Are percutaneous coronary interventions changing our coronary surgery practice?

Aim: The aim of this retrospective study was to assess the impact of a growing percutaneous coronary intervention (PCI) program on our coronary artery bypass graft (CABG) practice. Method: The data were collected from 300 consecutive surgical patients from January 2000 (early series) and from a similar number from July 2008 (recent series). Results: Our recent series presented an increased risk (mean Parsonnet scores rose from 5.5 to 7.3, mean euroSCORE rose from 2.4 to 3.1). The mean age increased from 60.3 to 63.8 years, with the percentage of patients over 70 rising from 14.3 to 29.1%. The proportion of females increased from 15.1 to 18.6%. Mean number of vessels grafted diminished from 3.24 to 3.02 per case. Fewer coronary arteries over 3mm diameter were grafted and more advanced atheroma was encountered at the site of grafting in the recent series. Conclusion: The rise in PCI was associated with a smaller surgical population presenting an increased risk and challenge to the cardiac surgical team.peer-reviewe

Coronary artery fistulae : 4 cases repaired surgically

Coronary artery fistulae involve a communication between a coronary artery and a heart chamber or part of the pulmonary circulation. Most are asymptomatic and discovered incidentally, whilst larger ones may cause coronary steal syndrome. Fistulae may produce continuous murmurs and are diagnosed at echocardiography or angiography. Treatment is by percutaneous coil embolisation or open surgery. This article reviews four cases treated with surgical closure. All patients were asymptomatic and diagnosed incidentally at angiography. One case involved a failed attempt at percutaneous coil embolization requiring immediate open surgery. The other three cases required other operative procedures and the fistulae were oversutured during the same procedure.peer-reviewe

Chest wall reconstruction following a speedboat propeller injury

Propeller blade injuries to the chest are uncommon but can result in devastating injuries. We describe a case of a 44 year-old male scuba diver who was dragged by sea currents into the propeller of a speedboat. He suffered extensive chest wall trauma but narrowly escaped damage to major organs and vessels. He was admitted directly to the operating theatre. There was significant loss of bone from the manubrium, costal cartilages, overlying skin and muscle which were stripped off in 3 horizontal bands. During reconstruction the bony fragments were anchored to the nearest stable sternal or costal cartilage entities using steel wires, to achieve stability. The overlying muscle and skin were sutured directly to its opposite edge in layers and in an interdigitating fashion following the shape of the propeller blade lacerations. The patient remained intubated for 3 days in ITU and was transported back to his home country. He required a small skin graft to one area of necrosis but eventually made a full recovery with only his scars as a reminder of his accident. There have been other cases of propeller injuries in Malta but this is unique in being a severe injury to the chest, in which the patient made a full recovery. This report highlights the importance of legislation in preventing propeller injuries by restricting swimmer zones and introducing propeller guards or jet drive systems.peer-reviewe

Sternal vascularity after harvesting of the internal thoracic artery

Reply to "Assessment of Sternal Vascularity With Single Photon Emission Computed Tomography After Harvesting of the Internal Thoracic Artery" by Cohen et al.peer-reviewe

Traumatic rupture of the aorta : a case report and discussion of clinical features

A young female patient was involved in a head-on collision and sustained a rupture of the aortic isthmus. She underwent emergency surgical repair of an aortic pseudo-aneurysm with an interposition graft. She made a good post-operative recovery and represents the first such case in Malta.peer-reviewe

Transfusion requirements of patients undergoing routine cardiac surgery

Background: Several factors contribute to the need for blood transfusion after cardiac surgery. These include perioperative blood loss, haemodilution on cardiopulmonary bypass, and pre-operative anaemia. Blood and blood products are at a premium and it is advantageous to decrease the burden on transfusion services by requesting fewer blood units to cover routine surgery. It has been customary in the past to cross-match 6 units of whole blood but this figure has been reduced over the years to 4 units and more recently to 2 units. Methods: A retrospective study of the transfusion requirements of our patients over a one-year period (2005-2006) was performed. Transfusions were classified as urgent (i.e. those required in the immediate post-operative period to replace losses and maintain haemodynamic stability) or non-urgent (i .e. those required after the first 24 hours in order to correct a residual anaemia). Results: 1431286 patients (50%) patients were transfused. A total of298 units, average 2.1 units per patient, were transfused. 58 patients received 1 unit of blood, 56 patients received 2 units of blood, 10 patients received 3 units of blood, 7 patients received 4 units of blood, and 12 patients received over 4 units of blood. Sixteen transfusion episodes were urgent, but no undue delay was experienced in administering treatment. Conclusion: The practice of reserving 2 units of packed cells for cardiac surgery has proved safe and adequate. Further studies should be performed in our unit to determine the rate of unnecessary transfusions.peer-reviewe

