Publications by authors named "Amr A Arafat"

32 Publications

Residual versus recurrent mitral regurgitation after transcatheter mitral valve edge-to-edge repair.

J Card Surg 2021 Feb 24. Epub 2021 Feb 24.

Department of Adult Cardiology, Prince Sultan Cardiac Center, Riyadh, Kingdom of Saudi Arabia.

Background: The number of MtraClip procedures is increasing, and consequently, the number of patients with residual or recurrent mitral regurgitation (MR). We aimed to characterize patients who had residual versus recurrent MR after MitraClip and report the outcomes of different treatment strategies.

Methods: From 2012 to 2020, 167 patients had MitraClip. Out of them, 16 patients (9.5%) had residual mitral regurgitation (MR), and 27 patients (16.2%) had recurrent MR.

Results: The median age in patients with residual MR was 67.5 (59-73) years versus 69 (61-78) years in patients with recurrent MR (p = .87). The etiology of mitral valve disease was functional in 13 patients (81.3%) and 22 patients (84.6%) in residual versus recurrent MR patients (p > .99). Cardiac resynchronization therapy-defibrillator implantation was higher in patients with residual MR (p = .02). Survival was 93.7% at 1 year, 76.4% at 3 years versus 92.5% at 1 year, and 84.5% at 3 years in residual versus recurrent MR (p = .69). Two patients in the residual MR group had re-clip, and three had surgery, and in the recurrent MR group, one patient had re-clip, and two patients had surgery (p = .23). Patients who had re-clip were older (p = .09). Surgery was associated with 100% survival at 5 years, 63% after medical therapy and the worst survival was reported in re-clip patients (p = .007).

Conclusion: The outcomes of patients with residual versus recurrent mitral regurgitation after MitraClip were comparable. Survival could be improved with surgery compared with medical therapy and re-clip.
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http://dx.doi.org/10.1111/jocs.15447DOI Listing
February 2021

Early Hemodynamic Profile after Aortic Valve Replacement - A Comparison between Three Mechanical Valves.

Braz J Cardiovasc Surg 2021 Feb 1;36(1):10-17. Epub 2021 Feb 1.

Department of Cardiac Sciences, College of Medicine, King Saud University, Riyadh, Saudi Arabia.

Introduction: There are scarce data comparing different mechanical valves in the aortic position. The objective of this study was to compare the early hemodynamic changes after aortic valve replacement between ATS, Bicarbon, and On-X mechanical valves.

Methods: We included 99 patients who underwent aortic valve replacement with mechanical valves between 2017 and 2019. Three types of mechanical valves were used, On-X valve (n=45), ATS AP360 (n=32), and Bicarbon (n=22). The mean prosthetic valve gradient was measured postoperatively and after six months.

Results: Preoperative data were comparable between groups, and there were no differences in preoperative echocardiographic data. Pre-discharge echocardiography showed no difference between groups in the ejection fraction (P=0.748), end-systolic (P=0.764) and end-diastolic (P=0.723) diameters, left ventricular mass index (P=0.348), aortic prosthetic mean pressure gradient (P=0.454), and indexed aortic prosthetic orifice area (P=0.576). There was no difference in the postoperative aortic prosthetic mean pressure gradient between groups when stratified by valve size. The changes in the aortic prosthetic mean pressure gradient of the intraoperative period, at pre-discharge, and at six months were comparable between the three prostheses (P=0.08). Multivariable regression analysis revealed that female gender (beta coefficient -0.242, P=0.027), body surface area (beta coefficient 0.334, P<0.001), and aortic prosthetic size (beta coefficient -0.547, P<0.001), but not the prosthesis type, were independent predictors of postoperative aortic prosthetic mean pressure gradient.

Conclusion: The three bileaflet mechanical aortic prostheses (On-X, Bicarbon, and ATS) provide satisfactory early hemodynamics, which are comparable between the three valve types and among different valve sizes.
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http://dx.doi.org/10.21470/1678-9741-2020-0273DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7918383PMC
February 2021

Long-term outcomes of tricuspid valve repair; the influence of the annuloplasty prosthesis.

Ann Thorac Surg 2020 Nov 23. Epub 2020 Nov 23.

Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia; Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt.

Background: The ideal tricuspid valve annuloplasty (TVA) prosthesis is controversial. This study aimed to compare the effect of rigid versus flexible TVA prostheses on long-term outcomes after repair of functional tricuspid regurgitation (FTR).

Methods: We included 713 patients who had repair of FTR from 2009 to 2017. Patients were divided into two groups according to the type of TVA prosthesis. Group1 (n=104) included patients who had repair using rigid rings, and group 2 (n=609) included patients with flexible bands. The median age was 53.5 (25- 75 percentiles: 42.5- 62) years in group1 vs. 56 (45- 65) years in group2 (p=0.11). Propensity score matching identified 91 matched pairs for comparison.

Results: In the matched pairs, operative mortality was identical (4 (4.4%) in both groups; p ˃0.99). The median follow-up was 55 (28- 83) months. The cumulative incidence of moderate or higher TR in the presence of death as a competing risk was higher in group 2 (SHR: 1.63; p= 0.019 and SHR: 1.6; p= 0.099, before and after matching, respectively). There was a trend of higher pacemaker insertion in group 1 (7(7.69%) vs.3(3.3%); p=0.34) that did not reach statistical significance after matching. There was no significant change in the degree of TR over time between both groups (OR:1.21, p= 0.53 and OR1.75, p= 0.21, before and after matching, respectively).

Conclusions: Both types of tricuspid valve annuloplasty prostheses had comparable efficacy in the management of FTR; however, freedom from moderate or more TR was higher in the rigid ring group.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.038DOI Listing
November 2020

Mechanical Versus Bioprosthetic Valve Replacement in the Tricuspid Valve Position: A Systematic Review and Meta-Analysis.

