The document describes a study of 27 patients in Iraq who underwent surgical treatment for left ventricular aneurysms between 2001-2011. Left ventricular aneurysms are complications that can arise after a myocardial infarction. The patients were mostly middle-aged males and had multiple blocked coronary arteries. Surgical techniques used to repair the aneurysms included linear repair and the Dor procedure. Post-operative complications were common, with the highest rate being bleeding. The overall hospital mortality rate for the surgeries was 18.5%.
Definition of LVA Centerline analysis of RWMA on LV angio in 30º RAO shows hypocontractile segments moving more than 2 standard deviations out of normal range.
Definition of LVA Centerline analysis of RWMA on LV angio in 30º RAO shows hypocontractile segments moving more than 2 standard deviations out of normal range.
Trans catheter intervention is emerging field in cardiac intervention. due to complex anatomy of mitral valve understanding of anatomy and three dimensional imaging is most important aspect of successful intervention and could be life saving in high risk surgical candidate
Isolated monomorphic premature ventricular complexes (PVCs) without
structural heart disease are generally benign.
► Frequent PVCs can cause reversible cardiomyopathy or aggravate an existing
cardiomyopathy.
► Short coupled PVCs can trigger sustained ventricular fibrillation. These are
often from the Purkinje tissue or rarely the outflow tract.
► Beta blockers are considered first-line therapy but have low efficacy.
Catheter ablation and AADs are reasonable to suppress PVCs in appropriate
patients.
► Ablation is often curative and success depends on location and accessibility
of PVCs.
► Implantable defibrillators are reasonable in patients at higher risk of sudden
cardiac death.
Trans catheter intervention is emerging field in cardiac intervention. due to complex anatomy of mitral valve understanding of anatomy and three dimensional imaging is most important aspect of successful intervention and could be life saving in high risk surgical candidate
Isolated monomorphic premature ventricular complexes (PVCs) without
structural heart disease are generally benign.
► Frequent PVCs can cause reversible cardiomyopathy or aggravate an existing
cardiomyopathy.
► Short coupled PVCs can trigger sustained ventricular fibrillation. These are
often from the Purkinje tissue or rarely the outflow tract.
► Beta blockers are considered first-line therapy but have low efficacy.
Catheter ablation and AADs are reasonable to suppress PVCs in appropriate
patients.
► Ablation is often curative and success depends on location and accessibility
of PVCs.
► Implantable defibrillators are reasonable in patients at higher risk of sudden
cardiac death.
Coronary angioplasty has revolutionized the management of coronary artery disease. It has not ceased to develop to become the reference method of myocardial revascularization. The aim of our study is to evaluate the ultrasound parameters of left ventricular function after coronary angioplasty. This is a prospective analytical study including patients with stable coronary artery disease with a known coronary artery anatomy programmed for coronary angioplasty. Transthoracic echocardiography was performed four hours before and seven days after myocardial revascularization.
Speckle tracking echocardiography is a new, unique and evolving tool to assess the myocardial deformation which can detect LV systolic dysfunction much earlier than can be reflected in LVEF. The importance of defining predictors is to predict whom patient will be at risk for the deleterious effect of RV pacing on LV function, and who will need observation with possible upgrading to biventricular pacing.
Role of Left Ventricular Mass Index Versus Left Ventricular Relative Wall Thi...Premier Publishers
In non-cardioembolic stroke patients, the cardiac manifestations of elevated blood pressure are of particular interest. The value of LV geometry in the prediction of cardiovascular risk is controversial. Many reports detected that left ventricular hypertrophy is independently associated with risk of ischemic stroke. The primary objective of this study was to identify the frequency of different patterns of altered left ventricular geometry in patients with non cardioembolic stroke, and to assess whether a significant number of patients will miss the diagnosis of LV remodeling if the left ventricular relative wall thickness(RWT) is not evaluated or reported. 100 patients were referred within 48 hours after an acute non cardioembolic ischemic stroke for a transthoracic echocardiogram. The echocardiographic findings were analyzed. Mean age was 61.86 ± 12.59 years, 45 % men. Concentric remodeling carried the highest frequency (43%), followed by normal pattern (27%), concentric hypertrophy (22%), and eccentric hypertrophy (8%). The frequency of abnormal left ventricular RWT (61.4%) was significantly higher than that of abnormal LVMI.
Coronary endarterectomy and patch angioplasty for diffuse coronary artery dis...Abdulsalam Taha
CABG may not be sufficient to treat the diffusely diseased coronary arteries. New techniques such as coronary endarterectomy with patch angioplasty may provide a solution.
