Explore the vast range of titles available.

Pseudoaneurysm of the ascending aorta is a rare but dreadful complication following cardiac surgery and it has more chances of rupturing in elderly females. It occurs as a result of lengthy cardiopulmonary bypass time and associated degenerative changes in old patients. Due to the poor prognosis, early diagnosis and management of this complication is essential. Our case is of a 68-year old female who developed a 44 mm large ascending aortic pseudoaneurysm 7 days after undergoing (coronary artery bypass grafting) CABG for long-standing. (Triple vessel coronary artery disease) TVCAD. The location of the pseudoaneurysm was found to be just above the vein graft to the RCA on (computerized tomography) CT-Aortogram. 2D-Echocardiography showed an Ejection Fraction of 45% and a 22 mm neck of the aneurysmal sac. Trans-catheter device closure was planned and the neck was successfully closed with no residual leak seen on (computerized tomography) CT-Aortogram performed after 3 days. However, she developed cardiac arrest during the device closure and even after successful resuscitation she went into a state of septic shock in the following weeks that did not respond to maximum medical treatment which unfortunately led to her death. A review of 3 similar cases of post-cardiac surgery aortic pseudoaneurysms which were successfully managed via trans-catheter device closure is also discussed. Early diagnosis and interventional treatment of post-cardiac surgery aortic pseudoaneurysms in elderly patients is necessary alongside very careful surgical technique while performing cardiac surgery to minimize the risk of aneurysm formation.

Objective: To determine the efficacy of Ondansetron as a prophylctic agent in patients undergoing Coronary Artery Bypass Grafting. Study Design: Quasi-experimental study. Place and Duration of study: Adult Cardiac Surgery Department, AFIC/NIHD Rawalpindi Pakistan, from Nov 2022 to Feb 2023. Methodology: A total of 156 patients undergoing Coronary Artery Bypass Grafting Surgery irrespective of age and gender were included in the study via nonprobability consecutive sampling. Patients who had a previous history of psychiatric illness, and those in whom delirium could not be reliably tested were excluded from the study. The study population was divided into two groups (group A and group B). Those in the group A received 8mg Ondansetron intravenously on zero, first and second post-operative day. Group B did not receive any intervention. Descriptive statistics were used to measure percentages, frequencies and Mean±SD. Comparison between variables was made by Chi-square test for categorical variables and t-test for continuous variables. p<0.05 was considered statistically significant. Results: Total 156 patients were included in the study and mean age of the patients was 59.47±10.98 years. A total of 3(14.3%) patients who had been given Ondansetron compared to 18(85.7%) patients who were not given Ondansetron developed delirium (p<0.001). Other factors significantly associated with post cardiotomy delirium were age (p<0.001), hypertension (p<0.001), and diabetes (p=0.03). Conclusion: Our study revealed that Ondansetron can be used effectively to reduce the incidence of post cardiotomy delirium in patients of coronary artery bypass grafting.

Objective: Experience of the conventional and a de novo Mitral repair techniques for the treatment of Severe Mitral Regurgitation (MR) in a Tertiary Care Cardiac Hospital of Pakistan. Study Design: Descriptive cross sectional Place and Duration of Study: Cardiac Surgical Division, Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi, Pakistan Methodology: This was a cross sectional study conducted over a period of 5 years from 2016 to 2020, which included SeventyFive (n=75) patients in the trial, 55 females and 20 males. The mean age was 23±9.5 years (range from 16 to 52 years). Amongst all cases of mitral regurgitation (MR) were five (6%) myxomatous degenerative changes, three (4%) ischemic MR & Sixtyseven (91%) patients had rheumatic aetiology. Five (05) patients with myxomatous diseases required only ring annuloplasty. In patients with ischemic MR, two required chordal shortening for anterior leaflet resuspension, and one required quadrangular resection of the posterior leaflet. Restrictive annuloplasty±Coronary Artery Bypass Grafting (CABG) was alsoperformed as part of the procedures. Sixty-seven (91%) patients having severe Mitral Regurgitation with rheumatic aetiology, required a myriad of procedures; including neo-chordae suspension for anterior & posterior mitral leaflets, quadrangular resection & reattachment of the posterior mitral leaflet. A novel innovative procedure, “Posterior annulus-sliding-plasty” (Nasir’s Technique) was adopted in patients with relatively fixed posterior mitral leaflet. Semi-rigid rings (Carbomedics® or Medtronic CG future®) were used in all the patients to stabilize our repair. Results: There was no operative mortality. Patients were followed up for 01-year. Most of the patients have been found to have adequate intact Mitral Valve Repair. Only 01 patient developed Grade-II MR after 06 months (ischemic aetiology). This patient is being followed up at 06 monthly intervals with transthoracic echo and is being treated as per guideline-directed medical therapy (GMDT) for functional MR. Conclusion: Mitral Valve Repair in the carefully selected subset of patients with severe MR, irrespective of aetiology can effectively be treated with satisfactory short-term and medium-term results.

