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Objective The aim of this study was to explore the fate of moderate ischemic mitral regurgitation (IMR) following isolated coronary artery bypass grafting (CABG). Background IMR is a frequently encountered problem seen in patients with coronary artery disease. A much-debated question is whether surgical revascularization alone will correct moderate (2+) IMR in such patients. Patients and methods The study group included 20 patients with moderate IMR associated with coronary artery disease undergoing isolated CABG. All patients had an ejection fraction of more than 30%. The patients were clinically and echocardiographically evaluated preoperatively, 1 week postoperatively and at 3- and 6-month intervals. Results CABG alone reduced the degree of IMR in 12 (60%) patients, did not improve it in five (25%) patients, and increased its degree to 3–4 + in three (15%) patients at 6-month follow-up echocardiography. Our study showed improved functional capacity of the patients. A significant reduction in the New York Heart Association functional class was observed. The mean preoperative value for New York Heart Association was 2.45 ± 0.51 versus 2.05 ± 0.88 postoperatively (P = 0.042). Some important variables showed a role in the progression of IMR. These were: left ventricular end-systolic dimension, left ventricular end-diastolic dimension, preoperative ejection fraction%, and failure to graft the diseased right coronary system. Conclusion The presence of moderate IMR in patients undergoing revascularization alone does not add additional burden to the operative risk nor does it affect the short-term outcome of these patients.

Objectives The aim of this study was to demonstrate whether transcatheter aortic valve implantation (TAVI) improves mortality and morbidity compared with surgical aortic valve replacement in high-risk patients who require intervention for aortic valve stenosis (AS). Many patients with severe AS and coexisting conditions are not candidates for surgical replacement of the aortic valve. Recently, TAVI has been suggested as a less invasive treatment for high-risk patients with AS. Patients and methods Fifty patients with severe AS for aortic valve intervention were classified as follows: group A, as TAVI group, included 25 patients who underwent aortic valve replacement by transcatheter femoral approach, and group B, as surgical aortic valve replacement group, included 25 patients who underwent aortic valve replacement by median sternotomy. Results Intraoperatively, procedure duration was 101.8 ± 10.6 and 191.2 ± 7.5 min in group A and B, respectively (P Conclusion In high-risk patients with severe AS, transcatheter and surgical procedures for aortic valve replacement were comparable for survival at 3 months, although there were important differences in periprocedural outcomes.

Objective To evaluate the risk factors affecting the early outcome of surgical treatment of infective endocarditis (IE). Background IE represents a series of clinical conditions with high in-hospital mortality, so early diagnosis and treatment can improve outcomes. Diagnosis depends on constant history and classic manifestations like sustained bacteremia or fungemia or active valvulitis. IE is a medical-surgical disease in which surgical treatment is a part of the therapeutic process rather than a result of the failure of medical treatment. Patients and methods A prospective cohort study was conducted on 50 consecutive patients diagnosed with definite IE and underwent cardiac surgery after being admitted to the Cardiothoracic Surgical Department, National Heart Institute, Giza, Egypt, during the period from December 2015 till March 2017. Preoperative, intraoperative, and postoperative data as potential predictors of mortality were tested. Results Our results showed that rheumatic heart disease was the most common underlying cardiac disease. Native valve endocarditis was present in 31 (62%) and prosthetic valve endocarditis in 19 (38%) patients. Mean Euro SCORE II was 5.71%. The hospital mortality was 22%, whereas the 6-month mortality was 10%. Congestive heart failure, embolization, and periannular extension of infection are the most powerful predictors of hospital mortality and also 6-month mortality. Conclusion Surgery for IE continues to be challenging. Euro SCORE II has a good discrimination ability to predict in-hospital mortality in IE surgery. Satisfactory results can be obtained with valve repair in IE.