Heart Lung Circ 2021 Mar 1;30(3):362-371. Epub 2020 Apr 1.

Cardiothoracic Surgery Department, Tanta University, Egypt.

Background: The ideal prosthesis for tricuspid valve replacement (TVR) continues to be debated. There are few published data comparing mechanical and bioprosthetic valves, and all are retrospective studies with relatively small sample sizes.

Aim: This study was conducted to compare mechanical and bioprosthetic valves for TVR.

Method: A literature search of six databases (PubMed, EMBASE, Ovid, ScienceDirect, JSTOR, and Wiley Blackwell's online library) was performed with the keywords "tricuspid valve disease, tricuspid valve replacement and (bioprosthetic or mechanical)". Primary outcomes were hospital mortality, long-term survival, tricuspid valve reoperation, valve failure, thrombosis, and thrombo-embolism. Risk ratio (RR) was used to compare dichotomous parameters and time-to-event outcomes. "Survival and re-interventions" were pooled using a meta-analysis of hazard ratios (HR). Publication bias was accessed using a funnel plot.

Results: A total of 23 retrospective studies involving 945 mechanical and 1,332 biological tricuspid prostheses were included. The studies were published between January 2002 and September 2019. Hospital mortality (30-day mortality) did not differ between groups (RR, 0.83; 95% confidence interval [CI], 0.66-1.05; p=0.12). Long-term survival was evaluated in 15 studies, and it was not significantly different between patients with mechanical compared with those with bioprosthetic valves (pooled HR, 0.97; 95% CI, 0.61-1.54; p=0.88). Freedom from tricuspid valve reoperation was assessed in eight studies, and no difference was found between the groups (pooled HR, 1.03; 95% CI, 0.63-1.69; p=0.89). Valve failure in the 5-year postoperative period was evaluated by seven studies, and there was no statistically significant difference between the two groups (pooled RR, 1.33; 95% CI, 0.42-4.27; p=0.63).

Conclusions: The results of this meta-analysis suggest an equal risk of 30-day and late mortality, reoperation, and 5-year valve failure in patients with mechanical versus biological TVR. The choice of the prosthesis in the tricuspid position should depend mainly on the patient's risk factors and no superiority of one prosthesis over the other in this position.
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http://dx.doi.org/10.1016/j.hlc.2020.03.011DOI Listing
March 2021

Giant Ascending Aortic Aneurysm with Painless Dissection in a Patient with Marfan Syndrome.

J Saudi Heart Assoc 2020 22;32(2):284. Epub 2020 Jul 22.

Department of Adult Cardiac Surgery- Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.

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http://dx.doi.org/10.37616/2212-5043.1081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7640561PMC
July 2020

Tricuspid Valve Regurgitation After Heart Transplantation: A Single-Center 10-year Experience.

J Saudi Heart Assoc 2020 20;32(2):213-218. Epub 2020 May 20.

Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.

Background: Tricuspid valve regurgitation may affect the outcomes after heart transplantation. There is a paucity of data reporting the outcomes of heart transplants in our region. The objectives of this study were to report the occurrence of tricuspid regurgitation after heart transplantation, its course, and its effect on survival.

Methods: From 2009 to 2019, 30 patients had heart transplantation at our cardiac center. Their age was 36.73 ± 13.5 years, and 25 (83.33%) were males. Indications for transplantation were dilated cardiomyopathy (n = 21; 72.41%), ischemic cardiomyopathy (n = 8; 26.67%) and hypertrophic cardiomyopathy (n = 1; 3.45%). Cardiopulmonary bypass time was 157.24 ± 34.6 min, and ischemic time was 138 ± 73.56 min. All patients had orthotopic heart transplantation with a bi-caval technique.

Results: Eleven patients had severe tricuspid regurgitation postoperatively (37%). The degree of tricuspid regurgitation decreased significantly after 6 months (p = 0.011) and remained stationary during the follow-up. Pre-transplant dilated cardiomyopathy was significantly associated with severe tricuspid regurgitation post-transplant (p = 0.017). The mean follow-up was 39.43 ± 50.57 months. Survival at 10 years was 90% in patients with less than moderate tricuspid regurgitation postoperatively compared to 43% for patients with moderate and severe tricuspid regurgitation (log-rank p = 0.0498).

Conclusion: Tricuspid regurgitation is a common problem after heart transplantation. Despite the improvement of the degree of tricuspid regurgitation after 6 months, survival was negatively affected by postoperative moderate or severe tricuspid regurgitation. Patients with dilated cardiomyopathy may benefit from concomitant tricuspid valve repair at the time of heart transplantation. Further larger studies are warranted.
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http://dx.doi.org/10.37616/2212-5043.1058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7640540PMC
May 2020

The trans-septal approach in transcatheter mitral valve-in-valve implantation for degenerative bioprosthesis.

J Saudi Heart Assoc 2020 11;32(2):141-148. Epub 2020 May 11.

Cardiothoracic Surgery Department, Tanta University, Egypt.

Background: Transcatheter Mitral Valve-in-Valve Implantation (TMViVI) has recently emerged as a novel therapy for degenerated mitral valve bioprosthesis. Re-operative mitral valve surgery is associated with a substantial risk of mortality and morbidity. The objective of this study was to describe the outcomes of transcatheter mitral valve-in-valve implantations in our cardiac center.

Methods: Twenty-two patients underwent the valve-in-valve procedure because of bioprosthesis degeneration from March 2017 to October 2018. Clinical, echocardiographic, procedural details and survival at follow up were assessed.

Results: Eight patients refused re-operative cardiac surgery while others were deemed a high risk for conventional re-operative sternotomy. All patients had TMViVI performed via a trans-septal approach, and the prosthesis was implanted successfully with immediate hemodynamic improvement in 20 patients. One patient had tamponade (4.55%), two had permanent pacemaker insertion (9.09%), two patients had a renal impairment (9.09%), and three patients had vascular complications (13.64%). There was one aborted procedure for the failure to cross the tissue valve with a transcatheter valve, and one patient was converted to an emergency mitral valve surgery. All patients were discharged in NYHA class I/II and NYHA class was markedly improved at one-year follow-up (p = 0.002).

