Endoscopic radial artery harvesting for coronary artery bypass grafting. A single center evolving experience.

AIM: We sought to evaluate our experience with endoscopic radial artery harvesting for coronary artery bypass grafting (CABG). METHODS: From October 2005 to June 2010, 50 patients who underwent endoscopic radial artery harvesting for an elective CABG were prospectively assessed for harvesting characteristics, complications, postoperative and mid-term outcomes. RESULTS: There were 34 (68%) males and 16 (32%) females, average age 60.8 ± 9.2 years. All but two RA grafts (96%) were successfully harvested endoscopically. Mean harvesting time was 46.2 ± 9.3 min and mean length of harvested grafts was 23.4 ± 2.2 cm. In the post-operative period there were no wound-healing complications; residual forearm edema was recorded in 6 patients (12%) and peripheral neuropathy in 4 patients (8%). At 3 months after the surgery, peripheral neuropathy and residual edema persisted in 2 patients (4%). A significant drop of overall harvesting time (56.2 ± 18.6 vs. 38.6 ± 8.6 min, P<0.05) and forearm ischemia time (41.8 ± 12.7 vs. 24.2 ± 3.2 min, P<0.01) was found between first and last ten cases in the group. CONCLUSION: Endoscopic radial artery harvesting was associated with low risk of post-harvesting complications and most of these disappeared within a 3 months follow-up. However, there was a significant learning curve.

Predictors of failure following restrictive annuloplasty for chronic ischemic mitral regurgitation.

AIM OF THE STUDY: We sought to determine the results of restrictive annuloplasty for chronic ischemic mitral regurgitation. METHODS: Hospital outcome and serial clinical and echocardiographic (preoperative, discharge, 3 months, 12 months, 24 months) follow-up assessments were analyzed in 87 consecutive patients with chronic ischemic mitral regurgitation having coronary artery bypass grafting. Persistent/recurrent mitral regurgitation was defined by grade ≥2 at discharge/during follow-up. RESULTS: Hospital mortality was 5.7% and persistence of regurgitation was present in 8.4%. Mean follow-up was 24.4 ± 1.7 months and recurrent mitral regurgitation was observed in 32.4% patients. In multivariate analysis only anterior leaflet angle remained an independent predictive factor for regurgitation recurrence with cutoff 27° (sensitivity of 67% and specificity of 76%, p = 0.04). CONCLUSION: There is high occurrence of early and delayed restrictive annuloplasty failure, particularly in patients with increased anterior leaflet tethering.

Persistent and recurrent ischemic mitral regurgitation.

BACKGROUND: Ischemic mitral regurgitation (IMR) is a consequence of coronary artery disease and the main underlying mechanism is augmented leaflet tethering due to outward displacement of the papillary muscles. Although mitral annuloplasty combined with coronary revascularization is usually effective in the treatment of IMR, occasionally the regurgitation can persist or recur and this can affect patient prognosis. METHODS: We searched Medline and Google scholar database for articles published since 1996 to June 2009. Search terms included ischemic mitral regurgitation, recurrent mitral regurgitation, persistent mitral regurgitation and annuloplasty failure. CONCLUSION: This article reviews current knowledge about IMR, the reasons and mechanisms of persistent and recurrent mitral regurgitation. We review clinic and echocardiographic predictive factors associated with persistence a recurrence of mitral regurgitation after annuloplasty.

Left internal thoracic artery harvesting: measurement of the length required for coronary bypass surgery.

The left internal thoracic artery (LITA) is used routinely for coronary bypass surgery. A simple technique for assessing, prior to harvesting, the length of LITA required for an individual bypass of the left anterior descending artery (LAD) is described.

Re-operations for bleeding in cardiac surgery: treatment strategy.

AIMS: Cardiac surgery patients are prone to bleeding postoperatively owing to the extensive sternotomy wound, multiple vessel and heart sutures, and disorders of hemostasis. In this study we retrospectively analyzed the outcomes for all patients in our department who were re-operated for bleeding, over a 5 year period. METHODS: A total of 4297 patients underwent heart surgery between February 2002 and January 2007, of which 98 (2.3 %) were emergency reoperations for bleeding. We analyzed the process of indication for repeat surgery, possible source of bleeding, and postoperative complications. RESULTS: Most (85.7 %) of the reoperated patients had undergone their first operation as an elective cardiac procedure. The mean blood loss before the reoperation was 1557 ml. The studied group was characterized by increased mortality (11.2 %), longer ventilation period (35.1 hours) and ICU (4.5 days) and hospital (13.3 days) stays. The postoperative outcomes did not differ significantly between patients with TEG-detected coagulation disorder and the rest of the patients, or between patients treated with antilysin and those who did not receive antifibrinolytics. CONCLUSIONS: It is vital for the indication process leading to reoperation of the bleeding patient to be as short as possible so as to minimize the delay to repeat surgery. Echocardiography including ultrasound of both pleural spaces, and TEG could shorten that time delay, and should always be included when evaluating patients. Platelets should be administered more often, with the use of antifibrinolytics reserved for cases with confirmed fibrinolysis.

Mistakes in dealing with aortic dissection. Lessons from three warning cases.