RECENT ADVANCES IN THE MANAGEMENT OF REFRACTORY HEART FAILUREApollo Hospitals
Heart failure is a pathophysiological state in which structural or functional cardiac disorder impairs the ability of the heart to function as a pump to support the physiological circulation. The medical therapy remains the
mainstay of treatment in these patients. The medical therapy can improve the quality of life and the longevity in
these patients, but this becomes insufficient in refractory heart failure. The heart failure is considered refractory when patients continued to be symptomatic despite optimal dose of medications, characterized by advanced structural heart disease. These patients will need frequent hospitalizations and the overall prognosis is very poor.
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
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- Prix Galien International Awards Ceremony
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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2. Management of Left Ventricular 128 Aneurysm: A Study from Iraq
2. Materials and Methods Twenty-seven patients (20 males and 7 females) with LVA who were admitted to Ibn-Albitar Centre for Car- diac Surgery (IBCCS) over the period from May 1st, 2001 to December 31st, 2011 were retrospectively studied. Patients’ informed consents and approval of the Hospital Ethics Committee were obtained. The case sheets of these patients were obtained. Information like age, sex, place of residency, presenting symptoms and signs, past medical history particularly ischemic heart disease (IHD) were looked for. The diagnostic work-up was reviewed looking for specific investigations like electrocardiogra- phy (ECG), chest radiography (CXR), echocardiography, cardiac catheterization and coronary angiography. All patients in this study were initially seen and thoroughly investigated by cardiologists. Thereafter, surgical candi- dates were referred for surgery. All patients had repair of aneurysm (mostly linear re- pair or Dor procedure) together with myocardial revas- cularization (CABG) except 3 patients who had repair of their aneurysm alone. Four patients with an associated VSD had closure of this defect as well. The operative notes and the perfusionists’ notes were all reviewed to get an idea of the conduct of the operation. Intra-aortic balloon pump (IABP) was used selectively (either before induction of anesthesia or at the end of operation). Operative procedure: The aneurysmal wall was in- cised and thrombi removed if present. Repair was done either by the linear method for small aneurysms or Dor procedure for big ones. In the linear method, after excis- ing the aneurysm, the edges of viable myocardium were sutured together by interrupted pledgeted sutures over Teflon felts. While in Dor technique, a purse string (2 zero) Polypropylene suture was used to narrow the defect. The remaining ventriculotomy was closed by a Dacron patch sutured interruptedly by pledgeted Polypropylene sutures over Teflon strips. The postoperative morbidity and mortality were stu- died. The follow-up was unfortunately not available apart from the interval between surgery and discharge. 3. Results The male to female ratio of patients was 2.8:1.
The youngest patient was a 36-year-old male and the oldest one was a 67-year-old lady. The mean age was 54.6 years old. The age and sex distribution of these pa- tients is displayed in Table 1. Most of the patients (96.3%) were above 40. All patients had history of IHD and therefore; LVA
was a complication of MI.
We could obtain ECG recordings from 19 patients on-ly.
These were studied carefully. The typical LV aneu-rysm
morphology (ST elevation seen > 2 weeks follow-
Table 1. The age and sex distribution.
Age (year)
31 - 40
41 - 50
51 - 60
61 - 70
Total
Males
1
8
5
6
20
Females
0
1
4
2
7
Total
1
9
9
8
27
ing acute MI, most commonly in the precordial leads, with a concave or convex morphology, associated with well-formed Q- or QS-waves and a relatively small am- plitude T-waves) was observed in 8 patients (42.1%). During the period of this study 1136 patients with IHD had CABG operations in IBCCS. Thus the overall rate of LVA repair to CABG operations was 2.4%. Regarding distribution of patients over years of the study, we found that 62% of them were seen in the last three years.
Echocardiography was done in 25 patients. The ejec- tion fraction values are shown in Table 2. The vast ma- jority (84.2%) had subnormal values. Other echocardio- graphic findings are shown in Table 3.
The sites of aneurysm are displayed in Table 4: apical and antero-apical locations were the commonest.
Most patients in this study had multi-vessel CAD. Review of the coronary angiograms revealed about 46 stenotic or occlusive lesions in 27 patients as shown in Table 5. The most frequently diseased artery was the LAD. The perfusion charts of 25 patients were reviewed. Almost one third of patients (8) required IABP support mostly at the end of operation.
