Surgical treatment of a difficult case of atrial tachycardia requiring multiple electrophysiologic procedures.

A 34-year-old male with incessant drug-refractory atrial tachycardia (AT) was referred to our clinic for catheter ablation. The procedure began with endocardial activation mapping. The earliest endocardial activation site was in the right atrial appendage (RAA). The procedure continued with mapping of the left atrium through a transseptal approach. The earliest local activation was recorded at the anterior site of the right pulmonary veins. Radiofrequency (RF) ablation of both localizations was performed synchronously but failed to terminate the arrhythmia. The procedure continued with isolation of the RAA using cryoballoon but failed again due to the anomalous structure of the RAA. Then, epicardial RF ablation was attempted but failed. Finally, AT could only be terminated by surgical excision of the RAA.

Serum Levels of Cholesterol and Lipoproteins in Patients With Symptomatic Paravalvular Leaks.

Paravalvular leak (PVL) is a complication of valve replacement surgery which may lead to serious clinical consequences including hemolytic anemia. This study aimed to retrospectively evaluate the effect of successful intervention on serum lipid parameters in patients with PVL. A total of 106 patients (mean age: 57.2 ± 13.6 years, male: 67) who underwent surgical or transcatheter closure for symptomatic PVL were enrolled in this study. During the follow-up period, hemolysis and lipid parameters were evaluated at each clinical visit. This is the first study describing the effects of PVL on lipid metabolism after surgical or transcatheter closure. In the study, 18 patients (17%) had aortic PVL, 84 patients (79%) had mitral PVL, and 4 patients (3.8%) had both aortic and mitral PVL. A total of 59 patients underwent transcatheter closure and 47 patients were treated surgically. Technical success of the procedures was 83%. After successful PVL closure, hemoglobin and haptoglobin levels increased significantly (9.5 ± 1.3 vs 11.9 ± 2.1 g/dl, p <0.001 and 16.6 ± 7.9 vs 34.1 ± 19.9 mg, p <0.001, respectively). A significant increase in total cholesterol (158.9 ± 42.7 vs 209.3 ± 58.7 mg/dl, p <0.001), low-density lipoprotein cholesterol (99.1 ± 33.8 vs 133.9 ± 45.7 mg/dl, p <0.001), and high-density lipoprotein cholesterol (39.8 ± 12.4 vs 44.8 ± 11.7 mg/dl, p <0.001) levels was observed after successful PVL closure. In conclusion, symptomatic patients with PVL had hypocholesterolemia, reflected by low serum lipoprotein levels. After successful PVL closure, an increase in serum lipoprotein levels was observed. The recovery in levels of lipoproteins could be used as a marker of successful PVL closure, and absence of recovery of lipoprotein levels may indicate incomplete closure.

Unexpected isolated native pulmonary valve endocarditis; really benign as thought?

BACKGROUND: Isolated pulmonary valve endocarditis is extremely rare, accounting for <2% of cases. Major predisposing factors are intravenous drug use, implanted cardiac devices, congenital heart diseases, and central venous catheters. Most patients respond well to appropriate antibiotherapy. AIM: We report a case with an isolated native pulmonary valve endocarditis due to methicillin-resistant staphylococcus-aureus infection which developed after a tooth abscess in a previously healthy non-drug user young male. After one week antibiotherapy, surgery was required due to acute severe pulmonary insufficiency and right heart-failure. After the operation, he had a multi-organ failure despite veno-arterial extracorporeal membrane oxygenation, antibiotherapy, and other supportive treatments, therefore the case concluded with mortality. DISCUSION AND CONCLUSION: Our case showed that pulmonary valve endocarditis may occur in patients without risk factors in case of portal of entry for bacteremia and it may carry worse prognosis than previously known. Virulence of the microorganism and vegetation size are the major predictors of prognosis. Pulmonary valve endocarditis should be kept in mind even in patients without any known risk factors.

Multidisciplinary approach to right ventricular myxoma

Abstract Right ventricular (RV) myxoma that obstructs the RV outflow tract is rare. Multimodality imaging is crucial due to the curved and triangular shape of the RV anatomy. Incomplete resection by the right atrial approach in cardiac myxomas may be prevented by preoperative imaging with echocardiography, computed tomography and magnetic resonance imaging to provide detailed visualization. Right ventriculotomy may be an alternative approach to the isolated atrial approach to get complete resection of RV myxoma in suitable patients. The preferred surgical treatment is not well defined for ventricular myxomas and careful preoperative planning is essential. Surgical resection should be performed as soon as possible to avoid outflow tract obstruction, which might result in sudden death. The collaboration between cardiologist and heart surgeon and the effective use of imaging tools are essential for successful treatment. In this article, diagnosis and treatment and the heart team approach to RV myxoma are discussed with a demonstrative patient.

