vs. off-pump CABG. Increased FXR and apoptotic signaling in on-pump CABG vs off-pump CABG and the demonstration of a positive correlation between FXR and the BAX/BCL2 ratio with on-pump CABG, suggests a potential benefit of off-pump CABG. The Farnesoid X receptor (FXR) a member of the nuclear receptor superfamily of ligand-activated transcription factors that functions as an endogenous sensor for bile acids, is expressed mainly in the liver, adipose tissue and intestine. Recent evidence suggests that FXR also acts as a novel functional receptor in murine myocardium, regulating apoptosis and contributing to ischaemia/reperfusion injury. The potential expression and possible function of FXR in the diseased human heart remains largely unknown. The present study aimed to examine the levels of FXR, its ligand proliferator-activated receptor gamma coactivator 1α (PGC1α), its target small heterodimer protein (SHP) at the mRNA and protein levels and parameters of apoptosis (pro-apoptotic BAX/anti-apoptotic BCL2 mRNA ratio) in 59 patients undergoing on- pump CABG and 31 patients off-pump CABG. The on-pump group consisted of 15 women and 44 men with a mean ± S.E. age of 66.57±1.78 and 64.02±1.25 years respectively, and the off- pump patients consisted of 3 women and 28 men with a mean + S.E. age of 69.00±2.08 and 63.46± 1.66 years respectively. We analyzed FXR, SHP, BAX and BCL2 mRNA expression by quantitative Real Time PCR using 18s as an internal control for standardization in right atrial biopsies taken before aortic occlusion and after reperfusion during CABG. FXR and SHP protein was determined by Western blot. FXR mRNA (fold change) post CABG was significantly (p<0.05) higher in on- pump (3.18±0.31) vs, off-pump (1.60±0.23) [mean ± s.e.]. SHP mRNA was also significantly (p<0.05) higher on-pump (4.58±0.60) vs, off-pump (2.06±0.31) post CABG. FXR and SHP protein paralleled mRNA levels. Post CABG, PGC1α mRNA/protein was not significantly different between on vs. off pump patients. The BAX/BCL2 ratio a measure of apoptosis, was significantly (p<0.05) increased in on-pump (3.50±0.44) vs, off-pump patients (1.44±0.24) post CABG. Of all the possible correlations tested, there was a positive correlation between FXR and BAX/BCL2 ratio (p=0.015, r=0.685) in on-pump patients post CABG. These results suggest that FXR and its target protein SHP are expressed in atrial tissue and are differentially regulated depending on on-pump vs. off-pump CABG. Increased FXR and apoptotic signaling in on-pump CABG vs off-pump CABG and the demonstration of a positive correlation between FXR and the BAX/BCL2 ratio with on-pump CABG, suggests a potential benefit of off-pump CABG.

Bilateral Saphenous Vein Graft Aneurysms

SESSION TITLE: Procedures Case Report Posters SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: More than 50 years have passed since CABG was first successfully performed in humans. Despite many improvements in surgical technique, complications of CABG continue to occur. Here, we present a rare case of bilateral saphenous vein graft aneurysm as a late complication of CABG. CASE PRESENTATION: 77 yo man with CAD status post CABG 12 years ago, presented for evaluation of chest pain and dyspnea. On examination, his vitals were stable and his exam was unremarkable. Basic labs, including cardiac enzymes, were unrevealing. A chest x-ray demonstrated fullness in the right hilum worrisome for a mass (1). CT of the chest with contrast confirmed two large anterior mediastinal masses as well as mediastinal lymphadenopathy. Percutaneous CT guided biopsy showed only blood and was complicated by a hemothorax. Further work up with bronchoscopy and biopsy was non diagnostic. Coronary CT angiography revealed aneurysms of two coronary bypass vein grafts (2). The right graft was patent to the RCA, but the left was occluded. Patient was offered surgical treatment, but he declined, opting for conservative management. He is doing well 1 year after initial diagnosis. DISCUSSION: Saphenous Vein Graft Aneurysm (SVGA) is a rare complication of CABG. The overall incidence is likely less than 0.5% of grafts. Proposed etiologies include exposure to arterial pressures, atherosclerotic changes, infection, and technical factors during harvest and transplant. Typical presentation is with chest pain, dyspnea, and MI, but a large number of patients are asymptomatic. Multiple studies have documented aneurysmal enlargement, however the rate of growth is variable. Large aneurysms have higher rates of mechanical complications, but increasing size has not been demonstrated to increase the risk of rupture or death. Treatment data is limited, with some case series advocating conservative management 1, and others suggesting surgical treatment 2. Recently, increasing percutaneous options are becoming available. CONCLUSIONS: Anterior mediastinal mass with a history of CABG should raise suspicion for SVGA. More data is needed to determine optimal treatment. Reference #1: Dieter, R. S., et al. (2003). “Conservative vs. invasive treatment of aortocoronary saphenous vein graft aneurysms: Treatment algorithm based upon a large series.” Cardiovasc Surg 11(6): 507-513. Reference #2: Sareyyupoglu, B., et al. (2009). “Surgical treatment of saphenous vein graft aneurysms after coronary artery revascularization.” Ann Thorac Surg 88(6): 1801-1805. DISCLOSURE: The following authors have nothing to disclose: Michael Tatusov No Product/Research Disclosure Information