The operative procedures done to the patients in this study are shown in Table 6. Twenty four patients (88.9%) had CABG. Four patients (14.8%) with an associated VSD had closure of these defects.
The type of repair of LV aneurysms is shown in Table 7. Linear repair and Dor technique were almost used equal- ly. The details of myocardial revascularization are shown in Table 8. Most of the patients had multivessel coronary artery disease and received complete revascularization. Regarding the outcome of patients with an associated VSD; one patient has died making a mortality of 25%. In regard to the duration of postoperative hospitaliza- tion, most patients (19, 70.4%) stayed for 1 - 2 weeks.
The complications are displayed by Table 9. The com- monest was bleeding. Five out of twenty-seven patients who were managed surgically had died (18.5%). This represents death during the first hospitalization only. The mortality after discharge might be higher as there was no recordable follow up. 4. Discussion The 27 patients with LVA repair represented 2.4% of the total 1136 patients who underwent CABG operations OPEN ACCESS IJCM
3. Management of Left Ventricular Aneurysm: A Study from Iraq 129
Table 2. Ejection fractions.
Subnormal
Normal*
EF %
21 - 30
31 - 40
41 - 50
51 - 55
56 - 60
61 - 70
71 - 80
Not mentioned
Total
Pts, n (%)
1 (5.3)
7 (36.8)
6 (31.5)
2 (10.6)
1 (5.3)
1 (5.3)
1 (5.3)
6 (24)
25 (100)
*Normal EF is 55% - 70% with a mean of 58%.
Table 3. Other echocardiographic findings.
Finding
Pts, n (%)
Finding
Pts, n (%)
Aneurysm
12 (48)
MR
8 (32)
Hypokinesia
12 (48)
TR
3 (12)
Dyskinesia
3 (12)
Akinesia
5 (20)
Dilatation of LV
13 (52)
VSD
4 (16)
Dilatation of LA
3 (12)
P*. effusion
2 (8)
Dilatation of RA
2 (6)
Thrombus
5 (20)
Dilatation of RV
3 (12)
*P: pericardial; TR: tricuspid regurgitation; MR: mitral regurgitation; VSD: ventricular septal defect.
Table 4. Sites of aneurysms.
Total
Inferior
Posteroinferior
Apical
Anteroseptal
Anteroapical
Site
27 (100)
4 (14.8)
2 (7.4)
10 (37.1)
2 (7.4)
9 (33.3)
Pts, n (%)
Table 5. Diseased vessels, n (%).
RCA
LMS
LAD
CX
TOTAL
13 (28.3)
2 (4.4)
21 (45.6)
10 (21.7)
46 (100)
RCA: right coronary artery; LMS: left main stem; LAD: left anterior descending; CX: circumflex.
Table 6. Operative procedures.
Operation
LVA repair + CABG + VSD closure
LVA repair + CABG
LVA repair/no CABG
Total
Pts, n (%)
4 (14.8)
20 (74)
3 (11.2)
27 (100)
CABG: coronary artery bypass grafting.
Table 7. Types of repair.
Type
Linear
Dor technique
Not specified
Patch
Linear + patch
Total
Pts, n (%)
11 (40.7)
10 (37.1)
4 (14.8)
1 (3.7)
1 (3.7)
27 (100)
Table 8. Details of myocardial revascularization.
No. of grafts
CABG X 1
CABG X 2
CABG X 3
CABG X 4
Total
Pts, n (%)
1 (4.2)
7 (29.2)
8 (33.3)
8 (33.3)
24 (100)
Table 9. Postoperative complications.
Complication
Bleeding
Wound infection
Low CO
Uremia
Pleural effusion
Bed sore
Total
Pts, n (%)
5 (38.4)
2 (15.4)
2 (15.4)
2 (15.4)
1 (7.7)
1 (7.7)
13 (100)
OPEN ACCESS IJCM
4. Management of Left Ventricular 130 Aneurysm: A Study from Iraq
during the period of the study in IBCCS. This figure is close to that reported by Antunes et al. from Portugal (2%) [4]. 4.1. Age & Sex Distribution LVA following MI has a similar age and sex distribution to IHD [4-10]. 4.2. Symptoms With regard to presenting symptoms, absence of angina pectoris and dyspnea as the predominating symptom was associated with early mortality according to a study by Vural et al. [11]. Moreover, lack of angina was an inde- pendent predictor for operative mortality [11]. It can be speculated that, preoperative angina, probably but not necessarily, may indicate viable myocardial tissue exis- tence, which is capable of generating power during sys- tole, more compliant during diastole and has less com- promising effect on ventricular geometry when compared to a totally fibrotic aneurysmal sac [11]. 4.3. Electrocardiography The typical LV aneurysm morphology in the ECG de- scribed earlier in the Results was observed in 8 patients (42.1%) only. This ECG pattern has a sensitivity of 38% and a specificity of 84% for the diagnosis of ventricular aneurysm [7].
