HTK solution helps to preserve endothelial integrity of saphenous vein: an immunohistochemical and ultrastructural analysis.

The aim of the study is to demonstrate the ability of HTK (Histidine-tryptophan-ketoglutarate) solution to preserve endothelium. Ten saphenous veins (SVs) were prospectively collected from 10 patients who underwent coronary artery bypass grafting (CABG). The SVs were divided into two sets of segments, one of which preserved in HTK solution at 4°C (group A), and the other preserved at 4°C in saline solution NaCl 0.9% (group B); ten pieces from the SVs were processed as control. The control sample was fixed in 10% neutral buffered formalin immediately after harvesting. The observation lasted up to the 5th postoperative day. A morphological, ultrastructural, and immunohistochemical analysis (CD31) was performed on each piece. Immunohistochemical analysis demonstrated significant protection on endothelium in group A compared to group B starting from the 1st observational day. Ultrastructural data confirmed immunohistochemistry. These preliminary results represent a basis for further analysis. They suggest the protective role of HTK solution in preserving endothelial integrity and may imply some clinical benefits in organ protection.

Composite lengthened arterial conduits: long-term angiographic results of an uncommon surgical strategy.

BACKGROUND: We sought to evaluate the long-term patency rate of composite lengthened conduits. METHODS AND RESULTS: From December 1991 to April 2000, 43 patients had a composite lengthened arterial conduit. There was a mean of 2.83 +/- 1.23 anastomoses per patient. No 30-day mortality occurred. Five patients died from 3 to 84 months after the operation (mean, 38.6 +/- 34.6 months). After a mean follow-up of 57.0 +/- 32.3 months (range, 3-99 months), all the survivors are asymptomatic. The only cardiac major events recorded were 2 (4.6%) late acute myocardial infarctions in the patients who died. Eight-year survival and event-free survival were both 80.4% +/- 9.1% (range, 3%-93%). In the early period (13.5 +/- 4.8 days) in 26 patients, 26 arterial composite lengthened conduits and 37 distal anastomoses had postoperative angiographic control; all the anastomoses were rates as grade A, according to Fitzgibbon classification. In the late period (29 +/- 30 months) in 23 patients, 23 arterial composite lengthened conduits and 34 distal anastomoses were checked; the patency rate was 22 (95.6%) of 23 for the composite lengthened conduits and 33 (97%) of 34 for the distal anastomoses. CONCLUSIONS: In particular situations, when the length of an arterial conduit is not enough to allow a correct use of the graft, lengthening of an arterial conduit can be a safe and effective technique.

Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of the strategy on early outcome.

BACKGROUND: The impact of myocardial revascularization without cardiopulmonary bypass (CPB) was evaluated in a series of consecutive patients with multivessel disease. METHODS: From May 21, 1997 to November 30, 2000, 1,843 consecutive patients underwent isolated myocardial revascularization. From this total, 919 patients were done without CPB (group A, 49.9%) and 924 patients were done with CPB (group B, 50.1%). Patients that converted from without CPB to with CPB were included in group A. Thirty-three variables were evaluated with univariate and multivariate analysis to identify the independent variables predictive of higher incidence of early mortality, acute myocardial infarction, cerebrovascular accident, and early major events. RESULTS: Early mortality was 2.2% (group A, 1.4%; group B, 3.0%; p = 0.016), acute myocardial infarction incidence was 1.8% (group A, 1.1%; group B, 2.6%; p = 0.027), cerebrovascular accident incidence was 0.9% (group A, 0.8%; group B, 1.0%; p = not significant), and early major events incidence was 6.7% (group A, 5.3%; group B, 8.2%; p < 0.001). Stepwise logistic regression analysis showed that CPB was an independent risk factor for higher mortality (odds ratio, 2.2; p = 0.0217), higher incidence of acute myocardial infarction (odds ratio, 2.5; p = 0.0185), and higher incidence of early major events (odds ratio, 1.8, p = 0.0034). CONCLUSIONS: When CPB was not used, patients experienced lower early mortality and incidences of acute myocardial infarction were less complicated, both at univariate analysis and stepwise logistic regression analysis.