2. Role of ascorbic acid & statin in reduction of the incidence of the atrial fibrillation in patients under B-blocker and undergoing coronary artery bypass graft operation in early post-operative period

Atrial fibrillation (AF) is the most common sustained arrhythmia that is associated with significant morbidity and mortality. Current available therapies remain inadequate in symptom control and secondary prevention and are often associated with significant side effects. The mechanisms underlying the pathogenesis of AF are poorly understood, although electrophysiological remodeling has been described as an important initiating step. Recently, increasing evidence implicates oxidative stress and inflammation in the pathogenesis of AF. We searched the literature for evidence to support the use of antioxidant vitamins C and anti-inflammatory statin combined with B-blocker in the prevention of AF post CABG. Antioxidant vitamin C, through its reactive-oxygen-species- (ROS-) scavenging effect, have shown a role in AF prevention post CABG. A prospective controlled randomized study will include(three hundred patients aged from 40 to 65 years of both sexes. They will be divided into three groups of patients: A hundred (CABG) patients commenced on only B-blocker for at least one week pre-operatively. A hundred (CABG) patients commenced on B-blocker & ascorbic acid for at least one week pre-operatively. A hundred (CABG) patients commenced on B-blocker & statin for at least one week pre-operatively. 24 patients out of 100 patients developed atrial fibrillation in 1st group, compared with 6 patients out of 100 patients in 2nd group, and 7 patients out of 100 patients in 3rd group developed atrial fibrillation. Combination of B-blocker with ascorbic acid & statin is better than B-blocker alone in reduction of atrial fibrillation after CABG in early post operative period.

Effect of Respiratory Muscle Stretch Gymnastics on Pain, Chest Expansion, Pulmonary Functions and Functional Capacity in Phase 1 Post-Operative CABG Patients

Background: Post operative complications after CABG are a major source of morbidity & mortality& increases hospital stay. Pain level which is experienced with an activity after CABG reduces the functional capacity & QOL. In this study we aimed to effectively reduce post CABG pain and improve respiratory functions in phase 1 post CABG patients with the help of Respiratory Muscle Stretch Gymnastics (RMSG) technique. Objective: To study the efficacy of combine Phase 1 cardiac rehabilitation & RMSG11 in post CABG patients with pain & impaired pulmonary function in phase 1 post operative CABG patients. Methods: In a pre test post test experimental study the subjects were randomly assigned to two groups Group A (n=15) performed conventional cardiac rehabilitation and RMSG 3 times/day from 3 rd POD to 7 th POD of phase 1 cardiac rehabilitation. Group B (n=15) performed only conventional cardiac rehabilitation for same frequency and number of days as above. Following outcome measures PCP, chest expansion, FEV1 and FEV6 were measured by numerical pain rating scale (NPRS), measuring tape and portable spirometer, respectively on 3 rd POD and at 7 th POD. Results: There were significant difference of pain intensity occurs in between group (p=0.001). The other respiratory parameters like chest expansion and pulmonary function test did not show any significant change with RMSG. (P> 0.05) Comparison of mean six minute walk distance at the time of discharge was higher in group A (299 ± 16.48 meter) than group B (292.04 ± 13.17 meter), but it was not significant (p =0.185). Conclusion: The study result shows that inclusion of RMSG in phase 1 cardiac rehabilitation can significantly reduces the post CABG pain and muscle ache around the scapula, and may improves exercise participation of patients as pain reduces.