Conclusions: Trans-septal mitral valve-in-valve implantation can be performed safely for degenerative mitral valve bioprosthesis and with favorable early clinical and hemodynamic outcomes.
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http://dx.doi.org/10.37616/2212-5043.323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7640552PMC
May 2020

Assessment of the quality of anticoagulation management with warfarin in a tertiary care center.

Saudi Med J 2020 Nov;41(11):1245-1251

Department of Pharmacy, Prince Sultan Cardiac Center, Riyadh, Kingdom of Saudi Arabia. E-mail.

Objectives: To evaluate the quality of an anticoagulation clinic in a tertiary hospital and identified factors affecting the time in the therapeutic range (TTR) and its relation to different complications. Methods: This single-center retrospective study conducted between March 2015 and June 2016 included 1914 patients receiving warfarin therapy. They were divided into 4 warfarin indication groups: non-valvular atrial fibrillation (AF) (n=403), valvular AF (n=227), prosthetic valves (n=700), and venous or pulmonary embolism (n=584).

Results: The median age was 56 (25th, 75th percentiles: [45, 67]) years, and 53.2% were female. The median TTR was 0.52 (0.28, 0.76). Low hemoglobin (0.007) and high alkaline phosphatase (0.020) levels negatively affected the TTR. Venous thromboembolism (VTE) was associated with low TTRs. Minor bleeding occurred in 64 (3.35%), gastrointestinal bleeding in 14 (0.7%), and stroke in 41 (2.2%) patients, with no inter-group differences. The TTR was not associated with minor bleeding (odds ratio [OR]=0.49; p=0.09), gastrointestinal bleeding (OR=0.29; p=0.18), or stroke (OR=1.15; p=0.79).

Conclusion: Reflecting the real-life experience of anticoagulation control, our patients spend less than half the TTR within the INR. The low target TTR mandates the need to improve service quality and control factors affecting the TTR, including hemoglobin levels and regular visits for patients with VTE.
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http://dx.doi.org/10.15537/smj.2020.11.25456DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7804229PMC
November 2020

Outcomes of biventricular repair for shone's complex.

J Card Surg 2021 Jan 8;36(1):12-20. Epub 2020 Oct 8.

Division of Cardiac Surgery, Department of Cardiovascular, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.

Background: Shone's complex is a rare lesion affecting the mitral valve (MV) and left ventricular outflow tract (LVOT). The objective of this study is to report the outcomes after Shone's complex repair, the growth of mitral and aortic valve and LVOT, and long-term survival.

Methods: This retrospective study included all patients diagnosed with Shone's complex, who underwent biventricular repair. Data including patients' characteristics, type of the MV lesion and the associated lesions were collected. Patients were followed up regularly with echocardiography, and the changes in mitral and aortic valve z-score and LVOT z-score were recorded.

Results: Thirty-seven patients were included in the study, the median age was 3.4 months, and 11 patients (30.6%) had pulmonary hypertension. The main procedure performed during the first surgical intervention was coarctation repair in 26 patients (70%). Twelve patients had MV repair, and five had MV replacement. Operative mortality occurred in 1 patient (2.7%), median follow up was 52 (25-75th percentile: 22-84) months. Survival at 1, 5, and 10 years was 94.4%, 90%, and 76.9%, respectively. Reoperation was required in 13 patients, mainly for LVOT repair (n = 8). Reoperation was significantly associated with associated aortic valve lesion (p = .044). The growth of the MV z-score was 0.35 per year; p < .001, aortic valve z-score 0.086 per year; p = 0.422, and the LVOT z-score was 0.53 per year; p = .01.

Conclusion: Biventricular repair of Shone's complex has good outcomes. Reoperation is frequently encountered, especially with low aortic valve z-score. The MV and LVOT have significant growth following Shone's complex repair.
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http://dx.doi.org/10.1111/jocs.15090DOI Listing
January 2021

The outcomes of bidirectional Glenn before and after 4 months of age: A comparative study.

J Card Surg 2020 Dec 8;35(12):3326-3333. Epub 2020 Oct 8.

Cardiovascular Department, Division of Cardiac Surgery, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.

Objective: We aim to present our experience with the bidirectional Glenn (BDG) in patients less than 4 months of age and to compare their outcomes with the patients who underwent BDG after the age of 4 months.

Methods: A retrospective review of data was performed for patients who underwent the BDG procedure from 2002 to 2018 at our institutions. We reviewed the patients' demographics, echocardiographic findings, cardiac catheterization data, operative details, postoperative data, and outcome variables.

Results: The study was conducted on 213 patients. At the time of the BDG operation, 32 patients were younger than 4 months (younger group) and 181 patients were older than 4 months (older group). The preoperative mean pulmonary artery pressure was significantly higher in the younger group (p = .035) but there were no significant differences between both groups in Qp/Qs, ventricular end-diastolic pressure, indexed pulmonary vascular resistance, and preoperative oxygen saturation. However, the initial postoperative oxygen saturation of the younger group was lower than the older group (p = .007). The duration of mechanical ventilation, duration of pleural drainage, ICU stay, and hospital stay after BDG were significantly longer in the younger group compared to the older group. The early mortality was higher in the younger group, but this difference did not reach statistical significance (p = .283).

Conclusion: Performing BDG procedure in infants less than 4 months of age is safe, with favorable outcomes. Early BDG is associated with a less-smooth postoperative course without a significant increase in early or late mortality.
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http://dx.doi.org/10.1111/jocs.15055DOI Listing
December 2020

Reinterventions after transcatheter edge to edge mitral valve repair: Is early clipping warranted?

J Card Surg 2020 Dec 29;35(12):3362-3367. Epub 2020 Sep 29.

Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.

Background: Reintervention after transcatheter edge to edge repair using MitraClip is still challenging. We aimed to report our experience in reinterventions after MitraClip procedures and describe the outcomes.

Methods: From 2012 to 2020, 167 patients had a transcatheter edge to edge repair; 10 of them needed reinterventions. At the time of the first MitraClip, the median EuroSCORE was 4.29 (2.62-7.52), and the ejection fraction was 30 (20-40)%.

Results: Emergency mitral valve replacement (MVR) was performed in two patients, elective MVR in three, cardiac transplantation in two, and repeat clipping in threepatients. The median time from MitraClip to the reintervention was 4.5 (2-13) months. One patient required extracorporeal membrane oxygenation support after elective MVR. Repeat clipping failed to control mitral regurgitation grade in all patients. Clip detachment was reported in five patients (50%). The median follow-up after the reintervention was 19.5 (9-75) months, and mortality occurred in two patients who had repeat clipping (20%).

Conclusions: MVR after MitraClip is feasible with low morbidity and mortality. Repeat mitral valve clipping had a high failure rate. Mitral repair was not feasible in all patients in our series, and the use of MitraClip to delay surgical interventions may not be feasible if mitral repair is an option.
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http://dx.doi.org/10.1111/jocs.15077DOI Listing
December 2020

Pain perception assessment using the short-form McGill pain questionnaire after cardiac surgery.

Saudi J Anaesth 2020 Jul-Sep;14(3):343-348. Epub 2020 May 30.

Department of Adult Cardiac Surgery, Prince Sultan Cardiac Centre, Riyadh, KSA.

Background: Pain management remains an integral part of patient care after cardiac surgery, and it required proper pain assessment. The aim of the study was to assess pain perception using validated Arabic version of the short-form McGill Pain Questionnaire (SF-MPQ) and to identify analgesics prescribing patterns post cardiac surgery.

Methods: This is a prospective study conducted in an adult cardiac critical care unit of a tertiary cardiac center from September 2018 to March 2019. The study enrolled 74 patients who underwent cardiac surgical procedures through a median sternotomy.

Results: The mean age of our patients was 57 ± 11 years and 47 (63.5%) were males. Patients described post-cardiac surgery pain as heavy ( = 37; 50%) and tiring-exhausting ( = 49; 66%), mainly at the site of incision ( = 20; 27%). Pain intensity at day 1 according to pain rating index (PRI) and numerical rating scale (NRS) was 7 (25, 75 percentiles: 2.8-15) and 6 (3-8), respectively. There was a significant change in pain intensity score between 2 days of assessment (PRI: 7 [2.8-15] vs 5 [2-11] = 0.010; NRS: 6 (3-8) vs 5 (2-8), = 0.021]). The most common analgesics prescribed were paracetamol (39%) and a combination of tramadol and paracetamol (33.8%).

Conclusion: Pain decreased the second day after cardiac surgery compared to day 1. Paracetamol was the most prescribed analgesic; however, there was an underutilization which might be affected by insufficient pain reporting. Future improvement could focus on multimodal pain management and proper communication of pain experience.
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http://dx.doi.org/10.4103/sja.SJA_34_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458021PMC
May 2020

Spontaneous Coronary Artery Dissection in the Gulf: G-SCAD Registry.

Angiology 2021 01 13;72(1):32-43. Epub 2020 Aug 13.

Department of Cardiovascular Medicine, 21645Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, USA.

Data on spontaneous coronary artery dissection (SCAD) is based on European and North American registries. We assessed the prevalence, epidemiology, and outcomes of patients presenting with SCAD in Arab Gulf countries. Patients (n = 83) were diagnosed with SCAD based on angiographic and intravascular imaging whenever available. Thirty centers in 4 Arab Gulf countries (Kingdom of Saudi Arabia, United Arab Emirates, Kuwait, and Bahrain) were involved from January 2011 to December 2017. In-hospital (myocardial infarction [MI], percutaneous coronary intervention, ventricular tachycardia/fibrillation, cardiogenic shock, death, implantable cardioverter-defibrillator placement, dissection extension) and follow-up (MI, de novo SCAD, death, spontaneous superior mesenteric artery dissection) cardiac events were recorded. Median age was 44 (37-55) years, 42 (51%) were females and 28.5% were pregnancy-associated (21.4% were multiparous). Of the patients, 47% presented with non-ST-elevation acute coronary syndrome, 49% with acute ST-elevation myocardial infarction, 12% had left main involvement, 43% left anterior descending, 21.7% right coronary, 9.6% left circumflex, and 9.6% multivessel; 52% of the SCAD were type 1, 42% type 2, 3.6% type 3, and 2.4% multitype; 40% managed medically, 53% underwent percutaneous coronary intervention, 7% underwent coronary artery bypass grafting. Females were more likely than males to experience overall (in-hospital and follow-up) adverse cardiovascular events ( = .029).
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http://dx.doi.org/10.1177/0003319720946974DOI Listing
January 2021

Clinical Presentation and Outcome of Patients With Spontaneous Coronary Artery Dissection Versus Atherosclerotic Coronary Plaque Dissection.

Crit Pathw Cardiol 2021 Mar;20(1):36-43

Department of Cardiovascular Medicine, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA.

Background: Atherosclerotic coronary plaque dissection (ACPD) is one cause of acute coronary syndrome (ACS) caused by underlying atherosclerosis. Spontaneous coronary artery dissection (SCAD) occurs outside the setting of atherosclerosis among young women and individuals with few or no conventional atherosclerotic risk factors, and has emerged as an important cause of ACS, and sudden death. A comparison between ACPD and SCAD has not been previously addressed in the literature. Our study will compare ACPD and SCAD.