Radial artery for myocardial revascularization: long-term clinical and angiographic results.

BACKGROUND: To evaluate the long-term clinical and angiographic results of the radial artery (RA) as a graft in coronary artery bypass surgery. METHODS: One hundred sixty-four patients had a RA graft from July 1992 to July 1994. In 128 (group A) the RA was connected end to side (115) or end to end (13) to the left internal mammary artery. In 36 (group B) the proximal anastomosis was on the ascending aorta. RESULTS: Early mortality was 1.8% (group A 1.6% and group B 2.8%). Eight-year survival was 83.2%+/-3.2% (group A 82.1%+/-3.8% and group B 86.7%+/-6.2%, p = not significant [NS]), and event free survival was 80.1%+/-3.5% (group A 79.9%+/-4.4% and group B 80.2%+/-7.3%, p = NS). Sixty-one patients (37.2%) had an early angiography within 90 days from the operation. Patency rate of RA distal anastomoses were 98.9% (88 of 89), 98.7% in group A (77 of 78), 100% in group B (11 of 11; p = NS). After a mean of 48+/-27 months (6 to 96), 72 patients (51.1% of the survivors) had a new angiography. Patency rate of RA distal anastomoses was 95.6% (87 of 91), 93.8% in group A (61 of 65) and 100% in group B (26 of 26; p = NS). All the intermediate RA-LIMA anastomoses were patent at the early and late control. Patency rate for RA and IMAs was similar both early (88 of 89 versus 82 of 82; p = NS) and after 48+/-27 months (87 of 91 versus 93 of 93; p = NS). CONCLUSIONS: Long-term clinical results after RA grafting are satisfying. Angiographic patency rate, both early and after 48 months, is higher than 90% and is similar to that obtained with internal mammary arteries. The site of the proximal anastomosis does not influence early and late patency.

Mitral valve procedure in dilated cardiomyopathy: repair or replacement?

BACKGROUND: Mitral valve (MV) procedure for dilated cardiomyopathy is becoming popular. We analyzed the indications to MV repair or replacement according to our 10-year experience. METHODS: From January 1990 to May 2000, 49 patients with dilated cardiomyopathy (12 idiopathic and 37 ischemic) underwent MV operation, 29 repair and 20 replacement. Preoperative evaluation included measurement of MV coaptation depth (CD) as a mirror of the abnormalities of MV apparatus leading to functional mitral regurgitation. RESULTS: Thirty-day mortality was 4.2% (2 patients). One-, 3-, 5-, and 10-year actuarial survival was, respectively, 90%, 87%, 78%, and 73%. The possibility of survival with at least one New York Heart Association functional class improvement was 88%, 76%, 71%, and 65%. Return of functional mitral regurgitation after MV repair was nearly inevitable; however, using a scale from 0 to 4, mean postoperative functional mitral regurgitation was 1.2+/-0.8 when preoperative MVCD was 10 mm or less and 2.5+/-0.7 when preoperative MVCD was 11 mm or higher (p < 0.05). Globally, functional results were not influenced by the strategy of treatment (MV repair or replacement). CONCLUSIONS: Mitral valve operation can give satisfying survival and good palliation of dilated cardiomyopathy. The MVCD can be helpful in the choice of the surgical strategy on the MV.

Early clinical experience with a new sutureless anastomotic device for proximal anastomosis of the saphenous vein to the aorta.