Objective This study aims to compare the efficacy of mitral valve surgery with left atrial maze versus isolated mitral valve surgery. Background Atrial fibrillation (AF) is the most common arrhythmia in clinical practice, especially with mitral valve disease. It represents a significant health burden especially with the associated thromboembolic complications. Several surgical approaches have been developed. The most effective one is Cox-Maze III procedure using cut-and-sew technique. Recently, surgical ablation has been transformed into an easier and faster procedure using radiofrequency, microwave, and cryothermal energy. Patients and methods This is a prospective cohort study conducted after the approval of the Human Ethics Committee of Faculty of Medicine, Menoufia University. A total of 100 patients with permanent AF and concomitant mitral valve disease have been recruited. The patients were allocated into two equal groups. Group A included mitral valve surgery and left atrial maze procedure, whereas group B included mitral valve surgery without left atrial maze. Results Group A had significant longer bypass and clamp times than group B (P Conclusion Left atrial maze with mitral valve surgery results in a better outcome in terms of myocardial function and dimensions. In addition, sinus rhythm restoration has the potential benefit of reducing the incidence of thromboembolic complications.

Objective The objective of this study was to evaluate tricuspid valve (TV) ring annuloplasty for moderate functional tricuspid regurgitation (FTR) in patients undergoing mitral valve (MV) surgery. Background TV ring annuloplasty during MV surgery for severe FTR is recommended but for moderate FTR is controversial. Patients and methods Eighty patients with moderate FTR who were listed for MV surgery were classified into group A, the TV annuloplasty group which included 34 patients who underwent MV surgery and TV annuloplasty and group B, the TV nonrepair group, 46 patients who underwent MV surgery alone. Results At 1-month follow-up, in group A: no, mild, and severe FTR were detected in 70.6, 26.5, and 2.9% of patients, respectively, whereas in group B, no, mild, moderate, and severe FTR were detected in 26.1, 58.7, 13, and 2.9% of patients, respectively (P = 0.001). Pulmonary artery pressure (PAP) in groups A and B was 27.2 ± 5.1 and 31.7 ± 6.8 mmHg, respectively (P = 0.001). At 6-month follow-up, in group A no, mild, and severe FTR were detected in 64.7, 32.4, and 2.9% of patients, respectively, whereas in group B, no, mild, moderate, and severe FTR were detected in 32.6, 50, 15.2, and 2.2% of patients, respectively (P = 0.01). PAP in groups A and B was 27.6 ± 5.1 and 32.2 ± 7.1 mmHg, respectively (P = 0.003). Conclusion Intervention for moderate FTR is recommended during MV surgery to avoid persistence or progression of the TR especially in patients with high PAP.

Objectives The aim of the study was to study the different types of valve-sparing aortic root reconstruction techniques to assess the short-term results with respect to improvement of patient's functional status, left ventricular dimensions and functions, and durability of competent aortic valve and to detect predictors of failure of aortic repair. Background The focus on valve-sparing operations and the concomitant re-evaluation of the functional anatomy of the aortic root have demonstrated that aortic root deformation often coexists with architecturally and morphologically normal valve leaflets. Thus, sparing and realigning the leaflets and reconstructing the aortic root have the potential for avoiding prosthetic valve disease. Materials and methods This was a prospective analytical study conducted on 50 consecutive patients with aortic root aneurysm and dissection associated with significant aortic regurgitation. These patients were operated upon using aortic valve reimplantation technique and studied for aortic valve competence. Results Follow-up echocardiography was performed within 30 days postoperative, after 6 months, 1 year, and then yearly. Moderate aortic incompetence was found in four patients (P = 0.001) at 1 year, with 100% freedom from reintervention for valve-related problems. Conclusion Valve-sparing aortic root reimplantation (Tirone-David technique) is effective in correcting aortic insufficiency due to aortic root diseases, with good results with respect to durability of aortic repair.

Objectives To evaluate and compare the early hemodynamic results and echocardiographic data after rheumatic mitral valve replacement (MVR) in patients with mild and severe pulmonary hypertension (PH). Background Development of PH in association with valvular dysfunction is a marker of advanced disease. Some authors have reported no greater risk in patients with severe PH compared with those with a mild degree of PH, whereas others reported that severe PH is associated with a greater operative risk and a poorer long-term prognosis. It is desirable to reassess the outcome in these patients with newer anesthetic agents, improved valve prostheses, myocardial protection, and postoperative care. Patients and methods Between September 2013 and May 2015, this multicenter prospective observational study included 40 patients who presented with rheumatic mitral stenosis indicated for elective MVR divided into two equal groups: group A, with a mean pulmonary artery pressure (mPAP) equal to 26-40 mmHg, and group B, with mPAP more than 55 mmHg. All patients underwent conventional surgical MVR using cardiopulmonary bypass. Early hemodynamic improvement was observed with follow-up transthoracic echo performed 1 week and 3 months postoperatively Results Our study included 17 male and 23 female patients with a mean age of 32.40 years; all of them underwent conventional MVR with cardiopulmonary bypass. Throughout our study, we detected a statistically significant difference between both groups regarding the duration of postoperative mechanical ventilation and improvement in mPAP in both groups. There was a single case of morbidity in group B with no cases of mortality for 3 months postoperatively in both groups. Conclusion MVR is safe and effective even in patients with severe PH.