Methods: Patients with confirmed diagnosis of SCAD and ACPD were retrospectively identified from 30 centers in 4 Arab Gulf countries between January 2011 and December 2017. In-hospital (ventricular tachycardia/ventricular fibrillation, myocardial infarction (MI), percutaneous coronary intervention, dissection extension, cardiogenic shock, death, implantable cardioverter-defibrillator placement) and follow-up (MI, de novo SCAD, spontaneous superior mesenteric artery dissection, death) events were compared between them.

Results: Eighty-three cases of SCAD and 48 ACPD were compared. ACPD patients were more frequently male (91.67% vs. 49.40%, P < 0.001) and older (58.5 vs. 44, P < 0.001). Cardiovascular risk factors were more prevalent in patients with ACPD, including diabetes mellitus (60.4% vs. 25.3%), dyslipidemia (62.5% vs. 38.5%), and hypertension (62.5% vs. 31.3%), P < 0.001. Hospital presentation of ST-elevation MI was diagnosed in 48% of SCAD versus 27% of ACPD patients (P = 0.012). SCAD patients received medical-only treatment in 40% of cases and ACPD in 21% (P = 0.042). In-hospital and follow-up events were comparable in both groups (P = 0.25).

Conclusions: Despite a completely different pathophysiology of ACS between SCAD and ACPD, in-hospital and follow-up events were comparable.
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http://dx.doi.org/10.1097/HPC.0000000000000233DOI Listing
March 2021

Bolus potassium in frustrated ventricular fibrillation storm: Evidence are growing!

J Card Surg 2020 Aug 11;35(8):2117. Epub 2020 Jul 11.

Division of Cardiac Surgery, Cardiovascular Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.

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http://dx.doi.org/10.1111/jocs.14732DOI Listing
August 2020

Multiple mycotic arterial aneurysms involving the left anterior descending coronary artery following mitral and aortic valve endocarditis: A case report.

J Card Surg 2020 Jul 29;35(7):1717-1720. Epub 2020 Jun 29.

Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Kingdom of Saudi Arabia.

We present a 57-year-old man with recent Streptococcus viridans endocarditis on mitral and aortic valves who had a mycotic aneurysm of the left anterior descending (LAD) coronary artery and associated superior mesenteric and cerebral artery aneurysms. The patient had preoperative renal failure and the infection was controlled with ceftriaxone. Mitral and aortic valve replacement were performed using tissue valves and the LAD aortic aneurysm was ligated and the patient had saphenous venous graft to the LAD. The postoperative course was complicated by pleural effusion and the patient had antibiotic therapy for 6 weeks postoperatively.
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http://dx.doi.org/10.1111/jocs.14653DOI Listing
July 2020

Surgical repair for persistent truncus arteriosus in neonates and older children.

J Cardiothorac Surg 2020 May 11;15(1):83. Epub 2020 May 11.

Cardiac Surgery Division, Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia.

Objectives: Persistent truncus arteriosus represents less than 3% of all congenital heart defects. We aim to analyze mid-term outcomes after primary Truncus arteriosus repair at different ages and to identify the risk factors contributing to mortality and the need for intervention after surgical repair.

Methods: This retrospective cohort study included 36 children, underwent repair of Truncus arteriosus in the period from January 2011 to December 2018 in two institutions. We recorded the clinical and echocardiographic data for the patients preoperatively, early postoperative, 6 months postoperative, then every year until their last documented follow-up appointment.

Results: Thirty-six patients had truncus arteriosus repair during the study period. Thirty-one patients had open sternum post-repair, and two patients required extracorporeal membrane oxygenation. Bleeding occurred in 15 patients (41.67%), and operative mortality occurred in 5 patients (14.7%). Patients with truncus arteriosus type 2 (p = 0.008) and 3 (p = 0.001) and who were ventilated preoperatively (p < 0.001) had a longer hospital stay. Surgical re-intervention was required in 8 patients (22.86%), and 11 patients (30.56%) had catheter-based reintervention. Freedom from reintervention was 86% at 1 year, 75% at 2 years and 65% at 3 years. Survival at 1 year was 81% and at 3 years was 76%. High postoperative inotropic score predicted mortality (p = 0.013).

Conclusion: Repair of the truncus arteriosus can be performed safely with low morbidity and mortality, both in neonates, infants, and older children. Re-intervention is common, preferably through a transcatheter approach.
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http://dx.doi.org/10.1186/s13019-020-01114-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216609PMC
May 2020

Should Moderate Functional Tricuspid Regurgitation Be Repaired During Surgery for Rheumatic Mitral Valve Disease?

Heart Lung Circ 2020 Oct 29;29(10):1554-1560. Epub 2020 Feb 29.

Department of Cardio-Thoracic Surgery, Tanta University, Tanta, Egypt. Electronic address:

Background: Surgical repair of concomitant functional moderate tricuspid valve (TV) regurgitation at the time of mitral valve (MV) surgery remains controversial.

Aim: The objective of this study was to evaluate the outcomes of concomitant repair of functional moderate tricuspid regurgitation (TR) during MV surgery for rheumatic valve disease.

Method: From 1998 to 2016, 1,240 patients had rheumatic MV disease associated with moderate functional TR: 974 patients had MV surgery and concomitant TV repair (group 1) and 266 patients had MV surgery alone (group 2). Study endpoints were operative outcomes, rehospitalisation for congestive heart failure (CHF), and TV reintervention. Propensity score matching identified 192 well-matched pairs for outcomes comparison.

Results: Patients who had concomitant TV repair were younger (p=0.02) and there were fewer diabetics (p=0.015). In matched patients, low cardiac output was significantly higher in group 2 (p=0.044) and there was no difference in ventilation time, intensive care unit stay, cardiopulmonary bypass, and ischaemic times (p=0.480, p=0.797, p=0.232, and p=0.550, respectively) between groups. Patients in group 2 required more TV reintervention (1 vs 35 in group 1 and 2, respectively; p=0.004) and rehospitalisation for CHF (5 vs 40 in group 1 and 2, respectively; p<0.001).