BACKGROUND: Avoiding aortic side clamping is useful to avoid local particulate embolization. A device that allows a saphenous vein graft to be anastomosed to the aorta without aortic manipulation is clinically evaluated. METHODS AND RESULTS: From July 1999 to March 2000, 17 patients who underwent myocardial revascularization had an aorta-saphenous vein graft anastomosis performed by means of an aortic anastomotic device. Eight were operated on with cardiopulmonary bypass and 9 without. The proximal anastomoses created by the aortic anastomotic device were performed before the institution of cardiopulmonary bypass or before the related distal anastomosis was performed. In 11 patients transcranial Doppler ultrasound was used. In 1 (6%) patient the saphenous vein graft was not deployed, and in 2 (12%) a single suture was added for minor bleeding. None of the 11 patients evaluated with transcranial Doppler ultrasound had evidence of particulate embolization during the procedure. No patient died or was reoperated on for bleeding. Six (35%) patients had a postoperative angiogram 48 +/- 26 days after the operation that showed widely patent proximal anastomoses. CONCLUSIONS: Use of an aortic anastomotic device allows a sutureless anastomosis to be created between the aorta and saphenous vein graft. The device could be used in totally endoscopic myocardial revascularization. A second-generation device is ready to solve the problems encountered and to increase the ease in handling the device.

Anthracycline metabolism and toxicity in human myocardium: comparisons between doxorubicin, epirubicin, and a novel disaccharide analogue with a reduced level of formation and [4Fe-4S] reactivity of its secondary alcohol metabolite.

Secondary alcohol metabolites have been proposed to mediate chronic cardiotoxicity induced by doxorubicin (DOX) and other anticancer anthracyclines. In this study, NADPH-supplemented human cardiac cytosol was found to reduce the carbonyl group in the side chain of the tetracyclic ring of DOX, producing the secondary alcohol metabolite doxorubicinol (DOXol). A decrease in the level of alcohol metabolite formation was observed by replacing DOX with epirubicin (EPI), a less cardiotoxic analogue characterized by an axial-to-equatorial epimerization of the hydroxyl group at C-4 in the amino sugar bound to the tetracyclic ring (daunosamine). A similar decrease was observed by replacing DOX with MEN 10755, a novel anthracycline with preclinical evidence of reduced cardiotoxicity. MEN 10755 is characterized by the lack of a methoxy group at C-4 in the tetracyclic ring and by intercalation of 2, 6-dideoxy-L-fucose between daunosamine and the aglycone. Multiple comparisons with methoxy- or 4-demethoxyaglycones, and a number of mono- or disaccharide 4-demethoxyanthracyclines, showed that both the lack of the methoxy group and the presence of a disaccharide moiety limited alcohol metabolite formation by MEN 10755. Studies with enzymatically generated or purified anthracycline secondary alcohols also showed that the presence of a disaccharide moiety, but not the lack of a methoxy group, made the metabolite of MEN 10755 less reactive with the [4Fe-4S] cluster of cytoplasmic aconitase, as evidenced by its limited reoxidation to the parent carbonyl anthracycline and by a reduced level of delocalization of Fe(II) from the cluster. Collectively, these studies (i) characterize the different influence of methoxy and sugar substituents on the formation and [4Fe-4S] reactivity of anthracycline secondary alcohols, (ii) lend support to the role of alcohol metabolites in anthracycline-induced cardiotoxicity, as they demonstrate that the less cardiotoxic EPI and MEN 10755 share a reduction in the level of formation of such metabolites, and (iii) suggest that the cardiotoxicity of MEN 10755 might be further decreased by the reduced [4Fe-4S] reactivity of its alcohol metabolite.

Bilateral internal thoracic artery grafting: long-term clinical and angiographic results of in situ versus Y grafts.

