Libman-Sacks endocarditis, first discovered in 1924, is a cardiac manifestation of systemic lupus erythematosus (SLE). Valvular involvement has been associated with SLE and antiphospholipid syndrome (APS). Mitral valve, especially its posterior leaflet, is most commonly involved. We report a case of a 34 year old woman with antiphospholipid antibody syndrome and SLE, who presented with mitral valve regurgitation. The patient underwent a prosthetic mitral valve replacement, with no followup complications. We suggest mechanical valve replacement employment in the management of mitral regurgitation in Libman-Sacks endocarditis, in view of the recent medical literature and our own case report.

Introduction Postoperative atrial fibrillation (AF) is the commonest of all the known cardiac arrhythmias after cardiac surgery. The postoperative AF has both short- and long-term adverse impacts on patients, like prolonged intensive care unit (ICU) stay, increased frequency of reoperations, myocardial infarction, increased use of inotropes, and intra-aortic balloon pump (IABP). There is a paucity of data regarding the postoperative AF after isolated coronary artery bypass grafting (CABG) and its risk factors in our geographic location. Therefore, the aim of this study was to determine the frequency of postoperative atrial fibrillation among patients undergoing isolated CABG at a tertiary care hospital of Karachi, Pakistan. Methods This prospective observational study was conducted on 163 consecutively selected patients undergoing first time isolated CABG at the Department of Cardiothoracic Surgery, Aga Khan University Hospital, Karachi. Patients with redo-sternotomy, preoperative atrial fibrillation and with other cardiac pathology were excluded from the study. Postoperative AF was defined in the patients with postoperative 12-lead electrocardiographic (ECG) finding of absence of P waves, replaced by unorganized electrical activity and irregular R-R intervals. Data analysis was carried out using IBM SPSS Statistics for Windows, Version 21.0 (IBM Corp., Armonk, NY, USA). Results A total of 163 patients were enrolled with the mean age of 58.66 ± 9.77 years ranging between 40 and 85 years with male predominance of 81% (132). The most common comorbidity was hypertension in about 68.1% (111), followed by diabetes mellitus in 54.6% (89) patients. Postoperative AF was observed in 42 (25.8%) patients. Most of the patients who developed postoperative AF, were overweight with mean body mass index (BMI) of 27.04 ± 4.85 kg/m 2 , 76.2% (32) had a history of hypertension, diabetes mellitus was associated with 33.3% (14) patients with postoperative AF and 50.0% (21) of them were smokers. Distribution of coronary artery disease in patients with postoperative AF was observed as three vessels coronary artery disease (3VCAD) in 83.3% (35), two-vessel coronary artery disease (2VCAD) was present in 7.1% (three), and rest of 9.5% (four) patients had single-vessel coronary artery disease (SVCAD). Conclusion The frequency of postoperative atrial fibrillation in our study was found to be 25.9% which is comparable to world literature. An important finding that comes through this study is a younger population undergoing CABG, which raises the possibility of early manifestation of ischemic heart disease in our region. This, however, needs further investigation. We were unable to point out the factors predictive of postoperative AF; studies with larger sample size would help in that regard.

A relatively rare occurrence, the incidence of ventricular septal defect (VSD) complicating penetrating cardiac trauma has been reported at 4.5%. Closing such defects may be challenging especially in an unstable patient where cardiopulmonary bypass may exponentially increase the surgical risk. In such patients, catheter-based device closure is a reliable and effective alternative. We describe case of a 30 year old man who presented with a stab wound to his anterior mediastinum. His injuries involved laceration to right and left ventricles and a VSD. His lacerations were repaired on a beating heart and the VSD was not addressed due to patient hemodynamic instability. The VSD was semi-electively closed using a 24 mm Amplatzer™ device as the patient demonstrated significant left to right shunt. Post-device closure, the patient developed hemolysis attributed to an intra- device residual leak. The hemolysis resolved without any complications by conservative medical management. At latest follow-up the patient is in NYHA functional class I-II.

Diabetic patients with increased serum creatinine preoperatively are at greater risk of kidney damage postoperatively; therefore, these patients should be monitored and treated critically in the perioperative period.

We present the case of a 3.5-year-old child who presented with recurrent chest infections and fever since birth. Antenatal ultrasonography had shown that she had a congenital cystic malformation of the left lower lobe of her lung. She was initially managed conservatively, and after a couple of years, underwent an uneventful left lower lobectomy via a posterolateral thoracotomy. She did very well after the procedure and her symptoms resolved significantly.

