Innovations in cardiovascular care: historical perspective, contemporary practice, recent trends and future directions

Abstract Cardiovascular diseases continue to be a major cause of mortality and morbidity in the world population. First open heart procedure was performed by Gibbon in 1953, since then many advancements have been introduced to the field of cardiac surgery. Minimally invasive techniques were introduced, which include minimally invasive coronary artery bypass grafting (CABG), off-pump technique, minimally invasive valve surgery or transcatheter techniques to implant stentless or sutureless valves. The hybrid strategy to address coronary disease combines catheterisation procedures with standard surgical techniques. Cardiac imaging has also progressed to provide three-dimensional images of the heart, enabling surgeons to plan procedures with greater accuracy. Left ventricular assist devices can be used in patients suffering from cardiogenic shock or awaiting heart transplantation. Total artificial heart can be used for biventricular mechanical support. As technology becomes increasingly used for patient management, the future surgeon needs to be trained in minimally invasive surgical techniques

Coronary artery bypass surgery in Guillain Barre syndrome

Guillain Barre Syndrome (GBS) is a rare autoimmune inflammatory polyneuropathy with established acute phase morbidity and mortality. Despite the positive outcome in majority of cases, there is hesitance in subjecting these patients to major surgical interventions under general anaesthesia. This case documents the successful undertaking of major coronary artery grafting under cardiopulmonary bypass and general anaesthesia, in a GBS patient. A review of the pathology is presented and the controversy addressed

Mechanical complications following acute myocardial infarction

Objective: To outline the outcome and management of patients with acute myocardial infarction presenting with mechanical complications such as post-infarction ventricular septal defect, mitral regurgitation and left ventricular rupture.Methods: The retrospective study, conducted in September and October, 2010 at the Aga Khan University Hospital, Karachi, included cases from January 1990 to December 2009. Only 18 cases were found who had presented with such complications. They were assessed for demographics as well as pre-operative, per-operative and post-operative management patterns. Data was analysed using SPSS version 17.0.Results: Out of the 18 patients, 10 had post-infarction ventricular septal defect, while 8 had mitral regurgitation defects. The mean time from myocardial infarction to the diagnosis of mechanical complications was 5.28 +/- 4.07 days, and from diagnosis to repair was 2.00 +/- 1.49 days. Overall, there were 3 in-hospital mortalities.CONCLUSION: The optimal timing of surgical intervention has always remained debatable. A high-level of clinical suspicion and earlier intervention can reduce morbidities and mortalities

Pulmonary embolism in pemphigus vulgaris, the need for judicious immunotherapy

Pemphigus vulgaris is a serious chronic mucocutaneous ailment. In recent decades advances in diagnostic and therapeutic measures have led to a significant decline in morbidity and mortality. However, with the advent of active and prolonged immunotherapy involving corticosteroids, there has been a rise in steroid-associated complications. This has led to significant concern globally over the sensible use of treatment regimen in pemphigus patients. We present a patient who underwent a massive pulmonary embolism following over usage of corticosteroid therapy for pemphigus vulgaris. Whilst the patient survived owing to timely assessment and aggressive surgical intervention, the need for cautious and judicious immunotherapy in pemphigus is emphasized

Life threatening mediastinal haematoma: a complication of central venous catheterization

Central venous catheterization (CVC) has established risks and benefits in its application as a vascular access source, particularly in situations involving temporary cannulation. We present a rare case of life-threatening mediastinal haematoma resulting from CVC usage. Even though aggressive intervention yielded survival, the patient was left with permanent vocal compromise owing to traumatic palsy of the right recurrent laryngeal nerve. One should be careful in selection of venous access and be aware of alternatives routes

A case of transient diabetes insipidus following cardiopulmonary bypass

Cardiopulmonary bypass surgery has been linked with a number of postoperative complications. One of the frequently reported physiological alterations is the relative diuresis seen in the immediate post-op period. Rarely reported though is the development of full-blown diabetes insipidus in such patients. The etiology is unknown and has only been hypothesized in the past. We present the clinical course of a 54 year old male who developed transient diabetes insipidus post bypass surgery with subsequent recovery following exogenous vasopressin administration. The physiological alteration leading to the development of diabetes insipidus in a small fraction of bypass patients remains unknown. We propose that the variation in natriuretic peptide levels in the post-bypass period could account for the transient event