Conclusions: Concomitant TV repair for moderate TR in patients undergoing rheumatic MV surgery was not associated with increased operative risk. Postoperative low cardiac output syndrome and the risk of late TV reinterventions and rehospitalisation for CHF were lower with TV repair. Concomitant repair of the moderate TV regurgitation maybe beneficial for patients undergoing rheumatic MV surgery.
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http://dx.doi.org/10.1016/j.hlc.2020.01.014DOI Listing
October 2020

Bovine jugular vein valved xenograft for extracardiac total cavo-pulmonary connection: The risk of thrombosis and the potential liver protection effect.

J Card Surg 2020 Apr 29;35(4):845-853. Epub 2020 Feb 29.

Department of Cardiothoracic Surgery, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.

Background: Currently, non-valved conduits are preferred for extracardiac total cavo-pulmonary connection (TCPC). However, previous work has failed to provide objective data comparing the postoperative outcome between non-valved TCPCs and bovine jugular vein valved xenograft (BJV) TCPCs. Hence, the objective of this study is to compare the postoperative outcomes in extracardiac TCPC patients who received BJV vs synthetic non-valved conduits and evaluate the effect of BJV on liver fibrosis.

Methods: Of 206 patients who had extracardiac TCPC from 2002 to 2017 were divided into three groups. Group A (n = 66) received BJV, group B (n = 37) received PET conduits and group C (n = 103) received polytetrafluoroethylene (PTFE) tube. Study endpoints were hospital outcomes, conduits thrombosis, reinterventions, and survival. Liver stiffness and fibrosis were assessed in eight patients with BJV.

Results: Preoperative parameters were comparable among groups. Thrombosis was significantly lower in group C (P < .0003) but no difference between groups A and B (P = .951). Reinterventions did not differ significantly among groups (Log-rank P = .598). Hospital deaths occurred in seven patients (3.4%). There was no difference in survival between groups (Log-rank P = .221). The median liver stiffness score was 18.65 kPa and the eight patients had advanced liver fibrosis (grade F3-4) in group A.

Conclusion: PTFE is the recommended conduit for TCPC with a lower risk of thrombosis compared to BJV and PET. BJV conduits in TCPC circuits may not protect against liver fibrosis. BJV should not be considered as an option for TCPC.
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http://dx.doi.org/10.1111/jocs.14484DOI Listing
April 2020

Evolution of the Norwood operation outcomes in patients with late presentation.

J Thorac Cardiovasc Surg 2020 03 22;159(3):1040-1048. Epub 2019 Nov 22.

Division of Cardiac Surgery, Cardiovascular Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia; Cardiac Surgery Section, Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia. Electronic address:

Objectives: We present the evolution of Norwood operation outcomes and practice pattern changes over 15 years from a single institution in Saudi Arabia. We intended to identify time trends in patient selection, procedural details, and outcome predictors over time.

Methods: Patients who underwent a Norwood operation (n = 145) between 2003 and 2018 with the use of a Blalock-Taussig shunt (BT group; n = 72), right ventricle to pulmonary artery shunt (Sano group; n = 66), or a primary cavopulmonary shunt (CPS group; n = 7) were included. The study outcomes were operative mortality, long-term survival, and multistate transition to CPS, Fontan, and death.

Results: Median age was 29 days. Predictors of operative mortality were lower weight (P = .026), and longer bypass time (P = .014), whereas age, and type of shunt were not. Predictors of improved long-term survival were greater weight at operation (P = .0016), later era (P = .006), and shorter bypass time (P = .001). The multistate model revealed that patients with lower weight were more likely to undergo Sano versus BT (P < .001), and if BT was chosen in such patients, they were more likely to die (P = .027). The likelihood of receiving Sano shunt was 3-fold greater in the recent era (P = .003).

Conclusions: Improved outcomes of the Norwood operation are evident in the recent era and with Sano shunt, especially in patients of smaller weight. Late presentation or older age is not a contraindication to Norwood operation. The incorporation of a primary CPS at stage one operation is feasible in selected patients.
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http://dx.doi.org/10.1016/j.jtcvs.2019.07.154DOI Listing
March 2020

Giant inferolateral left ventricular aneurysm post inferior myocardial infarction.

J Card Surg 2020 Feb 19;35(2):433-434. Epub 2019 Dec 19.

Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.

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http://dx.doi.org/10.1111/jocs.14400DOI Listing
February 2020

Bolus potassium in frustrated ventricular fibrillation storm.

J Card Surg 2020 Feb 25;35(2):480-481. Epub 2019 Nov 25.

Division of Cardiac Surgery, Cardiovascular Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.

Background: Ventricular fibrillation (VF) is a well-known ominous complication of ischemic heart disease. While firmly structured algorithms have been developed for its management, yet its mortality rate remains high.

Case Presentation: This is a case report of a 46-year-old gentleman who was a victim of recurrent cardiac arrest in the ward while awaiting coronary artery bypass grafting (CABG) surgery. Emergency CABG was performed, intraoperatively he experienced recurrent VF which was reverted by direct current cardioversion-Defibrillation. He was sent to the Cardiac Surgery Intensive Care Unit (CSICU) with an open chest on extracorporeal membrane oxygenation (ECMO) support and an intra-aortic balloon pump. Postoperatively in CSICU he still experienced malignant ventricular arrhythmia with dropping of ejection fraction to less than 10%. The last few episodes of VF were lengthy, lasting more than an hour (while on ECMO support) with the failure of various antiarrhythmic medications to abort them. Eventually, a decision was made to give him 20 mmol boluses of potassium chloride (KCl) intravenously aiming at introducing a state of asystole, but the rhythm changed to sinus rhythm.