BACKGROUND: We evaluated whether bilateral internal thoracic arteries provide the same long-term results when used as in situ grafts and as Y grafts. METHODS AND RESULTS: From October 1991 to February 2000, 1818 patients had bilateral internal thoracic arteries used as in situ (n = 1378, group A) or as Y grafts (n = 440, group B). The number of anastomoses per patient and the number of bilateral internal thoracic artery anastomoses per patient were higher in group B (3.1 +/- 0.9 and 2.7 +/- 0.9) than in group A (2.9 +/- 0.8 and 2.2 +/- 0.6) (both P <.001). The number of right internal thoracic artery anastomoses per patient rose from 1.0 +/- 0. 3 in group A to 1.4 +/- 0.6 in group B (P <.001), and the number of sequential anastomoses per right internal thoracic artery graft rose from 4.1% to 34.3% (P <.001). Thirty-day mortality was 2.0% in group A versus 2.5% in group B (P = not significant). No difference in postoperative course was detected. Eight-year survivals were 95.8% +/- 2.7% in group A versus 94.8% +/- 4.0% in group B (P = not significant), and event-free survivals were 95.2% +/- 2.9% in group A versus 93.6% +/- 4.4% in group B (P = not significant). Early angiograms were obtained in 295 patients (945 anastomoses, 863 distal and 82 proximal Y grafts), 213 patients (611) in group A and 82 patients (334) in group B. Patency rate was 98.8% in group A and 96.0% in group B (P = not significant), whereas grade A patency rate was 97.2% in group A and 96.4% in group B (P = not significant). Late angiograms were obtained in 88 patients (25 in group A and 63 in group B) at a mean of 17.5 +/- 18.4 months: patency rate was 100% in group A and 99.2 in group B (P = not significant), and grade A patency rate was 98.6% in group A and 98.8% in group B (P = not significant). No Y anastomosis was occluded or stenosed. COMMENT: Survival, incidence of cardiac events, and angiographic patency in the early and late phases are similar for bilateral internal thoracic arteries used either in situ or as Y grafts. However, Y grafting with bilateral internal thoracic arteries increases the number of anastomoses per bilateral thoracic artery, as well as the flexibility of the right internal thoracic artery.

Arterial revascularisation with two or more arterial conduits.

In the last decade arterial revascularisation has become more popular due to the routine use of the left internal mammary artery (LIMA). Left internal mammary artery grafting to the left anterior descending (LAD) coronary artery is widely recognised as the most important single determinant of improved results from coronary revascularisation. However, a question remains as to whether results can be further improved by using other arterial grafts in territories other than the LAD, or increasing the number of arterial anastomoses per patient. Although long-term results do not conclusively prove that arterial anastomoses to vessels other than the LAD increase the quality of late results, there are no results to disprove this hypothesis. In our institution we ensure that all mammary grafts are placed on the left coronary system. To achieve this we use skeletonised mammary conduits to increase graft length, and Y grafts to minimise the number of aortic anastomoses. We use the gastroepiploic artery as an in situ graft. With the radial artery we avoid aortic anastomoses by joining the radial artery to the internal mammary artery. With the increased use of skeletonised internal mammary arteries we use the inferior epigastric artery less frequently. This strategy for arterial revascularisation is based on results of 2236 patients undergoing myocardial revascularisation between October 1991 and June 2000. Of these, 75% had total arterial revascularisation where the early mortality was 2% and survival 93% at 7 years. We conclude that total arterial revascularisation using bilateral mammary grafts supplemented by other arterial conduits provides optimal results for myocardial revascularisation.

Off-pump myocardial revascularization using arterial conduits without cardiopulmonary bypass.

OBJECTIVE: The feasibility of myocardial revascularization via a median sternotomy with arterial conduits, without and with cardiopulmonary bypass (CPB), was evaluated. MATERIAL AND RESULTS: From May 21, 1997, to November 30, 1999, 721 patients had myocardial revascularization without CPB via median sternotomy using at least two arterial conduits. The procedure was performed without CPB in 322 patients (Group A); the remaining 399 patients (Group B) underwent the same operation with the aid of CPB. Group A patients were older, with a higher ejection fraction and less redo than Group B. There was no early death in Group A versus nine (2.3%) patients in Group B (p < 0.02). Incidence of cerebrovascular accident (CVA) and acute myocardial infarction (AMI) were similar in both groups. Early major events incidences were 1.2% versus 8.0% (p < 0.001) in Groups A and B, respectively. Postoperative angiographic controls showed a cumulative patency rate of 98.4% and a perfect patency rate of 96.7%. After 30 months, Groups A and B showed an actuarial survival of 98.1 +/- 0.7 and 96.5 +/- 2.8 (p = ns) and an event-free survival of 96.6 +/- 1.0 and 96.5 +/- 2.8 (p = ns), respectively. CONCLUSION: Myocardial revascularization without CPB using arterial conduits can be accomplished with the same quality of results obtained with the use of CPB.