Objectives Evaluation of early outcomes of surgical aortic valve replacement (AVR) for patients with isolated severe aortic stenosis (AS) associated with left ventricular (LV) dysfunction and low transvalvular gradient. Background AS is the most common valvular heart disease in elderly people, with an incidence of 2-7% in the population above 65 years. Sudden death may be the first presentation for severe AS. AVR is the effective treatment for AS. Benefits versus mortality of surgical AVR is still controversial in patients who presented with severe AS associated with LV dysfunction and low gradient. Materials and methods Between October 2012 and January 2015, this multicenter prospective observational study included 20 consecutive patients who presented with isolated severe AS (valve area Results Our study included 14 male and six female patients with a mean age of 64.75 years and a mean EUROSCORE II of 1.62. All participants underwent conventional AVR with a cardiopulmonary bypass mean time of 113.3 min and a mean cross-clamp time of 69.6 min. The postoperative course involved a mean ICU stay of 3.6 days but, unfortunately, with two (10%) cases requiring reopening and mortality occurring in two (10%) cases. Among the 18 survivors, we detect statistically significant improvements in LV dimensions and systolic function in the postoperative follow-up Echo after 6 months. Conclusion Despite the high mortality rate (10%), surgical AVR is still the gold standard management for severe AS even in the risky subgroup of patients with LV dysfunction and low gradient, due to its effect in the LV function improvement.

Objective The aim of the study was to evaluate the use of vertical thoracotomy as a thoracic approach. Background A carefully planned thoracic incision should provide effortless and excellent exposure, preservation of the underlying anatomy and function, and a cosmetically acceptable result. Materials and methods We conducted a prospective, cohort study in which 30 consecutive patients were exposed to two types of thoracotomies performed by the surgeons of the cardiothoracic surgery Department in Menoufia University Hospital from October 2012 to October 2014. The patients were classified randomly into two groups: group A (n = 15) in which vertical thoracotomy was performed and group B (n = 15) in which standard posterolateral thoracotomy was performed. Operative data were collected from all patients in both groups as regards indication of operation, type of operation, intraoperative complications such as bleeding, need of extension of the incision, total operative time, and time of opening and closure of the thoracotomy. Results Results showed that vertical thoracotomy can be used for a wide range of procedures in different age groups and in both sexes. Shoulder joint movement was significantly better when vertical thoracotomy was used (P = 0.044), and cosmetic results are better. Conclusion Vertical thoracotomy offers specific advantages of minimum trauma and maximum preservation of chest wall function with a cosmetically acceptable scar.

Objectives The aim of this study was to investigate the overall outcome of adult patients undergoing redo-mitral valve replacement as emergency cases against elective cases. Background Patients with mechanical prosthetic heart valves are at risk of reoperation. The reported risk of mortality may be as low as 5.4-11% for elective reoperation, but as high as 38-61.5% for emergency procedures. Patients and methods Forty patients who had undergone previous mitral valve replacement were admitted for redo-mitral valve replacement during the period between May 2011 and May 2013 at the National Heart Institute. They were divided into two groups: group A: 20 patients were admitted from the ER as emergency cases; group B: 20 patients were admitted from outpatient clinics as elective cases. A mechanical valve was inserted with horizontal mattress pledgeted nonabsorbable sutures. Sutures were placed from left atrium to left ventricle. Tricuspid valve incompetence, if present, was corrected by tricuspid valve repair (De-Vega suture). Results The hospital mortality was 20%. There was no effect regarding age, sex, cardiac rhythm, number of previous operations, type of the previous prosthesis, and interval from last implantation. Taking into consideration that mortality was higher in the emergency group, the New York Heart Association (NYHA) functional class, left ventricular end systolic diameter, left ventricular end diastolic diameter, redo-cardiac surgery sternotomy, and adhesiolysis carry a significant risk of catastrophic bleeding, especially with the rush accompanying hemodynamic instability. Infective cardiac tamponade, permanent pacemaker, residual infective endocarditis, the need for dialysis, and cerebrovascular accidents were not statistically significant. Conclusion When significant valve dysfunction is first noted, reoperation should be undertaken to minimize the operative risk to avoid mortality and postoperative morbidities.