Conclusions: This report highlighted the fact that optimum management of VF is still lacking and necessitates more studies. The appropriate effective dose of potassium replacement during VF might need to be reconsidered in patients with persistent VF.
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http://dx.doi.org/10.1111/jocs.14380DOI Listing
February 2020

Mitral valve replacement after transcatheter aortic valve implantation in a patient with rheumatic heart disease and prior Ross procedure: a case report.

Egypt Heart J 2019 Nov 14;71(1):22. Epub 2019 Nov 14.

Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Kingdom of Saudi Arabia.

Background: Reoperations are required frequently after the Ross procedure in rheumatic patients. The use of transcatheter aortic valve implantation (TAVI) in those patients could decrease the risk of future open procedure; however, the outcome may be affected by the concomitant mitral valve disease, and subsequent mitral reoperation may distort the implanted aortic valve.

Case Presentation: We present a female patient who had a beating mitral valve replacement after valve-in-valve TAVI in a patient with prior Ross procedure. Weaning from cardiopulmonary bypass was difficult, and the patient needed extra-cardiac membrane oxygenation (ECMO) and intra-aortic balloon pump because of right ventricular dysfunction. The right ventricular dysfunction could be due to the concomitant coronary artery disease or air embolism during the beating mitral valve surgery. Recovery was gradual, and the patient was discharged after 33 days. Pre-discharge echocardiography showed a maximum gradient of 9 mmHg on the aortic valve and mild paravalvular leak.

Conclusions: Mitral valve replacement in a patient with prior TAVI and the Ross procedure was feasible; it decreased the operative risk and did not distort the implanted aortic valve.
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http://dx.doi.org/10.1186/s43044-019-0030-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6856227PMC
November 2019

Immunoglobulin G4 Thymic Tumor.

Ann Thorac Surg 2019 10 23;108(4):e229-e231. Epub 2019 Mar 23.

Department of Cardiothoracic Surgery, Tanta University, Tanta, Egypt.

Thymic immunoglobulin G4 (IgG4) is a rare entity that can mimic anterior mediastinal tumors. Preoperative diagnosis is essential to prevent unnecessary surgery. Little is known about disease presentation, diagnosis, and response to therapy. A 40-year-old man presented with retrosternal chest pain. A roentgenogram showed an anterior mediastinal mass. Intraoperatively, dense adhesions to the phrenic nerve, aorta, and pulmonary artery deemed the tumor unresectable. Thymic IgG4 disease was diagnosed on the basis of tissue biopsy. The patient's postoperative serum IgG4 level was elevated, and no other organ was affected. The patient responded to prednisolone therapy, and after 18 months of follow-up, there was no recurrence or involvement of other organs.
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http://dx.doi.org/10.1016/j.athoracsur.2019.02.043DOI Listing
October 2019

Implementation of an evidence-based practice to decrease surgical site infection after coronary artery bypass grafting.

J Int Med Res 2019 Aug 21;47(8):3491-3501. Epub 2019 Mar 21.

2 Department of Cardiovascular Diseases, Cardiothoracic Surgery Section, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.

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http://dx.doi.org/10.1177/0300060519836511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6726785PMC
August 2019

Effect of Fast Cardioplegic Arrest Induced by Adenosine on Cardiac Troponin Levels After Heart Valve Surgery.

Heart Lung Circ 2019 Nov 12;28(11):1714-1719. Epub 2018 Sep 12.

Cardiothoracic Surgery Department, Tanta University, Egypt. Electronic address:

Background: Cellular injury is not avoidable with current cardioplegic solutions. The effect of adenosine on reducing cardiac injury post-surgery is controversial. The objective of the current study is to evaluate the effect of fast cardioplegic arrest induced by adenosine on high sensitive cardiac troponin I after heart valve surgery.

Methods: Forty-five (45) patients with rheumatic heart diseases underwent heart valve surgery using conventional approach through median sternotomy. They were classified into two groups, group I (n=21) patients received 0.25mg/kg adenosine into the aortic root just after aortic cross-clamping and before infusion of the cold hyperkalaemic crystalloid cardioplegia via antegrade route and group II (n=24) who received cold crystalloid hyperkalaemic cardioplegia without adenosine. Cardiac troponin I was measured preoperatively and on postoperative days 0, 3 and 7.

Results: There was no significant difference between both groups in the demographic, preoperative and operative data. Adenosine significantly reduced arrest time. Postoperative high sensitive cardiac troponin I increased significantly in both groups compared to the preoperative levels and the rise continued till postoperative day 3. Troponin levels were significantly lower in the adenosine group compared to the control at all measurements. The clinical outcomes were non-significant different between groups.

Conclusions: Using adenosine in inducing fast cardioplegic arrest in heart valve surgery after aortic cross clamp and prior to infusion of the cold cardioplegia had significantly decreased postoperative cardiac troponin levels which was used as a proxy for cellular injury compared to the control group.
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http://dx.doi.org/10.1016/j.hlc.2018.08.017DOI Listing
November 2019

Bilateral Paravertebral Block versus Thoracic Epidural Analgesia for Pain Control Post-Cardiac Surgery: A Randomized Controlled Trial.

Thorac Cardiovasc Surg 2020 08 16;68(5):410-416. Epub 2018 Aug 16.

Department of Cardiothoracic Surgery, Faculty of Medicine-Tanta University, Tanta, Gharbeya, Egypt.

Background: Adequate pain control after cardiac surgery is essential. Paravertebral block is a simple technique and avoids the potential complications of epidural catheters. The objective of this study is to compare the effect of ultrasound-guided bilateral thoracic paravertebral block with thoracic epidural block on pain control after cardiac surgery.

Materials And Methods: Between March 2016 and 2017, 145 patients who had cardiac surgery through median sternotomy were randomized by stratified blocked randomization into two groups. Group I ( = 70 patients) had bilateral ultrasound-guided thoracic paravertebral block and Group II ( = 75 patients) had thoracic epidural analgesia. The primary end point was the postoperative visual analogue scale (VAS). The duration of mechanical ventilation, intensive care unit (ICU), and hospital stay were the secondary end points. The study design is a randomized parallel superiority clinical trial.