Multidisciplinary Approach to Right Ventricular Myxoma.

Right ventricular (RV) myxoma that obstructs the RV outflow tract is rare. Multimodality imaging is crucial due to the curved and triangular shape of the RV anatomy. Incomplete resection by the right atrial approach in cardiac myxomas may be prevented by preoperative imaging with echocardiography, computed tomography and magnetic resonance imaging to provide detailed visualization. Right ventriculotomy may be an alternative approach to the isolated atrial approach to get complete resection of RV myxoma in suitable patients. The preferred surgical treatment is not well defined for ventricular myxomas and careful preoperative planning is essential. Surgical resection should be performed as soon as possible to avoid outflow tract obstruction, which might result in sudden death. The collaboration between cardiologist and heart surgeon and the effective use of imaging tools are essential for successful treatment. In this article, diagnosis and treatment and the heart team approach to RV myxoma are discussed with a demonstrative patient.

Effects of anticoagulant drugs on wound healing process in a rat model: a comparative study.

OBJECTIVE: This study aims to compare the efficacy of enoxaparin, rivoraxaban and dabigatran on wound healing using a rat model. METHOD: Sprague-Dawley female rats (n=56), 10-12 weeks old, weight 245±30g, were used in this study. The rats were divided into four equally-sized groups. A type 1 (secondary wound healing) and type 2 (primary wound healing) wound was opened surgically on each rat in each group. Anticoagulent drugs enoxaparin, rivoraxaban and dabigatran and physiological saline solution were administered to Groups 1, 2, 3 and 4, respectively. After wound healing was scored tissue samples were taken from euthanised rats at days five and 10 and examined histologically. Since time was used as a classification (days five and 10), a time effect was included. RESULTS: There was no statistically significant difference in total score distribution in rats between type 1 secondary wounds for days five and 10 (p>0.05). There was no statistically significant difference in the overall score distribution in rats between type 2 primary wounds for days five and 10 (p>0.05). CONCLUSION: In addition to the use of low molecular weight heparin with well-known anticoagulation activity, the new generation oral medications are used efficiently in thromboembolic diseases. However, there was no evidence observed in this study that these drugs could be either beneficial or harmful to wound healing.

Is hypoalbuminemia a predictor for acute kidney injury after coronary bypass grafting in diabetes mellitus patients?

Abstract Objective: Acute kidney injury (AKI) is one of the most important complications after coronary artery bypass grafting (CABG) procedure. Serum albumin, which is an acute phase reactant, is suggested to be associated with AKI development subsequent to various surgical procedures. In this study, we research the relation between preoperative serum albumin levels and postoperative AKI development in diabetes mellitus (DM) patients undergoing isolated CABG. Methods: We included a total of 634 diabetic patients undergoing CABG (60.5±9.1 years, 65.1% male) into this study, which was performed between September 2009 and January 2014 in a single center. The relation between preoperative serum albumin levels and postoperative AKI development was observed. AKI was evaluated and diagnosed using the Kidney Disease: Improving Global Outcomes (KDIGO) classification. Results: AKI was diagnosed in 230 (36.3%) patients. Multiple logistic regression analysis was performed to determine the independent predictors of AKI development. Proteinuria (odds ratio [OR] and 95% confidence interval [CI], 1.066 [1.002-1.135]; P=0.043) and low preoperative serum albumin levels (OR and 95% CI, 0.453 [0.216-0.947]; P=0.035) were found to be independent predictors of AKI. According to the receiver operating characteristic curve analysis, albumin level <3mg/dL (area under the curve: 0.621 [0.572-0.669], P<0.001) had 83% sensitivity and 10% specificity on predicting the development of AKI. Conclusion: We observed that a preoperative low serum albumin level was associated with postoperative AKI development in patients with DM who underwent isolated CABG procedure. We emphasize that this adjustable albumin level should be considered before the operation since it is an easy and clinically implementable management for the prevention of AKI development.