TCTAP C-018 Have a Guess for the Infarction Related Artery

### Patient initials or identifier number KJS ### Relevant clinical history and physical exam This 63 year-old man is a patient with CAD, left main and two vessel disease, status post CABG in 2001, DM, CKD, stage III, HTN, and dyslipidemia. He is a heavy smoker. He receives regular follow up in

Outcome of Percoutaneous Coronary Intervention in Patients With Prior Coronary Artery Bypass Surgery

in such patients. Patients and Methods: In this study, 111 symptomatic patients with pervious history of single coronary artery bypass graft (without concomitant vale surgery) underwent PCI by a single operator between March 2008 and March 2012. Then, they were followed during the following year after PCI and the incidence of death redo CABG, persistent cardiac symptom and rate of hospitalization were recorded Results: The successful rate of PCI in this study was estimated to be 94.5% (104 of 111). In hospital MACE was 9.6% (three deaths and one myocardial infarction). 67% (73) of patients were male and 33% (33) were female. 79.6% (86) of PCI procedures were done on native coronary arteries and 20.4% (22) on SVG grafts. During one year follow up, we had 7 death in patients with PCI on native vessels (group A) and 1 death in the patients whose PCI was performed on SVG grafts (group B), (P ≥ 0.999). In group A, 27.9% (24) patients were remained symptomatic; while in group B, 18.4% (4) patients were still symptomatic (P = 0.353). Hospitalization because of cardiac syndrome was recorded for 10.5% (9) patients in group A and 9.1% (2) patients of group B (P > 0.955). None of the patients of group B went under redo-CABG during the follow up but 2.3% (2) patients of group A did (P > 0.289). No case of stent restenosis or target vessel revascularization was recorded in either group. The overall rate of death was 7.6% (8 0f 104), persistent cardiac symptoms 27% (28 0f 104), hospitalization for cardiac symptoms 10.5% (11 f 14) and redo CABG 2% (2 of 104). Conclusions: This study shows that PCI in symptomatic post CABG patients follows by high successful and low complication rate and positive impression on their cardiac symptoms and could reduce the need for redo CABG. It seems that there is no difference that PCI is performing on SVG or native vessel, the intervention itself improves the patients’ quality of life.

Effect of Supervised Moderate Intensity Exercise Program in Phase one Cardiac Rehabilitation of Post Operative Cabg Patients - A Randomized Controlled Trail

Background: With the increasing number of cases for CABG, the cardiac rehabilitation has gained importance. The trends in rehabilitation of a coronary artery disease patient are changing by incorporating a variety of aerobic exercises and resisted training in to their rehabilitation program. The outcome of any exercise chiefly depends on the training parameters like intensity, frequency and duration. Hence the present study focused to know the effects of supervised moderate intensity exercises on patients during hospital discharge following CABG. The objective of is to study the effectiveness of supervised moderate intensity exercise on distance walked and Quality of Life at hospital discharge following CABG.Methods: Study recruited randomly 46 patients between age group 40-65 years who were posted for non-emergency CABG for the first time. Pre-operative assessment was done thoroughly and was divided in to two groups, Group A conventional treatment and Group B Moderate intensity exercise group. The patients were treated using different protocols in terms of intensity for 8-10 days immediate post CABG. Then the outcome parameters of 6MWT and sf-36 were compared for analysis.Results: Both groups individually showed extremely significant results for two outcome measures. 6 MWD difference between two treatment groups showed significant results with unpaired t test (t = 8.5720,p<0.001). Quality of life score difference within group showed very significant results but there is no difference found between both groups.Conclusion: Moderate intensity exercises can also be included in the immediate post-operative phase of CABG, as they reduce the length of hospital stay and quicken the cardiac rehabilitation process. But there need to be a lot of randomized control trails to confirm the benefits of moderate intensity exercises in phase one rehabilitation program after CABG.

Vascular Ectasias: A Rare Cause of GI Hemorrhage in the Patient With Cirrhosis and Cardiovascular Disease

