Keeping the mitral smile: is it durable? A comparative study of mid-term outcomes of mitral valve repair and mechanical mitral valve replacement in rheumatic heart patients

Background: Rheumatic heart disease is a significant cause of morbidity and mortality in endemic countries. Traditionally, mechanical valve replacement has been the preferred surgical approach for treating rheumatic mitral valve disease due to its favorable short-term outcomes and low incidence of postoperative complications. However, its midterm results are suboptimal due to increased risks of thrombosis and bleeding. This study compared the midterm outcomes of mitral valve surgeries, repair versus replacement, in rheumatic patients. Methods: A comparative retrospective clinical study was conducted from January 2016 to December 2018. The study included 203 patients who underwent mitral valve surgery for rheumatic heart disease. The patients were divided into two groups: Group A (n=107) had mitral valve repair, and Group B (n=96) had mitral valve replacement. Results: In Group A, the mean age was 45.5 ± 5.2 years, and 49% of the patients were male. While in Group B, the mean age was 46.2 ± 5.35 years, and 54.75% of the patients were males. The two groups had no significant difference regarding cardiac dimensions or function preoperatively. In Group A, the mean cardiopulmonary bypass time was 89 ± 9 minutes, and the mean cross-clamp time was 81 ± 7 minutes; in Group B, the mean cardiopulmonary bypass time was 77±12 min, and the mean cross-clamp time was 81 ± 7 min. The two groups had highly significant differences concerning cardiopulmonary bypass and cross-clamp times (p<0.001). Survival at 5 years was 98.5% for Group A vs. 93.15% for Group B (0.09). The reoperation rate was 9.0% in Group A vs. 4% in Group B (p= 0.261). The thromboembolism incidence was 0.47% in Group A vs. 7.3% in Group B (p= 0.03), and the bleeding-related complications were 0.94% in Group A vs. 7.3% in Group B (p= 0.03). Conclusion: The outcomes of mitral valve repair could be comparable to replacement in patients with rheumatic heart disease. Mitral valve replacement were associated with higher bleeding and thromboembolic complications compared to mitral valve repair

Early Outcomes of Thoracoscopic versus Open Extended Thymectomy in Myasthenia Gravis Patients

Background: The debate concerning the impact of surgical approaches for thymectomy on the outcomes of myasthenia gravis continues. This study aimed to present the preliminary outcomes of thoracoscopic versus transsternal thymectomy for patients with myasthenia gravis. Methods: A total of 60 patients participated in this cohort study. Twenty-seven of these patients underwent thymectomy via video-assisted thoracoscopic surgery (VATS) with one (n= 7) or two ports (n= 20) (Group I). Thirty-three patients underwent thymectomy via the transsternal approach (Group II). The study was conducted over one year, and the patients were followed for three months postoperatively. Results: The duration of the operation (88±9 vs. 131±6 min, P<0.001) and volume of blood loss (109±12 vs. 434± 54 ml; P<0.001) were significantly lower in the VATS patients. Additionally, early extubation was significantly more common in Group I than in Group II (100% vs. 48%; P <0.001). Compared with Group II patients, Group I patients had a significantly lower need for blood transfusions (0 vs. 6 (18%); P<0.001) and postoperative intensive care units (0 vs. 28 (85%); P <0.001). Compared with Group II, Group I had a lower VAS pain score after 24 h (4 (3-5) vs. 6 (6-7); P<0.001). Patient mobilization occurred significantly earlier in Group I than in Group II (5.89 ± 1.45 vs. 19.09 ± 6.38; P <0.001). No cases of video-assisted thoracoscopic surgery were converted to open surgery, and no cases of operative mortality were reported in either group. Conclusions: Compared with open thymectomy, thoracoscopic thymectomy might yield superior results. Thoracoscopic thymectomy is associated with a shorter duration of operation, less blood loss, less need for blood transfusion, less need for the ICU, a lower pain score, and an earlier timing of patient mobilization. Therefore, thoracoscopic thymectomy could be preferable to open thymectomy for the surgical treatment of myasthenia gravis

Comparative Analysis of the Pleural Vent versus the Intercostal Tube for Managing Spontaneous Pneumothorax