Is Hypoalbuminemia a Predictor for Acute Kidney Injury after Coronary Bypass Grafting in Diabetes Mellitus Patients?

OBJECTIVE: Acute kidney injury (AKI) is one of the most important complications after coronary artery bypass grafting (CABG) procedure. Serum albumin, which is an acute phase reactant, is suggested to be associated with AKI development subsequent to various surgical procedures. In this study, we research the relation between preoperative serum albumin levels and postoperative AKI development in diabetes mellitus (DM) patients undergoing isolated CABG. METHODS: We included a total of 634 diabetic patients undergoing CABG (60.5±9.1 years, 65.1% male) into this study, which was performed between September 2009 and January 2014 in a single center. The relation between preoperative serum albumin levels and postoperative AKI development was observed. AKI was evaluated and diagnosed using the Kidney Disease: Improving Global Outcomes (KDIGO) classification. RESULTS: AKI was diagnosed in 230 (36.3%) patients. Multiple logistic regression analysis was performed to determine the independent predictors of AKI development. Proteinuria (odds ratio [OR] and 95% confidence interval [CI], 1.066 [1.002-1.135]; P=0.043) and low preoperative serum albumin levels (OR and 95% CI, 0.453 [0.216-0.947]; P=0.035) were found to be independent predictors of AKI. According to the receiver operating characteristic curve analysis, albumin level <3mg/dL (area under the curve: 0.621 [0.572-0.669], P<0.001) had 83% sensitivity and 10% specificity on predicting the development of AKI. CONCLUSION: We observed that a preoperative low serum albumin level was associated with postoperative AKI development in patients with DM who underwent isolated CABG procedure. We emphasize that this adjustable albumin level should be considered before the operation since it is an easy and clinically implementable management for the prevention of AKI development.

Surgical Ablation of Atrial Fibrillation in Patients With Tachycardia-Induced Cardiomyopathy.

BACKGROUND: Atrial fibrillation (AF) is a common cause of tachycardia-induced cardiomyopathy (TIC). This study evaluated the outcomes of the Cox-Maze IV procedure in patients with TIC and significant left ventricular dysfunction. METHODS: Between January 2002 and January 2017, 37 consecutive patients with a left ventricular ejection fraction (LVEF) of 0.40 or less underwent stand-alone surgical ablation of AF. After dilated and ischemic cardiomyopathies were excluded, 34 of 37 patients met the criteria for the diagnosis of TIC. RESULTS: Patients were a mean age of 56 ± 11 years, and 24 (70%) had long-standing persistent AF. The median AF duration was 72 months (interquartile range, 9 to 276 months). Seventeen patients (50%) had at least one catheter-based ablation that failed. Mean LVEF was 0.32 ± 0.08. There were 11 patients (32%) with New York Heart Association Functional Classification III/IV symptoms. There was one (3%) 30-day mortality caused by a pulmonary embolus, despite full anticoagulation. At 12 months, freedom from atrial tachyarrhythmias on or off antiarrhythmic drugs was 94% and 89%, respectively. Postoperative echocardiograms were available for 27 of 33 patients (82%). The LVEF improved to a mean of 0.55 ± 0.08 (95% confidence interval, 0.51 to 0.58; p < 0.001). Of the 11 patients with New York Heart Association Functional Classification III/IV symptoms, 8 patients were in class I/II at the last follow-up (p = 0.02). CONCLUSIONS: Restoration of sinus rhythm with the Cox-Maze IV was associated with significant improvement in the LVEF in patients with AF and TIC. This retrospective study illustrates the efficacy of the Cox-Maze IV in this patient population both at restoring sinus rhythm and improving ventricular function. Patients with TIC and poor left ventricular function in whom other treatments have failed should be strongly considered for surgical ablation.

Validation of Renal Risk Score Models for Coronary Artery Bypass Surgery in Diabetic Patients.