Results: Both groups had similar preoperative and operative characteristics. No significant difference in VAS measured immediately after endotracheal extubation then after 12, 24, and 48 hours between groups ( = 0.45). Pain score significantly declined with the repeated measures (< 0.001) and the decline was not related to the treatment group. Postoperative pain was significantly related to diabetes mellitus ( = 0.039). Six patients in group I (8.5%) required an additional dose of morphine versus three patients (4%) in group II ( = 0.30). Patients in group I had significantly shorter ICU stay ( = 0.005) and lower incidence of urinary retention ( = 0.04) and vomiting ( = 0.018). No difference was found in operative complications between groups.

Conclusion: This randomized parallel controlled trial demonstrates that ultrasound-guided paravertebral block is safe and effective method for relieving post-cardiac surgery sternotomy pain compared with thoracic epidural analgesia but not superior to it.
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http://dx.doi.org/10.1055/s-0038-1668496DOI Listing
August 2020

Junctional ectopic tachycardia following tetralogy of fallot repair in children under 2 years.

J Cardiothorac Surg 2018 Jun 5;13(1):60. Epub 2018 Jun 5.

Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Research Center, MBC J-16, P.O Box: 40047, Jeddah, 21499, Saudi Arabia.

Background: Junctional ectopic tachycardia is a serious arrhythmia that frequently occurs after tetralogy of Fallot repair. Arrhythmia prophylaxis is not feasible for all pediatric cardiac surgery patients and identification of high risk patients is required. The objectives of this study were to characterize patients with JET, identify its predictors and subsequent complications and the effect of various treatment strategies on the outcomes in selected TOF patients undergoing total repair before 2 years of age.

Methods: From 2003 to 2017, 609 patients had Tetralogy of Fallot repair, 322 were included in our study. We excluded patients above 2 years and patients with preoperative arrhythmia. 29.8% of the patients (n = 96) had postoperative JET.

Results: JET patients were younger and had higher preoperative heart rate. Independent predictors of JET were younger age, higher preoperative heart rate, cyanotic spells, non-use of B-blockers and low Mg and Ca (p = 0.011, 0.018, 0.024, 0.001, 0.004 and 0.001; respectively). JET didn't affect the duration of mechanical ventilation nor hospital stay (p = 0.12 and 0.2 respectively) but prolonged the ICU stay (p = 0.011). JET resolved in 39.5% (n = 38) of patients responding to conventional measures. Amiodarone was used in 31.25% (n = 30) of patients and its use was associated with longer ICU stay (p = 0.017). Ventricular pacing was required in 4 patients (5.2%). Median duration of JET was 30.5 h and 5 patients had recurrent JET episode. Timing of JET onset didn't affect ICU (p = 0.43) or hospital stay (p = 0.14) however, long duration of JET increased ICU and hospital stay (p = 0.02 and 0.009; respectively).

Conclusion: JET increases ICU stay after TOF repair. Preoperative B-blockers significantly reduced JET. Patients with preoperative risk factors could benefit from preoperative arrhythmia prophylaxis and aggressive management of postoperative electrolyte disturbance is essential.
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http://dx.doi.org/10.1186/s13019-018-0749-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5989382PMC
June 2018

Surgical strategies protecting against right ventricular dilatation following tetralogy of Fallot repair.

J Cardiothorac Surg 2018 Jan 22;13(1):14. Epub 2018 Jan 22.

Cardiothoracic Surgery Department, Tanta University, Al-Geish Street, Tanta, 31527, Gharbya, Egypt.

Background: Right ventricular (RV) volume overload increases morbidity and mortality after tetralogy of Fallot (TOF) repair. Surgical strategies like pulmonary leaflets sparing and tricuspid valve repair at time of primary repair may decrease RV overload. Our objective is to evaluate early and midterm results of pulmonary leaflets sparing with infundibular preservation and tricuspid valve repair in selected TOF patients with moderate pulmonary annular hypoplasia.

Methods: From 2011 to 2016; 46 patients with TOF and moderate pulmonary annular hypoplasia had surgical repair with sparing of the pulmonary valve leaflets. Concomitant tricuspid valve repair was performed in 33 patients (71.8%). Mean age was 13.1 ± 4.8 months, 68% were males (n = 31) and mean weight was 9.5 ± 2.3 kg. Preoperative McGoon ratio was 1.9 ± 0.4 and pulmonary valve z-score ranges from - 2 to - 3. Preoperative pressure gradient of RVOT was 80.9 ± 7.7 mmHg and 10.9% had minor coronary anomalies (n = 5).

Results: All repairs were performed through trans-atrial trans-pulmonary approach. 87% had pulmonary valve commissurotomy (n = 40). Mean cardiopulmonary bypass time was 71 ± 6.3 min and ischemic time 42.4 ± 4.9 min. Hospital mortality occurred in 4.3% (n = 2). Mean RVOT pressure gradient decreased significantly postoperatively (28.8 ± 7.2 mmHg, p-value< .001) and at the last follow up (23.6 ± 1.8 mmHg, p-value< .001). Pulmonary regurgitation progressed by one grade in 2 patients compared to the postoperative grade. 1 patient (2.5%) had late mortality and reintervention was required in 5 patients (12.5%).

Conclusion: Pulmonary leaflets sparing, and tricuspid valve repair are safe for TOF repair with no added morbidity or mortality. These procedures could contribute to reducing right ventricular volume overload over time after TOF repair.
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http://dx.doi.org/10.1186/s13019-018-0702-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5778645PMC
January 2018

Left ventricular myxoma associated with mitral regurgitation.

J Card Surg 2017 Dec 23;32(12):803-804. Epub 2017 Nov 23.

Department of Cardiology, Tanta University, Egypt.

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http://dx.doi.org/10.1111/jocs.13254DOI Listing
December 2017