Objective: To compare the clinical outcomes of mitral valve surgery through right minithoracotomy versus median full sternotomy. Study Design: It was a comparative cross-sectional study Place and Duration of Study: Carried out at the Armed Forces Institute of Cardiology/National Institute of Heart Diseases(AFIC/ NIHD). Data was gathered from hospital database from Dec 2013 to Mar 2020. Methodology: From December 2013 to March 2020, 721 patients with various mitral valve diseases were treated at our institute with isolated mitral valve surgery. 50 patients had (MIMVS). 670 patients, on the other hand, underwent conventional median full sternotomy (MFS) mitral valve surgery. We selected 50 MFS patients with similar age, gender, Euro Score, NYHA functional class, Left ventricular ejection fraction (LVEF), mitral valve disease grade, renal and liver function. The outcome variables chosen for this study were cross clamp time (CXT), cardio pulmonary bypass (CPB) time, intensive care unit (ICU) stay, postoperative pain, and Length of stay (LOS). Results: The majority (n=42, 84%) of MIMVS group patients had CPB time between 122-201 minutes, whereas, majority (n=33,66%) of MFS group had CPB time between 81-134 minutes. In MIMVS group maximum number of the patients (n=36,72%)had ICU stay of 50-70 hours duration, whereas, in MFS group, maximum number of patients (n=40,80%) stayed in ICU for 10-30 hours duration. The mean CX time for MFS approach was 72.08 minutes while that for MIMVS was 96.9 minutes. Similarly,the median and mode for MFS were 68.5 minutes and 47 minutes respectively. Pain after surgery plus subsequent overall hospital length of stay (LOS) were reduced in MIMVS group. Conclusions: MIMVS is related with elevated CPB and CXT, which subsequently resulted in longer ICU stay while reduced post-operative pain lead to decrease in overall hospital length of stay.

Most patients with metastatic cancer eventually develop resistance to systemic therapy, with some having limited disease progression (ie, oligoprogression). We aimed to assess whether stereotactic body radiotherapy (SBRT) targeting oligoprogressive sites could improve patient outcomes. We did a phase 2, open-label, randomised controlled trial of SBRT in patients with oligoprogressive metastatic breast cancer or non-small-cell lung cancer (NSCLC) after having received at least first-line systemic therapy, with oligoprogression defined as five or less progressive lesions on PET-CT or CT. Patients aged 18 years or older were enrolled from a tertiary cancer centre in New York, NY, USA, and six affiliated regional centres in the states of New York and New Jersey, with a 1:1 randomisation between standard of care (standard-of-care group) and SBRT plus standard of care (SBRT group). Randomisation was done with a computer-based algorithm with stratification by number of progressive sites of metastasis, receptor or driver genetic alteration status, primary site, and type of systemic therapy previously received. Patients and investigators were not masked to treatment allocation. The primary endpoint was progression-free survival, measured up to 12 months. We did a prespecified subgroup analysis of the primary endpoint by disease site. All analyses were done in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT03808662, and is complete. From Jan 1, 2019, to July 31, 2021, 106 patients were randomly assigned to standard of care (n=51; 23 patients with breast cancer and 28 patients with NSCLC) or SBRT plus standard of care (n=55; 24 patients with breast cancer and 31 patients with NSCLC). 16 (34%) of 47 patients with breast cancer had triple-negative disease, and 51 (86%) of 59 patients with NSCLC had no actionable driver mutation. The study was closed to accrual before reaching the targeted sample size, after the primary efficacy endpoint was met during a preplanned interim analysis. The median follow-up was 11·6 months for patients in the standard-of-care group and 12·1 months for patients in the SBRT group. The median progression-free survival was 3·2 months (95% CI 2·0–4·5) for patients in the standard-of-care group versus 7·2 months (4·5–10·0) for patients in the SBRT group (hazard ratio [HR] 0·53, 95% CI 0·35–0·81; p=0·0035). The median progression-free survival was higher for patients with NSCLC in the SBRT group than for those with NSCLC in the standard-of-care group (10·0 months [7·2–not reached] vs 2·2 months [95% CI 2·0–4·5]; HR 0·41, 95% CI 0·22–0·75; p=0·0039), but no difference was found for patients with breast cancer (4·4 months [2·5–8·7] vs 4·2 months [1·8–5·5]; 0·78, 0·43–1·43; p=0·43). Grade 2 or worse adverse events occurred in 21 (41%) patients in the standard-of-care group and 34 (62%) patients in the SBRT group. Nine (16%) patients in the SBRT group had grade 2 or worse toxicities related to SBRT, including gastrointestinal reflux disease, pain exacerbation, radiation pneumonitis, brachial plexopathy, and low blood counts. The trial showed that progression-free survival was increased in the SBRT plus standard-of-care group compared with standard of care only. Oligoprogression in patients with metastatic NSCLC could be effectively treated with SBRT plus standard of care, leading to more than a four-times increase in progression-free survival compared with standard of care only. By contrast, no benefit was observed in patients with oligoprogressive breast cancer. Further studies to validate these findings and understand the differential benefits are warranted. National Cancer Institute.