Reoperative coronary surgery with and without cardiopulmonary bypass.

BACKGROUND: Reoperative coronary surgery without cardiopulmonary bypass (CPB) was analyzed to evaluate the technical profile of the patients studied and the benefit from this technique. MATERIAL AND METHODS: From November 21, 1994 to May 20, 1999, 166 patients had reoperative coronary surgery, 112 patients (Group A) with and 54 patients (Group B) without CPB. Median sternotomy was used in all the patients in Group A and in 13 patients in Group B. The remaining had a LAST (37 patients) or a posterolateral thoracotomy (4 patients). RESULTS: Anastomoses per patient were 2.4 +/- 0.8 in Group A and 1.1 +/- 0.4 in Group B (p < 0.001). When a single graft was needed, CPB was not used in 82.8% of the cases. However, when more than one graft was required, CPB was not used in only 5.6% of the cases. When a single territory had to be grafted, CPB was not used in 76.6% of the patients. If two territories were grafted, only 6.8% of the patients were in Group B, whereas no patient who needed a graft in all the three territories was in Group B. Overall mortality was 3.6% cerebrovascular accident (CVA) and acute myocardial infarction (AMI) incidence were 0.6% and 1.8%, respectively, and were similar in both groups. Incidence of early major events (overall 8.4%) was not different between groups. CONCLUSIONS: The primary endpoints (mortality, CVA rate, and AMI) were similar in both groups, but patients in Group B were less complicated. However, patients in the two groups were not the same, as the technical profile was quite different. As our results were similar to those obtained in the first operation, we think that consideration of different surgical possibilities, depending on territory to be grafted, will improve the results of redo coronary surgery, making them similar to those obtained in the first operation.

Current results in off pump surgery.

OBJECTIVE: We reviewed our experience with myocardial revascularization without cardiopulmonary by-pass (CPB) to evaluate early- and mid-term results compared with those obtained using CPB. METHODS: From May 21, 1997 to November 1998, 747 patients had isolated myocardial revascularization, 480 without CPB (Group A) and 267 with CPB (Group B). Exposure of the target vessels was obtained with four slings (two passed through the transverse sinus and two behind the inferior vena cava) and four deep pericardial sutures on the mobile pericardium around the left atrium (Lima stitches). The number of anastomoses/patient (when two or more conduits were used) was higher in Group B (3.1 +/- 1.0 vs 2.6 +/- 0.7, P < 0.001). More marginal branches were grafted in Group A (258 vs 239), but the percentage was higher in Group B (P < 0.001). Crude and risk adjusted mortality was similar in both groups, as well as cerebrovascular accident (CVA) and acute myocardial infarction incidences. Patients in Group A woke earlier, had less inotropes, lower creatinkinase myocardial band (CK-MB) peak, lower bleeding and less transfusion, shorter Intensive Care Unit (ICU) and postoperative stay in hospital than patients in Group B. 266 anastomoses were checked; of these 98.5% were patent and 97.0% were patent and not restrictive. CONCLUSIONS: Myocardial revascularization without CPB can provide good early- and mid-term results in selected patients. Primary endpoints (death and acute myocardial infarction) were similarly independent from the technique used. Some of the secondary endpoints were favorable in Group A: however their importance is minor. Even if we feel that some high risk patients with severe comorbidities can benefit from CPB surgery; this aspect is difficult to demonstrate scientifically.

Off or on bypass: what is the safety threshold?