Introduction: Gastric antral vascular ectasia, or GAVE, is an extremely uncommon cause of recurrent intestinal blood loss. Up to 30% of patients suffering from this type abnormal gastric vasculature also have concurrent cirrhosis. In this case, we describe a patient with past medical history of multiple hospitalizations for anemia secondary to significant GI bleeds, with findings of cryptogenic cirrhosis, severe gastric antral vascular ectasia, splenorenal varices, multiple AVMs of the small bowel, and cavernous hemangiomas. Methods: Our case discusses a 74-year-old female with significant cardiovascular disease (coronary artery disease status post CABG, systolic cardiomyopathy, diabetes, hypertension) and chronic anemia with recurrent GI bleeding, who was admitted to our facility with the chief complaint of increasing lethargy. The patient had been hospitalized on multiple occasions in the past for symptomatic anemia and had required numerous blood transfusions secondary to substantial gastrointestinal blood loss. During this admission, the patient’s hemoglobin was as low as 5.3, with multiple potential sources for a GI bleed. A capsule endoscopy performed 1.5 years prior to this admission revealed evidence of vascular ectasias in the small bowel. A gastroscopy performed 7 months prior and repeated 3 months afterward demonstrated multiple, hemorrhagic, gastric antral vascular ectasias. Colonoscopy performed 2 months prior to admission demonstrated multiple colonic polyps in the cecum and sigmoid colon with pathology revealing a cavernous hemangioma. Results: Upon further investigation of the etiology of her abnormal vasculature, she was found to have evidence of cirrhosis, splenorenal varices, and ascites on CT imaging. Interestingly, however, portal venogram demonstrated no evidence of portal hypertension, and venous duplex confirmed patent portal and splenic veins, ruling out thrombosis. After an exhaustive work-up to determine the source of bleeding, the patient underwent a spiral enteroscopy, which demonstrated actively pumping angio-ectasia within the ileum. She eventually developed a perforated viscus, which required exploratory laparotomy with small bowel resection. Conclusion: This case illustrates the significant GI bleeding caused by a rare case of vascular ectasias in the small bowel. The case also discusses our experience using argon plasma coagulation, electrocautery, and laparoscopic surgery that served as therapeutic options. The pathogenicity of vascular ectasias still remains unclear, and is associated with multiple conditions including cirrhosis, portal hypertension, and cardiovascular disease; however, no direct relationship or etiology has been identified.

Role of Ascorbic Acid and Statin in Reduction of the Incidence of the Atrial Fibrillation in Patients under B - Blocker and Undergoing Coronary Artery Bypass Graft Operation in Early Post - Operative Period

1. Hybrid approach to repair type A aortic dissection: Combined endovascular superior mesenteric artery stenting and Bental procedure Hamoud Yahya Obied, Ayman Ghoneim, Mohamed F. Ibrahim A Stanford Type A aortic dissection is a lifethreatening surgical emergency that requires emergent surgery. The mortality after repair is high especially if the aortic dissection is complicated by visceral or peripheral malperfusion. We describe a case of a male patient who presented with an aortic dissection involving the ascending aorta, aortic arch, descending thoracic and the abdominal aorta up to the iliac bifurcation. The dissection also involved the visceral and renal arteries with evidence of superior mesenteric artery (SMA) occlusion. Successful outcome was achieved by endovascular stenting of his SMA, followed by Bental procedure. To the best of our knowledge this is the first case report in English literature of SMA stenting followed by Bental procedure to treat acute type A aortic dissection complicated by SMA occlusion. http://dx.doi:10.1016/j.jsha.2015.05.182 2. Role of ascorbic acid & statin in reduction of the incidence of the atrial fibrillation in patients under B-blocker and undergoing coronary artery bypass graft operation in early post-operative period Hazem Bakr, Tarek Elsayegh, Mohamed Abd El Fatah Background: Atrial fibrillation (AF) is the most common sustained arrhythmia that is associated with significant morbidity and mortality. Current available therapies remain inadequate in symptom control and secondary prevention and are often associated with significant side effects. The mechanisms underlying the pathogenesis of AF are poorly understood, although electrophysiological remodeling has been described as an important initiating step. Recently, increasing evidence implicates oxidative stress and inflammation in the pathogenesis of AF. We searched the literature for evidence to support the use of antioxidant vitamins C and anti-inflammatory statin combined with B-blocker in the prevention of AF post CABG. Antioxidant vitamin C, through its reactive-oxygen-species(ROS-) scavenging effect, have shown a role in AF prevention post CABG. Methods: A prospective controlled randomized study will include(three hundred patients aged from 40 to 65 years of both sexes. They will be divided into three groups of patients: Group I: A hundred (CABG) patients commenced on only B-blocker for at least one week preoperatively. Group II: A hundred (CABG) patients commenced on B-blocker & ascorbic acid for at least one week pre-operatively. Group III: A hundred (CABG) patients commenced on B-blocker & statin for at least one week preoperatively. Results: 24 patients out of 100 patients developed atrial fibrillation in 1st group, compared with 6 patients out P.O. Box 2925 Riyadh – 11461KSA Tel: +966 1 2520088 ext 40151

Leukemoid like reaction in a post CABG patient.

The presentation of leukemoid reaction in patients post-cardiac surgery is rare with limited prior reports in the English language literature. We report a case of raised leukocyte count with no evidence of infection in a patient post coronary artery bypass graft surgery. The exaggerated inflammatory response by the patient to extra-corporeal circulation was drastically elevated, but fell short of the leukaemoid reaction definition – so we have defined it as a leukaemoid like reaction. A clear correlation between the extra-corporeal circulation and inflammatory response is documented.