Long-term survival following aortic valve replacement : the influence of age, prosthesis-patient mismatch and indexed effective orifice area

Background: Prosthesis-patient mismatch (PPM) has been linked to reduced long-term survival after aortic valve replacement. We studied the influence of age, PPM and indexed effective orifice area (iEOA) in this setting. Methods Patients (n=586) subjected to aortic valve replacement were followed up for a mean of 7.8 (maximum 20) years. The study population was divided into four equivalent groups by age. Mortality data was extracted from the National Statistics database. Data pertaining to patient body surface area and valve effective orifice area was collected prospectively and mismatch (moderate or severe) was defined according to established values. The Cox proportional hazard model was used to study the effect of age, mismatch and iEOA on survival. The Log Rank test was used to compare survival curves by age groups and date of surgery. Results The incidence of moderate PPM was 24.6%, and of severe PPM 3.9%. Mismatch increased the hazard of death by 31.2% for moderate PPM and 70.3% for severe PPM but did not reach statistical significance. Mean age of patients with mismatch (n=167) was 2.52 years less than in those without (63.35±10.61 versus 65.87±11.69, p=0.016). Age significantly affected survival, increasing the risk of death by 7.3% for every incremental year. Mean iEOA was 0.94±0.15cm2/m2; for every 0.1unit increase in iEOA the risk of death decreased by 8.8%. Conclusions Long-term survival was significantly affected by age at operation. Although mismatch increased hazard of death the effect did not reach statistical significance. A larger iEOA had a significant beneficial effect on survival.peer-reviewe

Measurement of chest wall forces on coughing with the use of human cadavers

Letter commenting on an article by Magovern et al.peer-reviewe

The difficulties in identifying and grafting an intramuscular coronary artery

Myocardial bridging involves tunnelling of one of the coronary arteries through the myocardium, resulting in what are known as intramyocardial coronaries. While most patients with intramyocardial coronary vessels are asymptomatic, there is evidence that myocardial bridging may be the cause of sudden death. Given the low detection rate on coronary angiography, myocardial bridging may complicate coronary artery bypass grafting (CABG). This case report discusses a 72-year-old gentleman who underwent CABG, during which an undiagnosed intramuscular left anterior descending (LAD) coronary artery was found. With only the tapering end of the LAD visible at the apex of the heart, a small incision was made at this site and a 1mm probe inserted. At the uppermost reach of the probe the tip was felt to point superficial and therefore a second more proximal incision was performed. The left internal thoracic artery (LITA) was than successfully anastomosed with the proximal arteriotomy and a length of saphenous vein was used for anastomosis with the distal arteriotomy where the probe was originally inserted. The patient was discharged home 5 days post operatively.peer-reviewe

The difficulties in identifying and grafting an intramuscular coronary artery

Myocardial bridging involves tunnelling of one of the coronary arteries through the myocardium. While most patients with intramyocardial coronary vessels are asymptomatic, there is evidence that myocardial bridging may be the cause of sudden death. Given the low detection rate on coronary angiography, myocardial bridging may complicate coronary artery bypass grafting (CABG). This case report discusses a 72-year-old gentleman who underwent CABG, during which an undiagnosed intramuscular left anterior descending (LAD) coronary artery was found. With only the tapering end of the LAD visible at the apex of the heart, a small incision was made at this site and a 1mm probe inserted. At the uppermost reach of the probe the tip was felt to point superficial and therefore a second more proximal incision was performed. The left internal thoracic artery (LITA) was than successfully anastomosed with the proximal arteriotomy and a length of saphenous vein was used for anastomosis with the distal arteriotomy where the probe was originally inserted. The patient was discharged home 5 days post operatively.peer-reviewe