The right ventricular annular velocity reduction caused by coronary artery bypass graft surgery occurs at the moment of pericardial incision.

BACKGROUND: Right ventricular (RV) long-axis function is known to be depressed after cardiac surgery, but the mechanism is not known. We hypothesized that intraoperative transesophageal echocardiography could pinpoint the time at which this happens to help narrow the range of plausible mechanisms. METHOD: Transthoracic echocardiography was conducted in 33 patients before and after elective coronary artery bypass graft. In an intensively monitored cohort of 9 patients, we also monitored RV function intraoperatively using serial pulsed wave tissue Doppler (PW TD) transesophageal echocardiography. RESULTS: There was no significant difference in myocardial velocities from the onset of the operation up to the beginning of pericardial incision, change in RV PW TD S' velocities 3% +/- 2% (P = not significant). Within the first 3 minutes of opening the pericardium, RV PW TD S' velocities had reduced by 43% +/- 17% (P < .001). At 5 minutes postpericardial incision, 2 minutes later, the velocities had more than halved, by 54% +/- 11% (P < .0001). Velocities thereafter remained depressed throughout the operation, with final intraoperative S' reduction being 61% +/- 11% (P < .0001). One month after surgery, in the full 33-patient cohort, transthoracic echocardiogram data showed a 55% +/- 12% (P < .0001) reduction in RV S' velocities compared with preoperative values. CONCLUSIONS: Minute-by-minute monitoring during cardiac surgery reveals that, virtually, all the losses in RV systolic velocity occurs within the first 3 minutes after pericardial incision. Right ventricular long-axis reduction during coronary bypass surgery results not from cardiopulmonary bypass but rather from pericardial incision.

Novel applications of Dermabond (2-octyl -cyanoacrylate) in cardiothoracic surgery.

Dermabond (Ethicon Inc., Somerville, NJ, USA) is a cyanoacrylate adhesive normally indicated for skin wound closure. This study describes the emergency use of this adhesive to control bleeding close to coronary anastomoses in exceptional cases. Dermabond was used in 17 patients who underwent cardiac surgery during an eight-month period, where other haemostatic interventions were unsuitable. It was applied for haemorrhage in 15 patients and control air leaks in two of the patients. Haemostasis was successful with Dermabond alone in 11 patients; the remaining four required additional interventions. It effectively controlled haemorrhage from ventricular pacing wires, vascular sling holes, peri-anastomotic bleeding, and epicardial tears. The adhesive was not placed directly on any graft because of embolic risk. In the two patients with visible air leaks, it was successfully used. No patient events were recorded as a result of haemorrhage and no reported toxicity. Dermabond may be indicated in circumstances in which haemostasis with traditional methods has failed or is inappropriate. A need for further high-quality objective research exists on the effectiveness and long-term safety of 2-octyl cyanoacrylate in cardiac surgery.

The Ross II procedure: pulmonary autograft in the mitral position.

The surgical management of mitral valve disease in women of childbearing age, young patients, and children with congenital mitral valve defects is made difficult by the prospect of lifelong anticoagulation. We suggest the use of a pulmonary autograft in the mitral position (Ross II procedure) as an alternative surgical technique. We present a review of the literature, historical perspectives, indications, selection criteria, and surgical technique for the Ross II procedure. Our literature search identified 14 studies that reported results from the Ross II operation. Performed in 103 patients, the overall in-hospital mortality was 7 (6.7%), with a late mortality of 10 (9%). Although further research is needed, current evidence suggests the Ross II operation is a valuable alternative in low-risk young patients where valve durability and the complication rate from other procedures is unsatisfactory and anticoagulation not ideal.

Should the internal thoracic artery be skeletonized?

Traditionally, the internal thoracic artery is harvested as a pedicle. In contemporary cardiac surgical practice, however, certain surgeons practice the internal thoracic artery-skeletonization technique. A systematic review of clinical studies reporting on the use of skeletonized internal thoracic arteries (SKT-ITA) has not yet been performed. The primary aim of this review article is to examine comprehensively the entire body of evidence regarding the use of SKT-ITA. In particular, we aimed to analyze the effects of skeletonization on sternal blood supply, wall damage and blood flow in the harvested vessel, postoperative graft patency, and clinical outcome. Advantages and disadvantages of the skeletonization technique are highlighted and discussed.

Relationship between connexins and atrial activation during human atrial fibrillation.

INTRODUCTION: Gap junctional connexin proteins (connexin40 [Cx40], connexin43 [Cx43]) are a determinant of myocardial conduction and are implicated in the development of atrial fibrillation (AF). We hypothesized that atrial activation pattern during AF is related to connexin expression and that this relationship is altered by AF-induced remodeling in the fibrillating atria of chronic AF. METHODS AND RESULTS: Isochronal activation mapping was performed during cardiac surgery on the right atria of patients in chronic AF (n = 13) using an epicardial electrode array. The atrial activation pattern was categorized using a complexity score based on the number of propagating wavefronts of activation and by grouping atria into those capable of uniform planar activation (simple) and those that were not (complex). The activation pattern was correlated with the levels of Cx43 and Cx40 signal measured by immunoconfocal quantification of biopsies from the mapped region. We studied the impact of electrical remodeling by comparing these findings with the unremodeled atria of patients in sinus rhythm during pacing-induced sustained AF (n = 17). In chronic AF, atria with complex activation had lower Cx40 signal than atria showing simple activation (0.013 +/- 0.006 microm(2)/microm(2) vs 0.027 +/- 0.009 microm(2)/microm(2), P < 0.02), with the relative connexin signal (Cx40/Cx40+Cx43) correlating with complexity score (P = 0.01, r =-0.74). This relationship did not occur in the unremodeled atria, and increased heterogeneity of distribution of Cx40 labeling in chronic AF was the only evidence of connexin remodeling that we detected in the overall group. CONCLUSION: The pattern of atrial activation is related to immunoconfocal connexin signal only in the fully remodeled atria of chronic AF. This suggests that intercellular coupling and pattern of atrial activation are interrelated, but only in conjunction with the remodeling of atrial electrophysiology that occurs in chronic AF.

Video assisted resternotomy in high-risk redo operations - the St Mary's experience.

The incidence of re-operative median sternotomy is rising. During resternotomy, catastrophic haemorrhage remains a dreaded complication. We describe our approach and experience with the combined use of Mayfield resternotomy retractor and anterior sternal retraction which allows division of adhesions between the sternum and mediastinal structures under direct vision with endoscopic or conventional instruments prior to resternotomy with a standard Hall reciprocating saw. The mean time to divide the retro-sternal adhesions was 26.4+/-16.7 min. No morbidity related to sternal division was observed. For redo surgery, repeat sternotomy under direct vision may reduce the sternotomy related morbidity (especially the need for cardiopulmonany bypass due to significant haemorrhage) and mortality.