Objective: To validate VO2 max testing with society of thoracic surgeon (STS) score in the preoperative assessment of patients undergoing coronary artery bypass graft surgery. Study Design: This was a single center and observational study. Place and Duration of Study: Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi Methodology: Forty four adult patients undergoing elective on pump coronary artery bypass graft surgery with an EF of >45% were included in this study as per inclusion criteria through non probability consecutive sampling. Five patients were lost to follow up. In 39 patients preoperative society of thoracic surgeons scoring was done and VO2 max of these patients was calculated. After coronary artery bypass graft surgery these patients were followed for mortality and morbidity. The discriminative capacity of VO2 max was compared with the STS risk scoring system using Receiver Operating Characteristic curves (ROC-curves). Results: We analyzed the data of 39 patients male 35 (89.7%), female 4 (10.3%). Mean age of our study population was 55.0 ± 10.2 years and a mean BMI of 26.8 ± 3.81. There were 20 (54.1%) hypertensives, 2 (5.4%) diabetics and 5 (13.5%) smokers. There was only one patient with a history of previous myocardial infarction. Majority of the patients belonged to NYHA class II 30 (76.9%) with a mean EF of 56.6 ± 5.17. Prolonged Ventilation (>24 hrs) was significantly associated with lesser values of VO2 max with a p-value of 0.01. Similarly, post-operative mortality and prolonged hospital stay in the low VO2 max groups correlated with the trends predicted by the society of thoracic surgeons scoring system. Conclusion: We conclude from this study that low preoperative VO2 max levels correlated well with STS scoring system for predicting mortality, ventilation time and length of hospital stay.

Objective: To compare the early outcome of Coronary Artery Bypass Graft surgery using a combination of antegrade and retrograde cardipoplegia with that utilizing antegrade cardioplegia alone in triple vessel coronary artery disease. Study Design: Comparative cross-sectional study. Place and Duration of Study: Department of Adult Cardiac Surgery of Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi, from Sep 2013 to Apr 2019. Methodology: A total of 160 patients with triple vessel coronary artery disease who underwent CABG surgery for 90% or greater stenos is in at least one major vessel in each of the three territories, namely the left anterior descending, the circumflex and the right coronary artery were investigated retrospectively. These were divided into 2 equal groups on the basis of the technique of administration of cardioplegia: in group-1 only ante grade blood cardioplegia was administered for myocardial protection and group-2 was given ante grade and retrograde cardiolplegia. Clinical outcomes like peri-operative mortality and morbidity were recorded, and serum creatine kinase MB, lactate, and mixed venous oxygen saturation levels were monitored. Two dimensional echocardiogram was performed on the 6th post-operative day and follow-up visits were planned 1 week and 4 weeksafter discharge from hospital. Results: There were 2 (2.5%) early deaths in group-1 and no peri-operative mortality in group-2. Five patients in group-1 (6.25%) and 2 (2.5%) in group-2 had non-fatal peri-operative myocardial infarction. However, significant differences included increased incidence of intra-operative ventricular dysrythmias, higher CK-MB levels at 24 hours after surgery, and increased requirement of intra-aortic balloon pump and inotropic support in Group-1. Conclusion: We conclude from this study that the combined delivery of ante grade and retrograde cardioplegia during CABG surgery for triple vessel coronary artery disease provides better myocardial protection and hence better outcome than antegrade cardioplegia alone.Keywords: , , ,

Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy but are associated with treatment-limiting immune-related cutaneous adverse events (irCAEs). Immune checkpoint inhibitor-related bullous pemphigoid (irBP), a severe, blistering irCAE occurs in 0.3%-1.5% of patients receiving ICI therapy. While systemic steroids can be effective, they are associated with significant toxicity and may mitigate -immunotherapy antitumor efficacy. Consequently, steroid-sparing therapies are needed. Dupilumab, an IL-4 and IL-13 receptor antagonist, has demonstrated efficacy in non-ICI-related BP and appears promising for managing irBP. We conducted a retrospective review of patients treated with dupilumab for irBP from April 2020 to April 2024. Clinical data, outcomes, and adverse events were assessed. Inhibitor-related bullous pemphigoid response was categorized as complete response (CR), partial response (PR), or no response (NR). In all, 17 patients (59% male, 82% non-Hispanic White; mean age 72.7 years) developed irBP while receiving PD-1/PDL-1 inhibitors. Sixteen patients (94%) received dupilumab for active irBP and one (6%) for prevention of recurrence. Dupilumab achieved CR of irBP for 12 patients (75%) and PR for 2 (12%) patients with active irBP. Ten (62%) achieved CR with dupilumab systemic monotherapy. Median time to first response was 19.5 days (range = 3-50). Most patients with CR (58%) failed prior oral corticosteroid therapy. The patient treated prophylactically experienced no irBP recurrence. Dupilumab was well-tolerated, with no adverse events. Dupilumab is a promising steroid-sparing option for irBP, achieving initial response in under 20 days for most cases. Dupilumab is a valuable tool to manage this challenging irCAE while minimizing risk related to systemic steroid treatment.

Abstract Background Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy but are associated with treatment-limiting immune-related cutaneous adverse events (irCAEs). Immune checkpoint inhibitor-related bullous pemphigoid (irBP), a severe, blistering irCAE occurs in 0.3%–1.5% of patients receiving ICI therapy. While systemic steroids can be effective, they are associated with significant toxicity and may mitigate ­immunotherapy antitumor efficacy. Consequently, steroid-sparing therapies are needed. Dupilumab, an IL-4 and IL-13 receptor antagonist, has demonstrated efficacy in non-ICI-related BP and appears promising for managing irBP. Methods We conducted a retrospective review of patients treated with dupilumab for irBP from April 2020 to April 2024. Clinical data, outcomes, and adverse events were assessed. Inhibitor-related bullous pemphigoid response was categorized as complete response (CR), partial response (PR), or no response (NR). Results In all, 17 patients (59% male, 82% non-Hispanic White; mean age 72.7 years) developed irBP while receiving PD-1/PDL-1 inhibitors. Sixteen patients (94%) received dupilumab for active irBP and one (6%) for prevention of recurrence. Dupilumab achieved CR of irBP for 12 patients (75%) and PR for 2 (12%) patients with active irBP. Ten (62%) achieved CR with dupilumab systemic monotherapy. Median time to first response was 19.5 days (range = 3–50). Most patients with CR (58%) failed prior oral corticosteroid therapy. The patient treated prophylactically experienced no irBP recurrence. Dupilumab was well-tolerated, with no adverse events. Conclusions Dupilumab is a promising steroid-sparing option for irBP, achieving initial response in under 20 days for most cases. Dupilumab is a valuable tool to manage this challenging irCAE while minimizing risk related to systemic steroid treatment.

Background: Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy but are associated with treatment-limiting immune-related cutaneous adverse events (irCAEs). Immune checkpoint inhibitor-related bullous pemphigoid (irBP), a severe, blistering irCAE occurs in 0.3%-1.5% of patients receiving ICI therapy. While systemic steroids can be effective, they are associated with significant toxicity and may mitigate mmunotherapy antitumor efficacy. Consequently, steroid-sparing therapies are needed. Dupilumab, an IL-4 and IL-13 receptor antagonist, has demonstrated efficacy in non-ICI-related BP and appears promising for managing irBP1 Methods: We conducted a retrospective review of patients treated with dupilumab for irBP from April 2020 to April 2024. Clinical data, outcomes, and adverse events were assessed. Inhibitor-related bullous pemphigoid response was categorized as complete response (CR), partial response (PR), or no response (NR). Results: In all, 17 patients (59% male, 82% non-Hispanic White; mean age 72.7 years) developed irBP while receiving PD-1/PDL-1 inhibitors. Sixteen patients (94%) received dupilumab for active irBP and one (6%) for prevention of recurrence. Dupilumab achieved CR of irBP for 12 patients (75%) and PR for 2 (12%) patients with active irBP Ten (62%) achieved CR with dupilumab systemic monotherapy. Median time to first response was 19.5 days (range = 3-50). Most patients with CR (58%) failed prior oral corticosteroid therapy. The patient treated prophylactically experienced no irBP recurrence. Dupilumab was well-tolerated, with no adverse events. Conclusions: Dupilumab is a promising steroid-sparing option for irBP, achieving initial response in under 20 days for most cases. Dupilumab is a valuable tool to manage this challenging irCAE while minimizing risk related to systemic steroid treatment. Key words: bullous pemphigoid; immunotherapy; dupilumab; ICI; toxicity; oncodermatology.