BACKGROUND: Coronary artery bypass grafting is applicable with very low mortality and morbidity rates around the world. However, exposure to even one of the risk factors increases mortality and morbidity significantly. There are three acute kidney injury definitions, and classification methods are applicable (Kidney Disease: Improving Global Outcomes (KDIGO); Risk, Injury, Failure, Loss of kidney function and End-stage kidney disease (RIFLE);" (for accuracy) and Acute Kidney Injury Network (AKIN)), for understanding and grading of renal impairment. With these definitions, it became possible to take measures at an early stage and start the management process. Methods for assessing renal impairment after coronary artery bypass grafting (CABG) specifically in patients with diabetes mellitus require further investigation. We compared these three acute kidney injury definitions for prediction of outcomes in diabetic patients undergoing coronary artery bypass grafting procedure. METHODS: Between January 2010 and December 2013, a total of 617 consecutive patients with diabetes mellitus undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass in our institution were included in the study. RESULTS: We considered 617 CABG operations on diabetes mellitus patients for this study from January 2010 to December 2013. The three scores provided good discriminative capacity in the global patient sample, with the area under the ROC curve (AUC) being higher, RIFLE (0.803, 95% CI: 0.724-0.882). The goodness of fit was good for all scales. CONCLUSIONS: Especially in on-pump CABG patients with diabetes mellitus, we can use AKIN, RIFLE, and KDIGO scoring systems to predict early diagnosis for acute kidney injury (AKI). In our analysis, the KDIGO criterion was superior to AKIN and RIFLE with regard its prognostic power.

The effect of time between angiography and coronary artery bypass grafting on postoperative acute kidney injury in patients with diabetes mellitus.

BACKGROUND: This study aims to investigate the effect of time interval between coronary angiography and coronary artery bypass grafting surgery on postoperative acute kidney injury in patients with diabetes mellitus. METHODS: Between December 2013 and November 2016, a total of 421 diabetic patients (274 males, 147 females; mean age 60±9.2 years; range, 31 to 84 years) who underwent coronary artery bypass grafting were included in the study. Data including demographic characteristics of the patients, comorbidities, medical, and surgical histories, previous coronary angiographies, and operative and laboratory results were retrospectively analyzed. The patients were divided into two groups as those with acute kidney injury (n=108) and those without acute kidney injury (n=313). The Risk, Injury, Failure, Loss, End-Stage Kidney Disease (RIFLE) criteria were used to define acute kidney injury. The patients were further classified into three subgroups according to the time interval: 0-3 days, 4-7 days, and >7 days. RESULTS: There was no statistically significant difference in the median time between coronary angiography and coronary artery bypass grafting between the patients with and without acute kidney injury (11.5 and 12.0 days; respectively p=0.871). There was no significant difference in the risk factors for acute kidney injury among the subgroups. Multivariate analysis revealed that previous myocardial infarction (odds ratio [OR]: 5.192, 95% confidence interval [CI]: 2.176-12.38; p<0.001) and the increase in the creatinine levels in the first postoperative day (OR: 4.102 and 95% CI: 1.278- 13.17; p=0.018) were independent predictors of acute kidney injury. CONCLUSION: Coronary artery bypass grafting can be performed without any delay after coronary angiography without an increase in the postoperative risk of acute kidney injury in patients with diabetes mellitus.

Management of Atrial Fibrillation in Patients Undergoing Coronary Artery Bypass Grafting: Review of the Literature.

Untreated atrial fibrillation is associated with an increased risk of all-cause mortality and morbidity. Despite the current guidelines recommending surgical ablation of atrial fibrillation at the time of coronary artery bypass surgery, most patients with concomitant atrial fibrillation and coronary artery disease do not receive surgical ablation for their atrial fibrillation. This review reports the efficacy of different surgical ablation techniques used for the treatment of atrial fibrillation during coronary artery bypass. PubMed was systematically searched for studies reporting outcomes of concomitant surgical ablation in coronary artery bypass patients between January 2002 and March 2018. Data were independently extracted and analyzed by two investigators. Twenty-four studies were included. Twelve studies exclusively reported outcomes of surgical ablation in patients undergoing coronary artery bypass, whereas the remaining 12 reported outcomes of concomitant cardiac surgery with subgroup analysis. Only four studies performed the concomitant Cox-Maze procedure. Freedom from atrial tachyarrhythmia was reported as high as 98% at 1 year and 76% at 5 years with Cox-Maze procedure, whereas lesser lesion sets had more variable outcomes, ranging from 35% to 93%. In most studies, the addition of surgical ablation was not associated with increased morbidity and mortality. Although the Cox-Maze procedure had the greatest short- and long-term success rates, most studies comprising the evidence documenting the safety and efficacy of adding surgical ablation were of low or moderate quality. There was a great deal of heterogeneity among study populations, follow-up times, methods, and definition of failure. To establish a consensus regarding a surgical ablation technique for atrial fibrillation in coronary artery bypass population, larger multicenter randomized controlled studies need to be designed.