Background: Evidence supporting using pleural venting over traditional intercostal chest drains for managing spontaneous pneumothorax is limited. Therefore, this study aimed to compare using pleural vents and intercostal tubes in managing spontaneous pneumothorax. Methods: In this randomized clinical trial, 61 patients with spontaneous pneumothorax were randomly assigned to two groups. Group I included patients initially managed via intercostal chest tubes (n= 31), and Group II included patients with a pleural vent as the initial management (n= 30). The study outcomes were pain score; the need for nonsteroidal anti-inflammatory medications (NSAIDs) or narcotics; wound infections; pleural effusion; the duration of treatment; the need for surgery; and patient satisfaction and recurrence of pneumothorax at 1, 3, and 6 months after discharge. Results: The baseline data were comparable between the groups, with no differences in the laterality or size of the pneumothorax. The requirements for NSAIDs (77% vs. 13%, p<0.001) and narcotics (42% vs. 0%, p<0.001) were more frequent in Group I. The duration of treatment was longer in Group 1 (3.71± 0.78 vs. 3.03± 0.61 days; p<0.001). Surgery was required more frequently in Group I (61% vs. 0%, p<0.001). Recurrence after three months was more common in Group I (11 (35.48%) vs. 1 (3.33%); p= 0.003). There was no difference in posttreatment pleural effusion between the groups, whereas wound infection was more common in Group I. Conclusions: Pleural vents for managing spontaneous pneumothorax offer significant advantages over traditional intercostal chest tube placement. Patients managed with pleural vents experienced markedly lower pain levels, reduced reliance on NSAIDs and narcotics, and shorter treatment durations. Additionally, the need for surgical intervention and recurrence rates were substantially lower in the pleural vent group

Early Results of Coronary Artery Bypass Grafting Surgery with or without Coronary Endarterectomy

Background: Managing patients with diffuse coronary artery disease is challenging. The advantages of coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) compared to CABG alone are controversial. This study compared short-term outcomes, including ICU and hospital stays, arrhythmias, postoperative myocardial infarction, renal impairment, and hospital mortality, between patients who underwent CABG without and with CE. Methods: This randomized controlled study included 100 patients who underwent CABG with or without CE. Participants were randomly allocated into two equal groups. Group I (n=50) included patients who underwent CABG alone, and Group II (n=50) included patients who underwent CABG combined with CE. Results: The right coronary artery was the most common vessel affected by CE (44%), followed by the left anterior descending artery (42%). Low-output syndrome and pleural effusion were more frequently observed in Group II; however, these differences did not reach statistical significance. There was no difference in postoperative complications or ejection fraction between the groups. The ICU stay was significantly longer in Group II (3.02±0.84 vs. 2.58±0.5 days; p=0.007). Additionally, patients in Group II had significantly longer hospital stays (14.48±1.87 vs. 11.98±1.35, p<0.001). Conclusion: Compared with CABG alone, CABG with CE might not be associated with increased short-term mortality or morbidity. CABG with CE was associated with prolonged hospitalization, necessitating a careful assessment of the benefits versus an extended hospital stay when considering this adjunctive procedure

Have Water Seal Drainage Systems Come to an End?

Background: We hypothesized that underwater seal drains are not mandatory after thoracic procedure when the visceral pleura remains intact. A small size drain with low auto-suction system (e.g., Hemovac) may be sufficient if no evidence of air leak.  Methods: This is an observational study on using low auto-suction drain as a solo pleural drain after thoracic procedures in which visceral pleura remained intact at the end of surgery. After completion of the procedure on the selected Cohort of patients, 10F Hemovac drain was inserted and fixed using 4/0 silk suture. Small collection bag, 250cc, was connected.  To ensure tight wound closure around the small caliber drain, a tunneled insertion techniques using valve mechanism for at least one intercostal space was used. Finally, by the end of the procedure, Seal/Suction test should be utilized to test for the presence of air leak either from around the drain site or disintegrated visceral pleural surface. The primary outcomes were to detect the feasibility of low-suction drain after selected thoracic procedures. The secondary outcomes were to monitor the incidence of postoperative complications related to drainage system in the short term. Results: the low-suction drain was used in 125 patients ranging between 4-86 years old. The drain was removed by the end of postoperative day 1 in 76%. Only 8 patients (6.4%) required drainage longer than 48 hours. Small apical air space (< 2cm) was detected on the immediate postoperative chest X-ray in only 8 patients (6.4%). Minimal pleural fluid was seen on the follow-up x-ray at one week in the outpatient clinic in 16 patients (%12.8). None of the patients required insertion of a chest drain or thoracocentesis. No complication related to using the Hemovac drain was reported.   Conclusion: Our observations suggest that low vacuum drainage systems are a feasible alternative to water-seal drainage systems in the remarkable number of thoracic procedures. This safe and practical drainage system could pave the way towards drainless surgery which is a culminating level for thoracic surgeons