4.4. Incidence
62% of patients were seen in the last three years of the
study. This could be related to a real increase in the inci-dence
of IHD and its complication like LVA, a concomi-tant
rise in CABG operations, a better diagnosis of LVA,
increased awareness of cardiologists about the role of
surgery in LVA and thus more referral of cases and a
significant increase in the number of efficient young co-ronary
surgeons capable of performing LVA repair with
concomitant CABG.
4.5. Diagnosis
Echocardiography has a sensitivity and specificity of
93% and 94%, respectively, for detecting LV aneurysm,
representing the most frequent and easily applied test for
such an anatomic abnormality. Left ventriculography,
however, remains the gold standard for the diagnosis [9].
4.6. Ejection Fraction
The vast majority of our patients (84.2%) had subnormal EF values. Results of many studies have shown that the ejection fraction of the total left ventricle is an important predictor of the outcome of open heart surgery [11,12]. Ventricular ejection fraction improves following aneu- rysm repair whether linear or patch technique is used [1]. 4.7. Other Echocardiographic Findings
In the present study, echocardiography was very useful. This is evident by looking at Table 4 which displayed many studied parameters. Mural thrombi were found in 20% of patients exactly the same as reported by Mang- schau et al. [13] and were removed surgically. Four post- ischemic VSDs were accurately diagnosed and fixed sur- gically thereafter. 4.8. Location In this study, anterior (11; 40.7%) and apical aneurysms (10; 37.1%) were the commonest. In clinical reports, LVA is usually located in the anterior wall, whereas in- fero-posterior or postero-lateral aneurysms are less com- mon. Postinfarction LVA follows pathology of the LAD- diagonal system (anterior aneurysm), circumflex branch- es (posterolateral aneurysm), or right coronary artery (inferoposterior aneurysm) [14]. In our series, a signifi- cant LAD lesion was present in 21 patients (77.8%). The prevalence of inferoposterior aneurysms is significantly higher in autopsy series than in clinical reports [14]. This may be due to the extensive infarction necessary for LVA formation. When this occurs in the inferoposterior wall, the result is often acute, severe mitral regurgitation and the patient dies in the acute phase rather than develops LVA [14]. 4.9. Linear vs. Patch Repair In the present series, linear and Dor repair were almost equally used (11 patients, 40.7% in each group), whereas the method of repair was not clear in 4 patients (14.8%). The basis on which patients were offered either type of repair is not known. Generally, the choice of repair tech- nique should not be made randomly, but depending on factors such as size and extension of scar tissue [11]. Although aneurysmectomy has been performed for almost five decades, the most appropriate surgical ap- proach to a patient with a dyskinetic LVA is still contro- versial [4]. Antunes et al. believed that the technique of repair of postinfarction dyskinetic LVAs should be adapted in each patient to the cavity size and shape, and the dimension of the scar [4]. Unduly wide excision of the scar area and linear closure of the LV defect might lead to deformation of the LV chamber and a reduction in LV diastolic volume [15]. 4.10. Impact of Coronary Revascularization
CABG is one of the important components of LVA sur- gery, and the revascularization rate varies in the literature OPEN ACCESS IJCM
5. Management of Left Ventricular Aneurysm: A Study from Iraq 131
from 68% to 100% [3] Twenty four patients in this study (88.9%) had CABG; which goes with the international standard.Most of the patients had multi-vessel coronary artery disease and received complete revascularization as shown in Table 9. Although the surgical risk is increased, patients with low LVEF and multi-vessel disease have a particular survival benefit after CABG [14]. The biolog- ical basis for this is recruitment of hibernating myocar- dium [14]. 4.11.When CABG Is Not Added! Three patients in this study had LVA repair without CABG. Two patients survived while the third (having total occlusion of RCA) died. It is noteworthy that RCA disease is associated with low cardiac output (CO) on multivariate analysis [3] which probably was the cause of death in this patient. In a study on 303 patients with LVA from Sweden, Stahle et al. reported an early mortality of 23% in patients who underwent aneurysm resection alone and 8.1% in cases of aneurysm resection with CABG [6]. This emphasizes the importance of concomitant CABG with LVA repair. Vural et al. in a retrospective analysis of 248 patients also found that concomitant CABG re- duced the incidence of low CO state [11]. 