Primary Cardiac Angiosarcoma with Rare Presenting Feature and Successful Surgical Treatment.

Primary angiosarcoma is a rare clinical entity, it's typically located within the right atrium and known to be rapidly fatal. A 37-year-old female was presented with a history of recurrent facial paralysis and left hemiparesis. A cranial mass was identified at cranial magnetic resonance imaging and she underwent neurosurgery operation. The immunohistochemical examination was determined as metastatic cardiac angiosarcoma. The tumor, as well as part of the right pericardium, were resected. A piece of bovine pericardium was used to reconstruct the right atrial wall. Tricuspid valve was reconstructed with ring annuloplasty. Due to resection of right coronary artery with the tumor, coronary bypass surgery was performed successfully. The patient is currently healthful without any recurrence and complaint 12 months after the diagnosis as followed up.

Primary cardiac angiosarcoma with rare presenting feature and successful surgical treatment

Abstract Primary angiosarcoma is a rare clinical entity, it's typically located within the right atrium and known to be rapidly fatal. A 37-year-old female was presented with a history of recurrent facial paralysis and left hemiparesis. A cranial mass was identified at cranial magnetic resonance imaging and she underwent neurosurgery operation. The immunohistochemical examination was determined as metastatic cardiac angiosarcoma. The tumor, as well as part of the right pericardium, were resected. A piece of bovine pericardium was used to reconstruct the right atrial wall. Tricuspid valve was reconstructed with ring annuloplasty. Due to resection of right coronary artery with the tumor, coronary bypass surgery was performed successfully. The patient is currently healthful without any recurrence and complaint 12 months after the diagnosis as followed up.

Comparison between iloprost and alprostadil for protection against ischemia/reperfusion injury in a rat model

Background/aim: Alprostadil and iloprost are successful agents used for both pulmonary hypertension and extremity ischemia treatment. Different systemic effects of these agents may change the preferences of clinical usage. Superiority of preventing ischemia/ reperfusion (IR) injury is a criterion for clinical preference of these agents. The present study was designed to compare the protective effects of alprostadil and iloprost in a rat model of IR injury. Materials and methods: Twenty-three male Sprague Dawley rats were used (aged 8-12 weeks, mean weight 230 ± 30 g). They were randomized into 4 groups: Group 1 (iloprost + IR), Group 2 (alprostadil + IR), Group 3 (saline + IR), and Group 4 (control). Under general anesthesia, in all groups except Group 4, the abdominal region was explored and the abdominal aorta was temporarily clamped for 60 min. After the clamp was removed, 120 min of reperfusion was applied. In Group 4, the rats were placed under general anesthesia and abdominal exploration was performed without the IR procedure. For all rats, body temperature was kept at 36 °C with a heater pad through the whole procedure. The rats were euthanized under general anesthesia to remove the kidneys and lungs for study. Histopathological and biochemical analyses were conducted with kidney and lung tissues. Histopathological scoring was done by analyzing cellular damage at tissue level. Malondialdehyde (MDA), superoxide dismutase, and glutathione levels were studied for biochemical analysis. Results: Histopathologic analysis showed that, as compared with alprostadil, iloprost provided a significantly higher level of renal protection against IR injury (P < 0.01). Renal tissue levels of MDA were significantly lower in the alprostadil group as compared to Group 3 (P < 0.05). Conclusion: Alprostadil and iloprost seem to provide protection against IR injury, with iloprost being more protective in renal tissue. Alprostadil is more effective than iloprost in protecting lung tissue against IR injury.

Factors associated with early mortality in haemodialysis patients undergoing coronary artery bypass surgery.