Transfusion related acute lung injury--TRALI: an under diagnosed entity

Transfusion related acute lung injury (TRALI) is a life-threatening complication of transfusion of blood and its components resembling acute respiratory distress syndrome (ARDS) or acute lung injury (ALI). TRALI is a particular form of ARDS that follows blood transfusion and is caused by donor-derived antibodies present in the transfused products, reacting with the recipients\u27 blood cells, inducing release of inflammatory mediators thus compromising lung functions. Anti-HLA antibodies are the most frequently indicted inducers in this category. Literature search has not revealed any documented case of TRALI from Pakistan. This in no way implies that TRALI is non existent in this part of the world but rather indicates that many clinicians may be unaware of the condition or may not recognize transfusion as the cause and like in other parts of the world, is almost certainly under-diagnosed. The lack of agreement on the definite cellular and molecular mechanisms underlying the development of TRALI renders the task of improving the safety of blood transfusion far more complex and potentially quite expensive. This review discusses the modern concepts of pathogenesis of TRALI along with its clinicopathological manifestations and management with the aim to improve awareness of our clinicians towards this dreadful and potentially fatal condition

Bringing efficiency into practice: a quality improvement initiative to reduce operating room turnaround time

Abstract Operating room (OR) turnaround time (TAT) is the minimal essential time required for cleaning of OR and preparation for the next case. The TAT inversely affects OR efficiency. Several factors related to personnel, equipment and scheduling have been identified as causes of increased TAT. We conducted the study to identify factors that affect OR TAT and to propose recommendations for its reduction. The retrospective study, conducted at Aga Khan University Hospital, Karachi, comprised TAT records related to March 2014. Of the 88 cases, 22(25%) showed a delay. Upon Pareto analysis it was found that in 8(36.6%) cases there was a delay of 70% related to scheduling of OR list and 5(22.7%) related to movement of patients from wards to OR. As such, improvement in these two broad areas can take care of majority of delays. We also recommend documentation of all processes as part of continuous improvement

Variability in lipid profile before and after coronary artery bypass grafting (CABG)

Objective: To investigate changes in total cholesterol, low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, and triglycerides in serum of Pakistani patients before, immediately after and 5 days post CABG.Method: Serum samples from 31 consecutive Pakistani angina patients undergoing CABG at the Aga Khan University Hospital were analyzed for total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides using kit methods.Results: Immediately after CABG, there is a significant decline in the mean levels of serum cholesterol, LDL cholesterol, HDL cholesterol and triglycerides. However, 5 days post CABG, there is a significant increase in the concentrations of total cholesterol (P = 0.01) and LDL cholesterol (P = 0.001) in nondiabetic angina patients (n = 13). Among the diabetic group of patients (n = 18), the levels of total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides went back to the pre-operative levels within 5 days post CABG. Compared to European patients, Pakistani patients tend to have very low levels of HDL cholesterol (24.9 +/- 7.1 mg/dl) and high levels of triglycerides (185 +/- 50 mg/dl) on day 5 post CABG.Conclusion: Since risk of mortality following CABG increases with low level of HDL cholesterol and high level of triglycerides, close monitoring and treatment of high lipid levels of Pakistani patients following CABG is necessary to prevent further coronary events

Carotid cavernous fistula in a patient with coronary artery disease

Carotid cavernous fistulas are abnormal communications between the carotid and cavernous vasculature, with potential for serious neurological and ocular sequelae. There is considerable literature on the neuro-radiological management of carotico-cavernous fistula depending upon their flow status. The coronary artery bypass grafting (CABG) for coronary artery disease (CAD) is a well established method of revascularization. However, the association of carotid cavernous fistula in presence of CAD is an infrequent occurrence. We present a case of coronary artery disease scheduled for bypass surgery, developed spontaneous bilateral carotid cavernous fistulas, highlighting a unique aspect of association between coronary and carotid disease