Prognostic Impact of Previous Percutaneous Coronary Intervention on the Outcome of Coronary Artery Bypass Grafting in Multivessel Disease Diabetic Patients

Background: Previous studies suggest that patients who receive percutaneous coronary intervention (PCI) are at a higher risk of undergoing coronary artery bypass grafting (CABG). This study aimed to investigate the risk of CABG in patients with a history of PCI. Methods: One hundred diabetic patients who underwent CABG from October 2020 to February 2022 were enrolled and divided into two groups. Group I consisted of 50 patients with no prior PCI, while Group II comprised 50 patients with a history of PCI. Results: The mean age was 57.4 ± 8.67 years for Group I and 59.72 ± 7.5 years for Group II (p= 0.155). The mean cardiopulmonary bypass time was 108.56 ± 34.53 minutes for Group I and 127.4 ± 35.93 minutes for Group II (p=0.009). The ischemic duration was 75.68 ± 19.94 minutes for Group I and 75.12± 23.02 minutes for Group II. The mean number of grafts was greater in Group I (3.5 (3 – 3.5) vs. 3 (2 – 4), p= 0.011). The mean ventilation time was 9 (5 – 13.75) hours for Group I and 10 (5 – 19) hours for Group II. The mean length of ICU stay was 1 (1–2) day for Group I and 2 (2–3) days for Group II (p<0.001). The length of hospital stay was 8 (7–9) days for Group I and 10 (9–11) days for Group II (p<0.001). There were statistically significant differences between the groups in terms of MACE (higher in the PCI group, p=0.046), improvement in wall motion abnormalities (higher in the non-PCI group, p=0.007), and postoperative normal ejection fraction (higher in the non-PCI group, p=0.032). There was no significant difference in hospital mortality between the two groups (0 vs 3), with a p value =0.07. Conclusion: A previous PCI could increase post-CABG morbidity and MACEs. However, no significant difference in postoperative mortality rates was found between patients who underwent prior PCI and those who did not

Custodiol versus Cold Blood Cardioloplegia in Minimally Invasive Aortic Valve Surgery: A Comparative Study

Background: Myocardial protection is a critical concern during aortic valve replacement. Custodiol cardioplegia and cold blood cardioplegia represent two primary strategies for myocardial preservation. This study sought to compare Custodiol and blood cardioplegia results for myocardial protection in aortic valve replacement. Methods: This prospective study included 200 patients who were evenly divided into two groups based on the cardioplegia solution used: the Custodiol group (Group A) and the cold blood cardioplegia group (Group B). The study evaluated postoperative mechanical ventilation duration, ICU and overall hospital stay lengths, and echocardiographic findings at three and six months postoperatively. Results: Compared with Group B, Group A had significantly shorter ventilation times (min-max: 6-9 vs. 9-15 hours), ICU stays (3-3 vs. 4-5 days), and hospital stays (7-9 vs. 10-20 days) (p<0.001 for all). Group A exhibited shorter cardiopulmonary bypass times (179 ± 9 minutes vs. 216 ± 14 minutes, p<0.001) and cross-clamp times (137 ± 8 minutes vs. 176 ± 18 minutes, p<0.001). Postoperative atrial fibrillation was more common in Group A (66% vs. 20%, p<0.001), while ventricular tachycardia and nodal rhythm post-defibrillation were greater in Group B. Mortality was lower in Group A (2% vs. 9%, p=0.03). However, at three and six months postoperatively, echocardiographic findings were significantly different in terms of left atrial diameter and left ventricular end-systolic diameter between Group A and Group B (p<0.001). Conclusion: Custodiol cardioplegia could be associated with superior postoperative outcomes, including shorter ventilation times, ICU and hospital stays, and lower mortality rates, compared to cold blood cardioplegia in minimally invasive aortic valve replacement surgery

Negative pressure wound therapy versus conventional therapy for the treatment of post-coronary artery bypass graft mediastinitis