BACKGROUND: Aortic dissection is a dangerous condition with a high mortality in the acute stage. Aortic dissection requires early diagnosis and treatment. METHODS AND RESULTS: This short review discusses and focuses on known complications of aortic dissection and its natural mortality applying data from already published reports and from cohorts and registers, especially IRAD. Survival data of patients with type A and type B of dissection are presented and treatment options are proposed. The review presents three interesting cases from our database pointing out mistakes made in the diagnostic process and in dealing with the patient even after establishing the correct diagnosis. In one case, a patient with chest pain + "immeasurable" BP was suspected to suffer from an acute myocardial infarction and cardiogenic shock instead of AoD + aortic branch obstruction. In another patient with chest pain + V1V2 ST elevation, again the acute coronary syndrome was suspected. In fact, AoD with a perforation to cardiac chambers through the interventricular septum was the explanation. In the third case, the correct diagnosis of AoD was established. This patient was at a significant risk of aortic rupture because of his uncontrolled blood pressure. Instead of sedation administration and effective BP lowering, the patient was stressed even more by detailed information about this life threatening disease. This led to an aortic rupture with cardiac tamponade. Other mistakes made when dealing with all these presented cases are also discussed. CONCLUSION: The high mortality in patients suffering from aortic dissection is often potentiated by misdiagnosing and mishandling of these patients in clinical scenario.

The choice of on- or off-pump coronary bypass grafting--a surgeon's dilemma.

BACKGROUND: Off-pump coronary bypass grafting (OPCAB) is a routine method of heart revascularization. This study was designed to compare the results of OPCAB and ONCAB performed by a single surgeon at our institution over a 3-year period. METHODS: The study enrolled 345 patients undergoing elective myocardial revascularization procedures, of which 173 (50.1%) were OPCAB and 172 (49.9 %) were ONCAB. The postoperative outcomes of both groups were analyzed, retrospectively. RESULTS: The mean number of grafts was significantly lower in the OPCAB group (2.9) than in the ONCAB group (3.7). There were no postoperative myocardial infarctions or hospital deaths in any of the patients. The postoperative total blood loss was significantly higher in the ONCAB group. The frequencies of postoperative confused states, strokes, postoperative transfusions, reoperations for bleeding, and atrial fibrillation, and the durations of intubation, ICU stay, and hospital stay did not differ significantly between the two groups. CONCLUSIONS: The OPCAB procedures are safe and provide good clinical outcomes, similar to those of ONCAB operations. The outcomes of this study favor neither of the compared techniques.

Simultaneous endoscopic radial artery and great saphenous vein harvesting for redo coronary artery bypass grafting. A report of two cases.

AIM: An ageing population and increase in patient co-morbidities are forcing cardiac surgeons to meticulously consider the benefits and risks of respective conduits and their harvesting techniques. CASE REPORTS: Two cases of simultaneous endoscopic radial artery and great saphenous vein harvesting, for redo coronary artery bypass grafting, are presented. A shortage of venous conduits after previous bypass grafting, as well as the presentation of several risk factors of wound-healing complications, favoured simultaneous utilisation of both endoscopic techniques. CONCLUSION: Endoscopic vessel harvesting together with the pre-harvesting duplex study is able to gain not only high-quality conduits but also minimize the risk of wound-healing and neurological disturbances associated the saphenous vein and radial artery harvesting.

Sequential bypass grafting on the beating heart: blood flow characteristics.

BACKGROUND: The sequential bypass technique is a routine method of myocardial revascularization. The aim of this study was to determine flow characteristics of individual and sequential bypass grafts created on the beating heart. METHODS: Between January 2003 and February 2004, a consecutive series of 50 patients underwent off-pump coronary bypass surgery with at least one venous sequential coronary graft. During the procedure, flow values and pulsatility indexes were measured in both segments of the sequential graft using a CardioMed transit time flow meter (CM 4008; Medi-Stim, Oslo, Norway). The flow values were simultaneously compared with those of individual venous grafts sutured to the same coronary arteries. RESULTS: The mean flow through the distal anastomosis (individual bypass; D1) was 37.4 mL/min, and this was not significantly influenced by the creation of a proximal sequential anastomosis (D2, 39.0 mL/min). In 32% of the patients, the sequential bypass was unwittingly connected proximally to a larger coronary bed; despite this, the flow in its distal segment was not less than that in the individual bypass. CONCLUSIONS: The blood flow through an individual bypass is comparable with that through the distal segment (end-to-side anastomosis) of a sequential bypass. The grafting of a sequential bypass proximally to the larger artery (coronary bed) in sequence does not appear to have a significant effect on the blood flow in the distal segment of a sequential bypass.

Unusual cause of femorofemoral cardiopulmonary bypass failure.

A case of femorofemoral cardiopulmonary bypass failure in a patient undergoing an emergent operation because of acute aortic dissection is described. The importance of the accurate deduction of preoperative transesophageal echocardiography findings is emphasized.

Cardiomed coronary flow meter for prevention of early occlusion in aortocoronary bypass grafting.

INTRODUCTION: The number of patients undergoing technically demanding off-pump myocardial revascularization is increasing, these days. Some researchers question the quality of the aortocoronary bypasses done on the beating heart and consequently their good patency. MATERIAL AND METHODS: 50 consecutive patients underwent off pump coronary surgery using sequential bypass technique, at our department. The quality of constructed grafts was evaluated using the CardioMed Trace System (CM4008, Medi-Stim As, Oslo, Norway) (TTFM). RESULTS: All sequential bypasses showed good per-operative quality with a mean fl ow of 69.4 ml/min. CONCLUSION: TTFM seems to be an effective tool for the per-operative aortocoronary bypass patency verification and should help to prevent early graft occlusion. ABBREVIATIONS: TTFM transit time flow meter.