BACKGROUND: To identify the technical profile of the patients operated on without cardiopulmonary bypass (CPB) and the benefit of the procedure. METHODS: From May 21, 1997, to December 31, 1998, 785 patients had coronary artery bypass grafting through a median sternotomy (group A: 472 without CPB; group B: 290 with CPB; group C: 23 converted). Technical aspects, mortality rate, cerebrovascular accident (CVA) incidence (crude and risk-adjusted), and incidence of major complications were recorded. RESULTS: Patients without CPB had mainly one to three grafts and one- or two-vessel disease. Multiple arterial grafting was not a limit, whereas sequential grafting was. Group A had lower complications rates, shorter intensive care unit and postoperative in hospital stays, and lower transfusion rates. Mortality rates and CVA incidence (crude and risk-adjusted) were similar in both groups and in each subgroup considered. In group A, a lower complications rate was present in some patients (aged greater than 70 years, female, with unstable angina). Group C showed higher mortality and complications rates. Failure of revascularization showed no difference between groups. CONCLUSIONS: Primary endpoints are not affected by the surgical strategy, whereas some of the secondary endpoints are. However, patients in group A experienced fewer complications. Both techniques can give satisfying results and must be applied according to the surgeon's preference.

Bilateral internal mammary artery grafting: midterm results of pedicled versus skeletonized conduits.

BACKGROUND: To increase the number of anastomoses per patient, bilateral internal mammary arteries (BIMAs) were harvested with a skeletonized approach instead of a pedicled one. METHODS: One thousand one hundred forty-six patients underwent isolated myocardial revascularization using BIMAs, 304 receiving pedicled grafts (group A, October 1991 through May 1994) and 842 receiving skeletonized conduits (group B, June 1994 through June 1998). Group B had a higher incidence of patients with diabetes (223 versus 40, p < 0.001). RESULTS: The number of BIMA anastomoses per patient was significantly higher in group B (2.4 +/- 0.3 versus 2.1 +/- 0.4, p < 0.001), as well as the number of sequential grafts (288 versus 42, p < 0.001). Twenty-three patients (2.0%) died in the first 30 days after surgery, 5 in group A (1.6%) and 18 in group B (2.1%) (not significant). Postoperative complications were similar in both groups; the incidence of sternal wound healing problems was higher as a whole and with regard to diabetic patients (4 of 40 [10%] versus 5 of 223 [2.2%], p < 0.05) in group A. Seventy-one patients in group A and 133 (15.8%) in group B underwent a postoperative angiography. Patency rate was similar, both early (100% in group A versus 98.6% in group B, not significant) and late (98.6% in group A versus 98.4% in group B, not significant). CONCLUSIONS: The use of skeletonized BIMA conduits allowed us to increase the number of BIMA anastomoses per patient with a lower rate of sternal wound complications and angiographic results similar to those obtained with pedicled BIMA conduits.

Multiple arterial conduits without cardiopulmonary bypass: early angiographic results.

BACKGROUND: Lack of angiographic results and technical difficulty in grafting the vessels in the lateral and posterior walls have reduced interest in myocardial revascularization without cardiopulmonary bypass (CPB). We describe our experience to demonstrate the feasibility of coronary surgical intervention without CPB in multivessel disease. METHODS: From May 21, 1997, through February 1998, 227 patients underwent revascularization with two or more arterial conduits as the first operation: 122 without CPB (group A) and 105 with CPB (group B). Group A included a greater number of high-risk patients. RESULTS: Mean +/- SD anastomoses per patient were 2.5 +/- 0.6 in group A and 2.8 +/- 0.8 in group B (p = NS). No patient died in group A, whereas 1 patient (0.9%) died in group B. The postoperative complication rate was low in both groups, but intensive care unit and in-hospital stays were shorter in group A than in group B (14.1 +/- 7.1 versus 27.3 +/- 36 hours, p < 0.001, and 4.1 +/- 1.6 versus 5.4 +/- 2.4 days, p < 0.001, respectively [group A versus group B]). Sixty-seven patients in Group A (54.9%) underwent postoperative angiography 33 +/- 35 days after operation. The patency rate was 98.9% (98.2% for the marginal branches). CONCLUSIONS: Arterial revascularization of the coronary arteries without CPB is feasible, with results similar to those obtained with CPB. The two techniques, in our opinion, are complementary, not antagonistic.

Minimally invasive mammary artery Doppler flow velocity evaluation in minimally invasive coronary operations.