Effect of Body Position on Peak Expiratory Flow Rate in Individuals Post Coronary Artery Bypass Graft Surgery

Objective : This study aims to compare the influence of body position on peak expiratory flow rate which has been used as a measure of huffing. Body position influences the rib cage mechanics and thereby influencing the strength of huff. The four positions used in this study were standing, chair sitting, long sitting and three quarter sitting the study. 43 male subjects who underwent elective CABG, aged 40yrs- 80yrs were taken. The subjects were positioned in random order in the 4 test positions and PEFR values were recorded in the four positions. The difference in PEFR values between the test positions were significant except between chair-sitting and long-sitting (P < 0.735). Standing position led to the highest PEFR value and three quarter sitting led to the lowest PEFR value. This implies that standing is a more appropriate starting position which can be used to clear the airways by huffing post CABG

Giant abdominal aortic aneurysm treatment with open surgery in a risky patient post CABG with stenotic coronaries

A 70 year-old syrian refugee male was admitted with history of a heavy smoking, post operative CABG operation of which 2 years ago with an open RCA graft but LAD %100 proximally plaque stenosis, %90 CX and multiple branch occlusions without angina with normal ejection fraction and normal valve functions. At the angiography no other grafts were observed and no epicrisis was obtained. He could not take any food because of vomiting and lose of weight day by day recently and with complaints of exceeding abdominal discomfort, increasing back pain and physical mobility discomfort in recent months duration. Physical examination revealed a giant, prominently visible, expansile, pulsatile, well-defined, nontender abdominal mass in the whole abdominal area. Computed Tomographic (CT) and angiography revealed a large infrarenal aortic giant aneurysm with a maximum transverse diameter of 13.6 cm without iliac extensions. Anatomy of the aneurysm did not permit Endo-Vascular Aneurysm Repair (EVAR). The patient underwent open surgical inclusion repair using an, aorto-bi-femoral 16 mm × 8 mm collagen-impregnated bifurcated Dacron graft. Postoperative recovery was uncomplicated and he discharged at the 10 th day from the hospital with no complaints and with good health. Histopathologic study is non significant.

Health Related Quality of Life Among Coronary Artery Bypass Graft Patient Attended at Combined Military Hospital, Dhaka

This descriptive type of cross sectional study was carried out among purposively selected 90 coronary artery bypass graft operated patients attended at cardiovascular surgery out patient department of combined military hospital, Dhaka from 01 March 2012 to 30 June 2012 with the objective to assess the quality of life by using the RAND Medical Outcomes Short Form 36 (SF- 36) questionnaire. The population studied had a mean age of 54.60 years with 92.2% were male and 7.8% were female. Most of the respondents were retired (43.3%) followed by service personnel (38.9%). Regarding educational qualification, most of them were between class VIII to SSC and 95.6% were Muslim. The mean monthly income of the respondents was Tk. 18127.78. The findings showed that post CABG respondents possessed a good level of QOL with an average score of 86.0921. The mental components score (87.8571) was found to be higher than physical component score (84.9153). It was found that the association between age and physical functioning domain of physical component was statistically significant (r= -.189*, p&lt;0.05) and association between all other domains (role physical, bodily pain, general health, vitality, social functioning, role emotional and mental health) were statistically not significant. The study also revealed a negative correlation of total quality of life with age but positive correlation with other socio demographic characteristics (level of income, education and occupation) though all of the relations were statistically not significant. No statistically significant difference revealed with the different domains of quality of life and socio demographic characteristics. In regards to the monthly income, highest score noted in Tk. 10000-30000 income groups in all the domains. Respondents' occupation showed significant difference with the general health domain (F= 3.456, p &lt;0.05) and physical component summary (F= 2.969, p &lt;0.05) of the SF- 36 items. The education level showed significant difference with the physical functioning of physical component domain (F= 2.675, p &lt;0.05). The findings showed that the highest score was for HSC education in both the components of quality of life. The post CABG respondents possessed a good level of QOL with good mental components score than physical component score. It is also revealed from the study that with increasing age the physical functioning of the patient decreases. From the study it depicts that higher education, better occupation and good monthly income of the respondents have better quality of life out come than that of others. Study on larger sample size may be carried out for more accurate results on quality of life after CABG operation. Anwer Khan Modern Medical College Journal Vol. 4, No. 2: July 2013, Pages 10-17 DOI: http://dx.doi.org/10.3329/akmmcj.v4i2.16918