Objectives The aim of this study was to evaluate surgical results in patients with moderate tricuspid regurge undergoing mitral valve surgery either with or without concomitant tricuspid repair 6 months after surgery. Background Moderate tricuspid regurge has a variable natural history, as it may regress after mitral valve surgery without tricuspid repair, or may progress; hence, the decision to repair moderate tricuspid regurge in concomitant tricuspid repair with mitral valve surgery remains controversial. Patients and methods This study was conducted from January 2010 to June 2013. A total of 50 patients underwent mitral valve replacement for the first time with concomitant moderate tricuspid valve regurge. They were divided into two groups: group A (26 patients) who underwent mitral valve replacement alone, and group B (24 patients) who underwent mitral valve replacement and tricuspid valve repair using De Vega annuloplasty technique. Results The result showed that the tricuspid regurgitation improved postoperatively, irrespective of whether the repair was performed or not. However, statistical differences between group A and group B were significant. Conclusion Concomitant tricuspid valve repair with mitral valve surgery offered better early postoperative tricuspid valve function in patients with moderate tricuspid regurge, who underwent mitral valve surgery for chronic mitral valve disease.

Objectives The aim of the study was to achieve arterial myocardial revascularization using the 'Y-graft or T-graft' techniques and to measure intraoperative graft flow by transit-time flowmetry. Background Composite grafting techniques for coronary artery bypass grafts have been widely used. However, it remains unclear whether this technique provides similar blood flow to the left coronary artery. In this study, we evaluated composite grafting techniques by intraoperative measurement graft flow by transit-time flowmetry. Materials and methods Fifty patients who underwent coronary artery bypass grafting during a time period of 24 months were enrolled in this prospective study. All patients received sequential grafting using both internal thoracic arteries and left radial artery joined as a composite Y or T graft. Intraoperative left internal mammary artery (LIMA) flow was measured by transit-time flowmetry. Results This study provided evidence that the LIMA limb of a composite Y or T graft had intraoperative increase in mean flow, and there was statistical significance ( P Conclusion LIMA has the potential to provide sufficient blood flow to revascularize left coronary system.

Objectives The goal of this study was to determine whether the surgical management of moderate chronic ischemic mitral regurgitation (IMR) is to revascularize only or to revascularize and perform mitral valve repair as well. Background Ischaemic mitral regurgitation is a frequent complication of left ventricular global or regional pathological remodeling due to chronic coronary artery disease. Although there are numerous possible treatment modalities, the management of patients with moderate chronic IMR remains uncertain. Patients and methods Forty patients referred for coronary artery bypass grafting with moderate IMR and an ejection fraction more than 30% were randomized to receive coronary revascularization plus mitral valve repair (20 patients) or revascularization only (20 patients). Survivors were clinically and echocardiographically assessed early postoperatively and at 3 months' follow-up. Results There was no significant difference between the two groups as regards preoperative and demographic data. The operative time, ventilation time, and ICU stay were significantly higher in the repair group. Use of cardiac supports, complications, in-hospital mortality, and ward stay were not statistically significantly different. Postoperative and follow-up echocardiographic data showed no statistically significant difference in left atrial dimension, left ventricular dimension, and function between the two groups. Although the grade of mitral regurgitation showed improvement in both groups, there was significantly higher improvement in the repair group compared with the revascularization-only group. Conclusion Adding mitral repair to coronary revascularization in patients with moderate IMR may improve mitral regurgitation severity without additional risk. Improvement in functional capacity and left ventricular reverse remodeling was observed in both procedures.