BACKGROUND: Left internal mammary artery Doppler flow velocity assessment during the Azoulay maneuver (patient's legs are passively lifted up and actively maintained by the patient) can increase the information on the anastomosis quality after left internal mammary artery to left anterior descending coronary artery grafting after the left anterior, small thoracotomy operation. METHODS: One hundred patients had an early postoperative angiography and a Doppler flow velocity assessment at rest and during the Azoulay maneuver. Peak and mean systolic velocities, peak and mean diastolic velocities, and peak and mean diastolic to systolic velocity ratios were recorded in all patients. RESULTS: In 95 patients with no restrictive conduit or anastomosis, peak and mean diastolic to systolic velocity ratios increased during the Azoulay maneuver; all but 1 patient showed at least one ratio equal to or greater than 1. In 4 patients with restrictive conduit or anastomosis, peak and mean diastolic to systolic velocity ratios were always less than 1 during the Azoulay maneuver. In the patient with an occluded conduit these ratios were less than 0.6. CONCLUSIONS: Peak and mean diastolic to systolic velocity ratios less than 1 during the Azoulay maneuver are suggestive of conduit or anastomosis malfunction. If we limit the angiographic controls to these patients, it is very likely that a pathologic anastomosis or conduit will not be missed.

The LAST operation: techniques and results before and after the stabilization era.

BACKGROUND: Left anterior descending artery stabilization allows performance of left internal mammary artery grafting via a left anterior small thoracotomy on a beating heart. Our surgical experience was reviewed to assess if surgical results have improved as result of specialized instrumentation. METHODS: Of 545 patients who had the left anterior small thoracotomy operation, 261 underwent this procedure for single left anterior descending artery disease. Two groups were considered, before and after the use of specialized instrumentation: group A (n = 93), operated on from November 21, 1994, to April 20, 1996; and group B (n = 168), operated on from April 21, 1996, to December 1997. RESULTS: Early mortality was similar in the two groups. The further revascularization (operation or percutaneous transluminal coronary angioplasty) and the rate of occlusion of the conduit were higher in group A, whereas anastomotic or conduit malfunction was not. Cumulating angiography and Doppler flow evaluation, 92.5% of the anastomoses in group A and 98.8% in group B (p = 0.026) were patent, and 90.3% in group A and 97.6% in group B (p = 0.031) were patent and not restrictive. At 19 months, survival was similar, but the event-free survival was higher in group B. CONCLUSIONS: Both left anterior descending artery stabilization and safer left internal mammary artery harvesting contributed to improve angiographic and clinical results after the left anterior small thoracotomy operation.

Midterm results after minimally invasive coronary surgery (LAST operation)

BACKGROUND: Our experience with a left internal thoracic artery graft to the left anterior descending artery via a left anterior small thoracotomy is reviewed to evaluate midterm results. METHODS: From November 1994 to April 1997, four hundred sixty patients were scheduled to undergo a left internal thoracic artery graft to the left anterior descending coronary artery via a left anterior small thoracotomy; 26 of these patients (5.7%) were converted and 434 of them had the operation. Two hundred fourteen patients (49.3%) had isolated disease of the left anterior descending artery, and 220 patients (50.7%) had multiple vessel disease. A sufficient length of the left internal thoracic artery was harvested to reach the left anterior descending artery. RESULTS: Three hundred nine patients (71.2%) underwent extubation by hour 2. Mean intensive care unit stay was 4.2 +/- 4.5 hours; mean postoperative hospital stay was 66 +/- 29 hours; the 30-day mortality rate was 1.1%; the late mortality rate was 1.4%. Eighteen patients underwent reoperation early (< or = 30 days), and eight patients underwent reoperation late (> 30 days) because of conduit/anastomotic malfunction. Four patients underwent reoperation with patent anastomosis for progression of disease (n = 3) or pericarditis (n = 1). Three patients had a percutaneous transluminal coronary angioplasty. Cumulating angiographic and stress Doppler flow assessment results, a patent anastomosis was obtained in 417 patients and a nonrestrictive anastomosis in 404 patients. Twenty-nine months after surgery, survival was 97.1% +/- 0.7% (95% confidence interval 90.5% to 100%) and event-free survival 89.4% +/- 1.2% (95% confidence interval 78.2% to 100%). In the last 190 patients, with our increased experience and better instruments, we obtained a patent anastomosis in 188 patients (98.9%) and a nonrestrictive anastomosis in 185 (97.4%). CONCLUSIONS: Left anterior small thoracotomy gives acceptable midterm results. Incidence of patent and nonrestrictive anastomoses was satisfactory, especially in the most recent part of our experience, when the learning curve ended.