Background: Various treatments, such as negative pressure wound therapy or traditional therapy, can be employed to manage postoperative mediastinitis. The superiority of one approach over the other is still a subject of discussion. Our purpose was to compare the results of negative pressure wound therapy and conventional therapy for treating postcoronary artery bypass graft mediastinitis. Methods: This study included 50 individuals with mediastinitis after coronary artery bypass grafting. Patients were divided into Groups A and B according to whether the wound was treated with negative pressure wound therapy (n= 25) or conventional therapy (n= 25), respectively. Results: The studied groups were comparable concerning age (P = 0.5), sex (P = 0.395), and body mass index (P = 0.556). No significant differences were detected among the studied groups concerning diabetes mellitus (P = 0.733), chronic obstructive pulmonary disease (P = 0.564), previous myocardial infarction (P = 0.370), isolated or combined surgery (P = 0.508), left main stenosis (P = 0.569), or emergency surgery (P = 0.508). Group A exhibited a significantly shorter hospital stay (26 ±4 days) than Group B (37 ±6) (P < 0.001). In contrast, no significant differences were observed among the studied groups concerning ventilation hours (P = 0.913) or ICU stay (P = 0.524). Group A demonstrated significantly lower reinfection than Group B (24% vs. 52%, respectively; P = 0.041). No significant differences were noted concerning reoperation for bleeding (P = 1.0) or mortality (P = 0.1). Group A demonstrated a significantly lower mean cost than Group B (110±23 vs. 140 ±37, respectively; P = <0.001). Conclusion: Negative pressure wound therapy for postcoronary artery bypass graft mediastinitis could be more effective than the conventional treatment methods

Penetrating chest trauma: A prospective study of prognostic factors for worse outcome after emergency surgery

Background: Even though chest penetrating injuries are common as well as challenging to treat, most of the time they can be dealt without surgery. This study aimed to evaluate contemporary outcome following emergent surgical interventions for penetrating chest trauma and possible factors associated with poor prognosis. Methods: This prospective study included 100 cases admitted to benha university hospital with either Stab Wound or Gunshot wound to the chest, with systolic blood pressure ≤90 mmHg and who underwent through Thoracotomy or sternotomy within duration of one hour of arrival. Results: This study included 81 patients (77 stabbings, 4 gunshots) underwent a thoracotomy and 19 underwent median sternotomy within 60 minutes after the penetrating trauma, the mean period of surgery was 3 ±0.9, There were 94 male and 6 female cases and their mean age was 25 ±10.14 years, the mean Intensive care unit stay was 2 ±0.83 days in addition mean hospital stay was 6 ±1.06 days, the individuals who died had trauma at mid-clavicular line of the chest (100%) compared to survivors (5.5%), lesser systolic blood pressure on presentation in the emergency room (71 ±11 mmHg) equated with those who survived (90 ±9 mmHg, P<0.001) and lower hemoglobin level (6.4 ±0.5) compared with those who survived (8.4 ±1, P<0.001). As a whole, the mortality rate was 9% (n=9). individuals' Death Rates with stab wounds was 5/96 (5.2%) compared with 4/4 (100%) for patients with gunshot wounds. Right ventricular injury (P=0.03) was associated with mortality. Conclusion: Early referral, within one hour, to emergency surgery results in acceptable postoperative mortality in patients with penetrating chest trauma. Anterior location of injury, initial hemodynamic instability, and gunshot wounds associated with poor prognosis

Timing of Intrapleural Streptokinase administration for Managing Post traumatic Clotted Hemothorax

Background: The optimal timing of intrapleural fibrinolytic therapy with streptokinase for managing posttraumatic clotted hemothorax is controversial. This study investigated the appropriate timing for fibrinolytic therapy initiation using streptokinase in post traumatic clotted hemothorax. Methods: We conducted a randomized clinical study that included 60 patients with a clotted hemothorax recruited between December 2023 to July 2024. Patients were grouped according to the timing of intrapleural streptokinase injection into two groups. Group I (n= 30) included patients who received intrapleural streptokinase between day 3 and day 7, and Group II (n= 30) included patients who received streptokinase 7 days after the diagnosis of clotted hemothorax. Results: There were no significant differences in age, sex, the prevalence of diabetes mellitus, hypertension, addiction, or smoking between the groups. The most common mode of trauma was stabbing wounds, with no difference in trauma mode or laterality between the groups. The number of streptokinase doses was significantly lower in patients who had streptokinase early (p<0.001), and their total drainage after administration was significantly greater than that in those who had streptokinase late (275 (200–400) vs. 100 (100–150) ml, p<0.001). The infection rate was higher in patients with late streptokinase administration (1 (3.33%) vs. 8 (26.67%), p= 0.026). No bleeding was reported in either group. The length of hospital stay was significantly longer in patients with late streptokinase administration (8 (7--9) vs. 19 (17--20), p<0.001). The success rate was 90% in the early group and 53% in the late group (p= 0.004). One patient in the early group and 23 (77%) in the late group required further surgical evacuation (p<0.001). Conclusion: Early intrapleural administration of streptokinase (within 3–7 days of clotted hemothorax) appears to be more effective than late administration (after 7 days) for managing posttraumatic clotted hemothorax