INTRODUCTION: Coronary artery bypass grafting (CABG) results in higher morbidity and mortality rates in end-stage renal disease (ESRD) patient populations than in patients with normal renal function. This study aimed to identify the early results of CABG performed on ESRD patients, and the factors that affected the mortality rates of those patients. METHODS: A retrospective evaluation of our hospital database revealed 84 haemodialysis-receiving patients who underwent CABG during the years 2006 to 2012. Mortality was observed in 21 patients (group 1), and this group was compared with the remaining patients (group 2) for peri-operative parameters such as age, EuroSCORE, functional capacity, myocardial infarction, use of inotropes and completeness of revascularisation. RESULTS: The study included 60 male (71.4%) and 24 female patients (28.6%); the participants' mean age was 59.50 ± 9.93 years. The pre-operative additive EuroSCORE was 7.96 ± 2.88 (range: 2-18). Pre-operative functional capacity was impaired in 35.7% of the patients [New York Heart Association (NYHA) classes III-IV]. Mean age and preoperative EuroSCORE values of group 1 were significantly higher than those of group 2. Impaired functional capacity (NHYA classes III-IV) was also associated with mortality (OR: 3.333; 95% CI: 1.199-9.268). Fifty-four patients (64.3%) underwent on-pump CABG procedures, and 30 (35.7%) underwent off-pump CABG procedures. The study found no statistically significant difference in mortality rates between these two techniques. Mortality occurred in 12 patients (22.2%) in the on-pump group and in nine (30%) in the off-pump group. Complete revascularisation was performed on 46 patients (85.2%) in the on-pump group and seven (23.3%) in the off-pump group (p < 0.001). CONCLUSION: Advanced age, impaired NYHA functional capacity and pre-operative hypertension were determinative for early-term surgical mortality. An on-pump surgical technique is recommended to ensure completeness of revascularisation.

Comparison of Early Outcomes with Three Approaches for Combined Coronary Revascularization and Carotid Endarterectomy.

Objective: This study aims to compare three different surgical approaches for combined coronary and carotid artery stenosis as a single stage procedure and to assess effect of operative strategy on mortality and neurological complications. Methods: This retrospective study involves 136 patients who had synchronous coronary artery revascularization and carotid endarterectomy in our institution, between January 2002 and December 2012. Patients were divided into 3 groups according to the surgical technique used. Group I included 70 patients who had carotid endarterectomy, followed by coronary revascularization with on-pump technique, group II included 29 patients who had carotid endarterectomy, followed by coronary revascularization with off-pump technique, group III included 37 patients who had coronary revascularization with on-pump technique followed by carotid endarterectomy under aortic cross-clamp and systemic hypothermia (22-27ºC). Postoperative outcomes were evaluated. Results: Overall early mortality and stroke rate was 5.1% for both. There were 3 (4.3%) deaths in group I, 2 (6.9%) deaths in group II and 2 (5.4%) deaths in group III. Stroke was observed in 5 (7.1%) patients in group I and 2 (6.9%) in group II. Stroke was not observed in group III. No statistically significant difference was observed for mortality and stroke rates among the groups. Conclusion: We identified no significant difference in mortality or neurologic complications among three approaches for synchronous surgery for coronary and carotid disease. Therefore it is impossible to conclude that a single principle might be adapted into standard practice. Patient specific risk factors and clinical conditions might be important in determining the surgical tecnnique.

Comparison of early outcomes with three approaches for combined coronary revascularization and carotid endarterectomy

Abstract Objective: This study aims to compare three different surgical approaches for combined coronary and carotid artery stenosis as a single stage procedure and to assess effect of operative strategy on mortality and neurological complications. Methods: This retrospective study involves 136 patients who had synchronous coronary artery revascularization and carotid endarterectomy in our institution, between January 2002 and December 2012. Patients were divided into 3 groups according to the surgical technique used. Group I included 70 patients who had carotid endarterectomy, followed by coronary revascularization with on-pump technique, group II included 29 patients who had carotid endarterectomy, followed by coronary revascularization with off-pump technique, group III included 37 patients who had coronary revascularization with on-pump technique followed by carotid endarterectomy under aortic cross-clamp and systemic hypothermia (22-27ºC). Postoperative outcomes were evaluated. Results: Overall early mortality and stroke rate was 5.1% for both. There were 3 (4.3%) deaths in group I, 2 (6.9%) deaths in group II and 2 (5.4%) deaths in group III. Stroke was observed in 5 (7.1%) patients in group I and 2 (6.9%) in group II. Stroke was not observed in group III. No statistically significant difference was observed for mortality and stroke rates among the groups. Conclusion: We identified no significant difference in mortality or neurologic complications among three approaches for synchronous surgery for coronary and carotid disease. Therefore it is impossible to conclude that a single principle might be adapted into standard practice. Patient specific risk factors and clinical conditions might be important in determining the surgical tecnnique.