Recent advances in multivessel coronary grafting without cardiopulmonary bypass.

BACKGROUND: Coronary artery bypass grafting (CABG) without the heart lung machine has been possible for easily accessible targets such as the anterior descending or proximal right coronary. Until now technical difficulty in reaching lateral and inferior wall targets imposed significant barriers to multivessel off-pump grafting. To expand the potential for off-pump CABG the authors have devised new exposure and stabilization techniques suitable for all target vessels. In this report we relate our experience with these new techniques and demonstrate that multivessel coronary bypass can be safely performed without cardiopulmonary bypass (CPB). METHODS: From February 8, 1993 to December 16, 1997 a total of 280 patients underwent myocardial revascularization on the beating heart via median sternotomy. Until May 20, 1997 only patients with high preoperative risk factors for CPB were considered for this approach (Group A; N = 122). After this date any patients with favorable anatomy were included (Group B; N = 158) and were subsequently compared with patients operated on using CPB during the same time interval (Group C; N = 114). In Group B patients lateral and/or inferior wall targets were exposed by means of 4 cloth slings (2 through the transverse sinus and 2 behind the inferior vena cava) and by positioning the patients in Trendelenburg with rightward rotation of the table. Regional stabilization of the target artery was obtained with a commercial stabilizing foot plate. RESULTS: Thirty day hospital mortality was only 2 patients (1.6%) in Group A, 3 patients (1.9%) in Group B, and 3 patients (2.6%) in Group C (NS). Postoperative complications were low in both Group A and B. When Group B was compared with a similar cohort in whom CPB was used (Group C), there were statistically significant improvements in ICU and hospital stay demonstrated when CPB was not used (16.8+/-10.7 vs 26.3+/-38.6 hours respectively; p = 0.007, and 4.1+/-1.5 vs 5.5+/-2.4 days respectively, p<0.001). Angiographic followup was available for 78 patients in Groups A and B with a global patency rate (all grafts) of 98.6%, including a patency rate of 96.7% for 60 grafts to obtuse marginal branches of the circumflex). CONCLUSIONS: Multivessel CABG without CPB is possible with results similar to those obtained with pump-oxygenator support using simple exposure and stabilization techniques.

Minimally invasive coronary artery surgery: the last operation.

Left anterior descending grafting with a left internal thoracic artery on a beating heart via a small left anterior thoracotomy is a procedure that is becoming popular, even if not yet standardized. From November 21, 1994 through February 20, 1997, 411 patients underwent a small left anterior thoracotomy; 206 had single-vessel disease, 205 had multiple-vessel disease. The early mortality rate was 1.0% (4 patients); causes of death were cardiac, not operation-related in 3, and non-cardiac in 1. The late mortality rate was 1.4% (6 patients); causes of death were cardiac operation-related in 1, non-cardiac in 3. All patients had a postoperative Doppler-flow velocity assessment; 231 (56.2%) underwent an angiographic control during the first postoperative year. Some patients were selected, as every patient with conduit or anastomotic malfunction underwent angiography. The patency rate was 92.4% (214/231); perfect distal anastomoses were obtained in 87.0% (201/231). With increasing experience and new instruments for left internal thoracic artery harvesting and left anterior descending artery stabilization, from April 21, 1996, patency rate increased to 98.2% (107/109) and perfect patency rate to 95.4% (104/109); results are therefore improving with time. The left anterior small thoracotomy procedure gives acceptable midterm results and is a reasonable alternative to the median sternotomy when the left anterior descending artery needs to be grafted with the left internal thoracic artery.