Congenital Absence of Pericardium: A Case Report and Technical Considerations in Cardiac Surgery

This case report describes a rare instance of left-sided congenital pericardial agenesis (CPA) encountered during coronary artery bypass grafting (CABG) in a 77-year-old male. In this unique case, the presence of an unusual strip of left pericardium containing the phrenic nerve posed significant surgical challenges. Special attention was required for the graft lay, ensuring adequate filling of the heart during assessment before closure, as well as emphasis on the need for generous graft length. Additionally, the evaluation of graft positioning prior to cardiopulmonary bypass was crucial. Despite these complexities, CABG was successfully performed with no complications to note. This case underscores the importance of adaptability in surgical technique to manage the unique challenges posed by CPA, leading to a positive outcome despite the atypical cardiac anatomy.

An Overview of First 100 Cardiac Surgery Cases at a Newly Developed Satellite Center in Sukkur, Pakistan

Introduction

The aim of this research is to evaluate the in-hospital and early outcomes of the first 100 adult cardiac surgeries performed at a newly developed satellite center in Sukkur, Pakistan.

Methods

This is an audit of the first 100 adult cardiac surgeries performed at a newly developed satellite center of the National Institute of Cardiovascular Diseases (NICVD) at Sukkur, Pakistan, from March 2018 to November 2018 with 12 months of post-operative follow-up. Patients were offered off-pump coronary artery bypass (OPCAB), on-pump coronary artery bypass (ONCAB), mitral valve replacement (MVR), aortic valve replacement (AVR), minimally invasive cardiac surgery (MICS), and congenital adult congenital heart disease (ACHD) procedures by expert faculty of NICVD with a minimum of five years of post-fellowship experience.

Results

The mean age was 47.11 ± 14.6 years, with a male predominance of 77%. Hypertension and smoking were the most common risk factors that were observed in 32% and 33%, respectively, followed by diabetes and dyslipidemia with a frequency of 20% and 9%, respectively. The mean EuroSCORE (European System for Cardiac Operative Risk Evaluation) II for this patient cohort was 1.165 ± 0.50, with a maximum score of 2.3 in one patient. Out of 100 procedures, 51 were ONCAB, 19 were OPCAB, 16 were MVR, three were AVR, nine were ACHD, and two were MICS. Survival status post-operative as well as after one year was 100%. The frequency of post-operative bleeding was 7%, mean post-operative mechanical ventilation time was 213 ± 273 hours, and in-hospital stay was 5.41 ± 0.165 days. Lost to follow-up at one year was 4% (four). During the follow-up assessment, 39.5% of the patients had complained of mild-to-moderate intensity retrosternal pain and 4.2% had superficial surgical site infection of the sternal wound. A significant improvement in functional class was observed in 38.5% of patients, whereas 4.2% (four) had a significant drop in functional class post-operatively.

Conclusion

Providing tertiary care and early cardiac surgical facility to the people of Sukkur at their doorstep, in a newly developed satellite center, has resulted in improved outcomes, early quality treatment facility, and avoidance of long travel time.

Conversion from Off to On-Pump Coronary Artery Bypass Grafting. Is it Avoidable?

Background

With the emergence of new technologies to stabilize the heart off-pump coronary artery bypass grafting (OPCAB), there is an increasing trend that is being observed throughout the world. In certain circumstances, OPCAB needs to be converted to on-pump CABG (ONCAB). In this study, we aim to identify certain risk factors mandating conversions and their associated short-term outcomes.

Methods

After approval from the institutional ethical review committee and exemption from informed consent, retrospective data of 100 patients meeting the inclusion criteria who underwent OPCAB operations at our institution from August 2018 to July 2019 were included. Preoperative, intraoperative, and postoperative variables were recorded and compared in conversion and non-conversion groups. This study was conducted at the National Institute of Cardiovascular Diseases, Karachi, Pakistan.

Results

A total of 100 patients were included in this study, out of which 82% (82) were male, with age ranging between 18 and 77 years with a mean age of 56.34 ± 8.3 years. In nine of the cases, OPCAB was emergently converted to ONCAB due to arrhythmias. In nine (9%) cases, off-pump CABG was emergently converted to on-pump CABG (ONCAB). Emergent conversion was due to arrhythmias in five cases, due to hypotension during OM graft in two cases, and due to hypotension during ramus graft for the remaining two cases. The emergent conversion was significantly associated with higher New York Heart Association (NYHA) functional classification and comorbid conditions such as chronic obstructive pulmonary disease (COPD).

Conclusion

Emergency conversion from off-pump to OPCAB is the most catastrophic event causing higher morbidity and mortality. Conversion rate was observed to be 9% with arrhythmias being the common cause and patients with higher NYHA status and COPD at baseline were found to be at increased risk of emergency conversion. Considering our results in patients with diagnosed COPD and higher NYHA status, the decision for off-pump CABG should be wisely taken carefully weighing the risks and benefits.