Background: Guide wire breakage and entrapment inside the coronary circulation are rare but extremely dangerous complications of coronary intervention that can be life-threatening by resulting in embolization of thrombi, perforation of the coronary vasculature, and thrombus development. Case Presentation: A male patient who developed a complication of left circumflex artery guide wire looped and trapped under left anterior descending artery (LAD) stent during Primary PCI and went for emergency cardiac surgery for removal. Management & Results: Guide wire entrapment during the intervention should always consider this as a risk factor, especially when intervening in the tortuous coronary vasculature, and it is important to keep several wires, snare wires, and a surgical team on board as a backup. Conclusion: Although guide wire entanglement infrequently occurs during interventions, interventionists should always be on the lookout for it, especially in patients with convoluted coronary arteries. Before working on these patient's coronary arteries, it's essential to have a surgical team, lots of wires, and snare wires on hand. These preventative measures may be effective in reducing death and morbidity under adverse conditions.

BackgroundBiopsy of the temporal artery is considered fundamental to making the diagnosis of temporal arteritis. Besides carrying a significant false negative rate owing to skip lesions, the procedure has a small risk of significant complications including facial nerve injury1, scalp necrosis2 and stroke3. The procedure may be contraindicated by delay in undertaking the biopsy from commencement of treatment, patient's wishes or bleeding diathesis.ObjectivesTo study the incidence of biopsy-proven temporal arteritis in the population surrounding Chesterfield Royal Hospital, United Kingdom.MethodsA retrospective review of 235 consecutive patients who underwent a temporal artery biopsy in Chesterfield Royal Hospital from January 2009 to January 2015. Study variables included age at diagnosis, gender, CRP, ESR and ALP results prior to treatment.ResultsAmong these 235 patients who underwent temporal artery biopsy, the mean age of those in the biopsy-positive group, 76.4 years (95% CI 73.8, 79.0), was higher than that of those in the biopsy-negative group, 70.4 (95% CI 69.0, 71.8). Using a two sample t-test, this generated a p value of 0.0002. A logistic regression model showed there is a statistically significant increase in the odds of a positive temporal artery biopsy of 1.072487 (CI 1.03045 to 1.116238) for every year increase of age, in addition to an odds increase of 1.022069 (CI 1.011327 to 1.032925) for every 1mm/hr increase in ESR. There was no statistical correlation between biopsy positive and biopsy-negative groups for CRP or ALP level; but a number patients had no CRP (97) or ALP (71) measured prior to diagnosis.ConclusionsOur results show there is a significant increase of likelihood of a positive temporal artery biopsy as the patient's age increases and the higher the value of ESR. Given a large enough sample, these results suggest that a scoring system may be created which can attempt to predict the likelihood of a positive temporal artery biopsy. This may be useful for patients in which temporal arteritis is suspected and biopsy is precluded.ReferencesSlavin ML. Brow droop after superficial temporal artery biopsy. Arch Ophthalmol 1986. 1041127.Dummer W, Zillikens D, Schulz A. et al. Scalp necrosis in temporal (giant cell) arteritis:implications for the dermatologic surgeon. Clin Exp Dermatol 1996. 21154–158.158.Haist SA. Stroke after temporal artery biopsy. Mayo Clin Proc 1985. 6053.Disclosure of InterestNone declared

Objectives: In this study we determined the frequency of renal dysfunction and its outcomes in terms of morbidity and mortality in patients who underwent open heart surgery at the Aga Khan University Hospital, Karachi, Pakistan. Methods: A total of 175 patients aged between 15-80 years having open heart Surgery(OHS) were included. Preoperative and postoperative serum creatinine (SCr) was noted and the glomerular filtration rate (GFR) calculated by Cockcroft-Gault equation. Their hospital course was charted and followed-up for 30-day. Results: The mean age and mean BMI were 58.1±12.6 years and 26.4±4.3 kg/m2 respectively. Females were 18.3%, out of which 51.4% hypertensive, 46.9% diabetics, 45.1% had dyslipidemia, 2.9% had preoperative renal dysfunction and 40% had moderate ejection fraction. On follow up, 30.3% developed postoperative renal dysfunction within 30-days after OHS with mean SCr and GFR as 1.6±0.7 and 56.9±24.5, respectively. In RD group more patients showed positive outcomes i.e. prolonged inotropic requirement (75.5% vs. 18%, p-value <0.005), diuretic infusion usage (47.2% vs. 3.3%, p-value <0.005), dialysis/renal replacement therapy (17% vs. 0%, p-value <0.005), requirement for prolonged ventilation (35.8% vs. 6.6%, p-value <0.005), prolonged ICU and hospital stay (15.4% vs. 1.6%, p-value <0.005 and 41.5% vs. 17.2%, p-value <0.005), sepsis (20.8% vs. 1.6%, p-value <0.005) and death (9.4% vs. 2.5%, p-value 0.05). Conclusion: Timely recognition of renal dysfunction, early renal replacement therapy, diuretics or dialysis and proper nutritional and inotropic support to maintain adequate hemostasis shows survival benefits. doi: https://doi.org/10.12669/pjms.37.7.3865 How to cite this:Ali TA, Tariq K, Salim A, Fatimi S. Frequency of Renal Dysfunction and its effects on outcomes after open heart surgery. Pak J Med Sci. 2021;37(7):---------. doi: https://doi.org/10.12669/pjms.37.7.3865 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.