4.12. LVA + VSD This is an important complication of MI that has been commonly associated with progression to death [16]. Surgery is routinely performed in patients with acute VSD during MI [16]. Schlichter et al. reported a 3% in- cidence of VSD in a series of 102 patients with LVA [17]. Acquired VSD was first surgically repaired by Cooley et al. (1957) using CPB and hypothermia [17]. In 1962, Collis et al. described the repair of a VSD and LVA in a man of 59 [17]. When LVA coexists with a VSD, there is an obvious route for access to the septum since the left ventricular myocardium is already damaged [17]. The approach from the left which is thus afforded is ideal, first in that the septum on this side is smoother and the defect thus is more easily defined, and secondly the left ventricular pressure keeps the patch in contact with the septum, whereas a patch applied from the right side may be forced away from the septum [17]. Lazopoulos et al. described a case of giant LVA and VSD following a si- lent MI managed by an endoventricular circular plasty (Dor procedure), interrupted suturing of ventricular sep- tum and CABG [18]. In the present series, 4 patients had LVA + VASD (14.8%). One patient died (25% mortality). This is higher than what was reported by Olearchyk et al. (20%) [19]. 4.13. Morbidity
The commonest postoperative complication was bleeding. In other studies [3,4] low CO was on the top of the list.
4.14. Overall Mortality
5 out of 27 patients who were managed surgically had
died (18.5%). In a collection of 3439 operations for LVA
performed between 1972 and 1987, hospital mortality
was 9.9% and ranged from 2% to 19% [1] and it has re-cently
fallen to 3% to 7% in the last decade [1]. In view
of these figures, our mortality is obviously high. The
most likely reason is the small number of patients and the
limited experience in the management of this condition.
In regard to the possible causes of death, postoperative
bleeding was blamed in 2, low CO in 1 while it remained
unknown in 2 patients. Low CO accounted for 34% of
early mortality in Vural et al. series [11]. Mukkadirov et
al. also believes that severe low CO is one of the main
causes of early mortality after aneurysmectomy [3].
4.15. Perfusion Time and IABP
The mean perfusion time in this study was 100 minutes,
higher than that reported by Antunes et al. (82.7 minutes)
[4]. Long periods of aortic-cross clamping have detri-mental
effects during weaning from CPB [20].
IABP was used in 8 patients (32%) in this study, whe-reas
Eid used it in 26.7% of his patients [20]. IABP has
become a prerequisite for surgical repair of LVA [20]
especially in patients with compromised LV function
[20].
REFERENCES
[1] G. D. Di and L. J Ei, “Left Ventricular Aneurysm,” In: L. H. Cohn and L. H. Edmunds Jr., Eds., Cardiac Surgery in the Adult, McGraw-Hill, New York, 2003, pp. 771-788.
[2] M. Mukaddirov, R. G. Demaria, L. P. Perrault, J.-M. Fradier and B. Albat, “Reconstructive Surgery of Post In- farction Left Ventricular Aneurysms: Techniques and Un- solved Problems,” European Journal of Cardio-Thoracic Surgery, Vol. 34, No. 2, 2008, pp. 256-261. http://dx.doi.org/10.1016/j.ejcts.2008.03.061
[3] M. Mukkadirov, J.-M. Frapier, R. G. Demaria and B. Albat, “Surgical Treatment of Post Infarction Left Ven- tricular Aneurysms: Linear vs. Patch Plasty Repair,” In- teractive Cardiovascular and Thoracic Surgery, Vol. 7, No. 2, 2008, pp. 256-261. http://dx.doi.org/10.1510/icvts.2007.160093
[4] P. E. Antunes, R. Silva, J. F. de Oliveira and M. J. An- tunes, “Left Ventricular Aneurysms: Early and Late Long- Term Results of Two Types of Repair,” European Jour- nal of Cardio-Thoracic Surgery, Vol. 27, No. 2, 2005, pp. 210-215. http://dx.doi.org/10.1016/j.ejcts.2004.11.010
[5] L. Menicanti and M. Di Donato, “Left Ventricular Aneu- rysm/Reshaping Techniques,” MMCTS, Vol. 2005, No. 0425, 2005. http://dx.doi.org/10.1510/mmcts.2004.000596
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6. Management of Left Ventricular 132 Aneurysm: A Study from Iraq
[6] E. Stahle, R. Bergestrom, S. O. Nystrom, B. Edlund, I. Sjorgren and L. Holmberg, “Surgical Treatment of Left Ventricular Aneurysm-Assessment of Risk Factors for Early and Late Mortality,” European Journal of Cardio- Thoracic Surgery, Vol. 8, No. 2, 1994, pp. 67-73. http://dx.doi.org/10.1016/1010-7940(94)90094-9
[7] Ed Burns, ECG Library, Life in the fastlane.com.
[8] J. Edhouse, et al., “ABC of Clinical Electrocardiography,” BMJ, Vol. 324, No. 20, 2002, pp. 963-969. www.bmj.com
[9] W. J. Brady, R. A. Harrigan and T. Chan, “Diagnosis: Left Ventricular Aneurysm,” Cases in Electrocardiogra- phy. Emergency Medicine News, Vol. 28, No. 6, 2006, p 38. http://dx.doi.org/10.1097/00132981-200606000-00025
[10] V. N. Singh and J. A. Strom, “Ventricular Aneurysm Imaging,” 2012.
[11] K. M. Vural, E. Sener, M. A. Ozatic, O. Tasdemir and K. Bayazit, “Left Ventricular Aneurysm Repair: An As- sessment of Surgical Treatment Modalities,” European Journal of Cardio-Thoracic Surgery, Vol. 13, No. 1, 1998, pp. 49-56. http://dx.doi.org/10.1016/S1010-7940(97)00287-X
[12] L. E. Watson, D. W. Dickhaus and R. H. Martin, “Left Ventricular Aneurysm: Preoperative Haemodynamics, Chamber Volume and Results of Aneurysmectomy,” Cir- culation, Vol. 52, No. 5, 1975, pp. 868-873. http://dx.doi.org/10.1161/01.CIR.52.5.868
[13] A. Mangschau, S. Simonsen, M. Abdelnoor, B. Laake and O. Geiran, “Evaluation of Left Ventricular Aneurysm Resection: A Prospective Study of Clinical and Haemo- dynamic Characteristics,” European Journal of Cardio- Thoracic Surgery, Vol. 3, No. 1, 1989, pp. 58-64. http://dx.doi.org/10.1016/1010-7940(89)90013-4
[14] R. Lundblad, M. Abdelnoor and J. L. Svennevig, “Repair of Left Ventricular Aneurysm: Surgical Risk and Long- Term Survival,” The Annals of Thoracic Surgery, Vol. 76, No. 3, 2003, pp. 719-725. http://dx.doi.org/10.1016/S0003-4975(03)00677-5
[15] A. V. Marchenko, A. M. Cherniavsky, T. L. Volokitina, A. S. Alsov and A. M. Karaskov, “Left Ventricular Di- mension and Shape after Postinfarction Aneurysm Repair,” European Journal of Cardio-Thoracic Surgery, Vol. 27, No. 3, 2005, pp. 475-480. http://dx.doi.org/10.1016/j.ejcts.2004.12.025
[16] O. Shindler, A. Spotnitz and D. Shindler, “Aneurysm and Ventricular Septal Defect Following Myocardial Infarc- tion,” E-Chocardiography Journal, 1995. http://rwjms1.umdnj.edu/Shindler/vsdaneurysm.html
[17] A. D. Heath, A. M. Harris and M. P. Wright, “Clinical Features and Repair of Ventricular Septal Defect and Left Ventricular Aneurysm Complicating Myocardial Infarc- tion,” British Heart Journal, Vol. 32, No. 6, 1970, pp. 863-866. http://dx.doi.org/10.1136/hrt.32.6.863
[18] G. Lazopoulos, M. Manns-Kantartzis and M. Kantartzis, “Giant Left Ventricular Aneurysm and Intra-Ventricular Septal Defect after Silent Myocardial Infarction,” The Hellenic Journal of Cardiology, Vol. 50, 2009, pp. 142- 143.
[19] A. S. Olearchyk, G. M. Lemole and P. M. Spagna, “Left Ventricular Aneurysm. Ten Years Experience in Surgical Treatment of 244 Cases. Improved Clinical Status, He- modynamics and Long-Term Longevity,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 88, No. 4, 1984, pp. 544-553.
[20] H. E. Eid, “Role of Intra-Aortic Balloon Pump in Left Ventricular Endoaneurysmorrhaphy,” Asian Cardiovas- cular and Thoracic Annals, Vol. 7, No. 4, 1999, pp. 276- 281. http://dx.doi.org/10.1177/021849239900700406
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